New York Codes, Rules and Regulations
Title 11 - INSURANCE
Chapter III - Policy and Certificate Provisions
Subchapter A - Life, Accident and Health Insurance
Part 52 - Minimum Standards For Form, Content And Sale Of Health Insurance, Including Standards Of Full And Fair Disclosure
Section 52.15 - Specified disease coverage
Universal Citation: 11 NY Comp Codes Rules and Regs ยง 52.15
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Specified disease coverage is a policy or certificate which pays benefits on an indemnity basis for the diagnosis and treatment of a specifically named disease or diseases which are life threatening in nature and could cause a person to incur substantial financial out-of-pocket expenses for the diagnosis and treatment of a specifically named disease or diseases.
(b) General rules.
(1) A policy or certificate covering a single
specified disease or combination of specified diseases may not be sold or
offered for sale other than as specified disease coverage pursuant to this
section. All forms of the specified disease or diseases must be
covered.
(2) Any policy or
certificate issued pursuant to this section which conditions payment upon
pathological diagnosis of a covered disease, shall also provide that if such a
pathological diagnosis is medically inappropriate, a clinical diagnosis will be
accepted in lieu thereof. Any type of medically appropriate diagnosis shall be
accepted.
(3) An individual policy
containing specified disease coverage shall be at least guaranteed renewable
for life.
(4) Except for any policy
or certificate provision regarding other insurance with the insurer providing
specified disease coverage, benefits for specified disease coverage shall be
paid regardless of other coverage.
(5) Except in the case of direct response
insurers, no specified disease policy or certificate shall be delivered or
issued for delivery in this Sate unless the appropriate disclosure form in
section 52.66 of this Part describing the
policy's or certificate's benefits, limitations and exclusions, and expected
benefit ratio is delivered to the applicant at the time application is made and
written acknowledgment of receipt or certification of delivery of such
disclosure form is provided to the insurer. Direct response insurers shall
deliver the requisite disclosure form at the time the policy or certificate is
delivered.
(6) The only permissible
preexisting condition limits are those which exclude coverage for no more than
six months after the effective date of coverage under the policy or
certificate, for a condition for which medical advice was given or treatment
was recommended by, or received from, a licensed health care provider within
six months before the effective date of the coverage.
(7) The only permissible limitations and
exclusions are those set forth in section
52.16 of this Part.
(8) An insurer shall file its overinsurance
rules with the Insurance Department. Overinsurance shall be deemed to exist
when an insured has more than one specified disease policy or certificate for
the same specified disease whether it is with the same or a different insurer.
In no event may an insurer issue a specified disease policy or certificate to
any person which will result in that person being covered for eight or more
specified diseases.
(9) Every
specified disease policy or certificate shall contain, on the first page of the
policy or certificate in boldface type, in at least 14-point size but not less
than the size of type used for policy captions, a prominent statement, as
follows: "This is a limited policy (or certificate). It pays benefits for (name
of specified disease) treatment only. Read it carefully with the Required
Disclosure Statement."
(10) No
advertisement of a policy or certificate shall imply coverage beyond the terms
of the policy or certificate. Synonymous terms shall not be used to refer to
any disease so as to imply broader coverage than is the fact.
(11) A specified disease policy or
certificate where a benefit is a lumpsum payment for the diagnosis of a
specified disease without further coverage for treatment of the disease can
only be offered if it meets the requirements set forth in subdivision (d) of
this section.
(12) Specified
disease coverage shall only be issued to persons who are covered by either at
least major medical insurance as defined in section
52.7 of this Part, or at least
basic hospital insurance and basic medical insurance as defined in sections
52.5 and
52.6 of this Part.
(13) Application forms shall include a
question designed to elicit information as to whether the applicant has at
least major medical insurance, or at least basic hospital insurance and basic
medical insurance in force on the date of the application.
(14) No later than 30 days following delivery
of the policy or certificate, the insurer must ask the insured person(s) in a
written request whether the insured person(s) has in force at least major
medical insurance, or at least basic hospital insurance and basic medical
insurance on the effective date of the specified disease coverage. Where the
insured person(s) responds to the insurer in writing that such underlying
coverage is not in force on the effective date of the specified disease
coverage, the policy or certificate shall be voided from its beginning with a
full premium refund. The method by which the insurer implements the
requirements of this paragraph must be approved by the
superintendent.
(15) Application
forms shall include questions designed to elicit:
(i) whether, as of the date of the
application, the applicant has in force or application(s) pending for another
specified disease policy or certificate for the same specified disease with the
same or a different insurer; and
(ii) the number of specified diseases for
which either the applicant has coverage in force as of the date of application
or application(s) pending as of the date of application.
(16) Reductions in benefits such as when
certain events occur or ages are reached are not permissible.
(c) Rules applicable to specified disease coverage written on an indemnity and recurring (e.g., conditions benefits on ongoing treatment) basis.
(1)
Notwithstanding any other provisions of this Part, a policy or certificate
shall provide benefits to any covered person not only for the specified
disease(s) but also for any other condition(s) or disease(s) directly caused or
aggravated by the specified disease(s) or the treatment of the specified
disease(s).
(2) Payments may be
conditioned upon a covered person receiving medically necessary care or
treatment, given in a medically appropriate location, under a medically
accepted course of diagnosis or treatment.
