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 52.43 - Standards for maintaining experience data

Universal Citation: 11 NY Comp Codes Rules and Regs ยง 52.43

Current through Register Vol. 46, No. 39, September 25, 2024

(a) The following rules shall apply with respect to experience data for individual insurance.

(1) Maintaining experience. Premium and loss data shall be recorded for each policy form and, where more than one coverage may be provided at the option of the insured under a single policy form, for each major combination of coverage and each age group (i.e., under age 65 and age 65 and over) on the following basis for each calendar year:
(i) premiums written or paid;

(ii) each reserve component (i.e., the increase in premium reserves, policy reserves, and claim reserves and liability);

(iii) earned premiums by duration, in durations corresponding to the expected loss ratios in section 52.40(d)(1)(x) of this Part. Approximations by duration may be used when included as part of the filing under section 52.40(d)(1) of this Part, or by separate prior approval;

(iv) paid losses;

(v) incurred losses;

(vi) the interest assumptions used in the applicable expected future loss ratio calculations; and

(vii) dividends incurred, as used in the policy experience exhibit.

Other than subparagraphs (vi) and (vii), the above terms are as defined in the current New York Instructions for Completion of the Life and Accident and Health Annual Statement. For policies issued on an attained age rating basis, or where benefits or premiums are changed at attained age 65, experience must be separately maintained for those under age 65 and age 65 and over. Experience, by age, need not be maintained for certain coverages, such as travel accident, with the prior consent of the superintendent.

(2) Combining experience. Experience under different policies where the coverage is substantially the same, and the premium rates are on a consistent basis, may be combined, but only with the prior consent of the superintendent.

(b) Standards for maintaining experience data for benefits under the Disability Benefits Law. Premium and loss data shall be maintained yearly:

(1) separately for each of the following categories:
(i) male vs. female; and

(ii) each premium basis the insurer has on file, including experience-rated vs. nonexperience-rated;

(2) for each of the following items:
(i) premium earned;

(ii) claims paid, by number, duration and amounts; and

(iii) claims incurred.

(c) Additional standards for maintaining data concerning those insured by and the benefits paid by long term care insurance, nursing home insurance only, home care insurance only, or nursing home and home care insurance should be as follows:

(1) for each insured:
(i) insured's identification number, such as policy or certificate number;

(ii) policy form number;

(iii) brief summary of the insured's benefits (including types of coverage provided, benefit amounts, elimination period, maximum benefit, inflation protection and nonforfeiture option);

(iv) whether this policy provides individual or family coverage;

(v) relationship of insured to policyholder or certificateholder;

(vi) date of issue;

(vii) sex;

(viii) date of birth;

(ix) risk classification (standard or substandard);

(x) current state of residence and zip code;

(2) for each claim:
(i) insured's identification number, such as policy or certificate number;

(ii) claim identification number;

(iii) claim incurral date;

(iv) claim termination date;

(v) paid claims by coverage type;

(vi) benefit days/visits by coverage type.

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