New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 4 - ACTUARIAL SERVICES
Subchapter 53 - MINIMUM STANDARDS FOR SPECIFIED DISEASE AND CRITICAL ILLNESS COVERAGES
Section 11:4-53.2 - Definitions
The following words and terms, as used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise:
"Aggregate loss ratio" means the ratio of the accumulated value of past paid benefits (from the original effective date of the form to the date as of which the ratio is determined) and the present value of future paid benefits to the accumulated value of past paid premiums (from the original effective date of the form to the date as of which the ratio is determined) and the present value of future paid premiums. Benefits shall not be increased nor premiums reduced by actual or anticipated dividends, and interest shall be included in the accumulated and present values on the same basis as in the present values of the anticipated loss ratio. For purposes of this ratio, no reserves shall be included in the benefits or premiums.
"Anticipated loss ratio" means the ratio of the present value of the expected paid benefits, not including dividends, to the present value of the expected paid premiums, not reduced by dividends, over the entire period for which rates are computed to provide coverage. For purposes of this ratio, the present values must incorporate realistic rates of interest that are determined before Federal taxes but after investment expenses. Benefits and premiums shall be discounted from the year of payment, with reasonable assumptions as to time of payment within the year. For purposes of this ratio, no reserves shall be included in the benefits or premiums.
"Association" means an organization of persons joined together for a special purpose or business, or the attainment of some common objective, other than a legally established corporation or partnership, or fraternal benefit society, organized without capital stock, and whose activities are carried on for the sole benefit of its members and for purposes other than obtaining insurance.
"Carrier" means any insurance company operating pursuant to 17B:17-1 et seq., or fraternal benefit society operating pursuant to N.J.S.A. 17:44-1 et seq., transacting or authorized to transact the business of health insurance in the State of New Jersey.
"Certificate" means a statement of the coverage and provisions of a policy of group specified disease or critical illness coverage, which has been delivered or issued for delivery in New Jersey, and includes riders, endorsements and enrollment forms, if any.
"Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance.
"Critical illness coverage" means coverage that pays a level lump sum benefit upon diagnosis of a specified disease without payment of further benefits in connection with hospital and medical care for the treatment of the specified disease.
"Department" means the New Jersey Department of Banking and Insurance.
"Policy," "policy form," or "form" means any policy, contract, rider, certificate, or other document that sets forth or summarizes the essential features of the coverage issued to an individual or group, including an association, by a carrier.
"Specified disease coverage" means coverage that pays fixed-sum benefits on an indemnity non-expense incurred basis in connection with hospital or medical care for the treatment of a specifically named disease or diseases that are life threatening in nature.