(3) No policy or certificate issued pursuant
to this section shall contain a probationary period greater than 30 days from
the coverage effective date during which time period the insurer may take the
actions described in this paragraph. A provision may be included in the policy
or certificate which shall indicate that for a specified disease diagnosed
within the initial 30 days of coverage, the policy or certificate is either
void from its beginning with a full premium refund to the insured, or the
coverage for such diagnosed specified disease is delayed for a period not to
exceed 12 months from the coverage effective date. The provision shall also
indicate that the insured elects whether the policy or certificate is to be
voided with a full premium refund or coverage is delayed.
(4) Benefits shall begin with the first day
of medical care or hospital confinement if such care or confinement is for a
covered disease, even though the diagnosis is made at some later
date.
(5) A lump sum payment no
greater than $5,000 may be made to cover resultant costs such as travel,
lodging, household costs, and other living expenses.
(6) The following minimum benefit standards
apply.
(i) The coverages must provide covered
persons:
(a) a fixed sum payment of at least
$200 for each day of hospital confinement for at least 365 days; and
(b) a fixed sum payment equal to at least
one-half of the hospital confinement in-patient benefit for at least 365 days
of treatment for each day of hospital or non-hospital out-patient surgery; and
(1) for specified disease coverages for
cancer only, chemotherapy and radiation therapy; or
(2) for specified disease coverages other
than for cancer only, medically appropriate outpatient treatment.
(ii) Benefits for
confinement in a skilled nursing home or for home health care are optional. If
a policy or certificate provides these benefits, the coverage must equal a
fixed sum payment of at least one-fourth of the hospital confinement in-patient
benefit for each day of skilled nursing home confinement for at least 100 days,
and a fixed sum payment of at least one-fourth of the hospital confinement
in-patient benefit for each day of home health care for at least 100 days.
Notwithstanding any other provision of this Part, any restriction or limitation
applied to the benefits in the above requirements, whether by definition or
otherwise, shall be no more restrictive than those under Medicare.
(iii) All specified disease coverages may
include a deductible amount not in excess of $250 and an overall aggregate
benefit limit, per person, of not less than $10,000 for services other than
those stated in subparagraphs (i) and (ii) of this paragraph and a benefit
period of not less than two years. If benefits are not payable for a period of
180 days, then a covered person shall be entitled to a new benefit
period.
(7) In order to
assure that benefits are reasonable in relation to the premium charged, the
minimum loss ratio for such policies or certificates shall be:
(i) 60 percent in the case of individual
insurance issued under the age of 65;
(ii) 65 percent in the case of individual
insurance issued at ages 65 and over, except that if one rate is charged for
all ages under 65 and 65 and over, and the policy or certificate is issued at
all ages 25 and over, the applicable standard for policies or certificates
issued to ages under 65 shall apply;
(iii) 65 percent in the case of franchise
insurance; and
(iv) 70 percent in
the case of group or blanket insurance.
(d) Rules applicable to specified disease coverage written on an indemnity and non-recurring (e.g., pays a lump sum benefit on diagnosis) basis.
(1) Dollar
benefits shall be offered for sale only in even increments of $1,000 not to
exceed $500,000. As long as the policy clearly indicates, in cases of clearly
identifiable forms of diseases with significantly lower treatment costs, lesser
amounts may be offered, but in no event shall such amounts be less than
$250.
(2) No policy or certificate
issued pursuant to this section shall contain a probationary period greater
than 30 days from the coverage effective date during which time period the
insurer may void the policy or certificate from its beginning with a full
premium refund to the insured for a specified disease diagnosed within the
initial 30 days of coverage.
(3)
Indemnity amounts for any one specified disease cannot be paid in more than two
equal installments for any reoccurrences or spread of the same specified
disease or a new primary occurrence of the same specified disease or the
resulting death of the insured due to the same specified disease.
(4) New probationary periods for any one
specified disease cannot be instituted for any reoccurrences or spread of the
same specified disease or a new primary occurrence of the same specified
disease. Probationary periods in addition to those allowed by paragraph (2) of
this subdivision are prohibited. However, the insurer can require reasonable
and appropriate medical certification that the insured is afflicted with a
specified disease covered by the policy or certificate.
(5) Benefit amounts payable for any one
specified disease can be subject to a maximum policy or certificate benefit for
all specified diseases covered under the policy or certificate.
(6) The policy or certificate shall clearly
specify the criteria that must be satisfied in order to trigger the payment of
benefits. Subject to paragraph (2) of this subdivision, a benefit shall always
be payable upon initial and medically appropriate diagnosis of the specified
disease covered by the policy or certificate.
(7) In order to assure that benefits are
reasonable in relation to the premium charged, the minimum loss ratio for such
policies or certificates shall be:
(i) 60
percent in the case of individual insurance issued under the age of
65;
(ii) 65 percent in the case of
individual insurance issued at ages 65 and over, except that if one rate is
charged for all ages under 65 and 65 and over, and the policy or certificate is
issued at all ages 25 and over, the applicable standard for policies or
certificates issued to ages under 65 shall apply;
(iii) 65 percent in the case of franchise
insurance; and
(iv) 70 percent in
the case of group or blanket insurance.
Disclaimer: These regulations may not be the most recent version. New York may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
