Current through Register Vol. 46, No. 39, September 25, 2024
(a) No
individual accident and health insurance policy shall be delivered or issued
for delivery in this State, unless the appropriate disclosure form in sections
52.55 through
52.62 of this Part is completed as
to such policy and accompanies or is incorporated in such policy when
delivered, or unless such appropriate disclosure form is delivered to the
applicant at the time application is made and acknowledgment of receipt or
certification of delivery of such disclosure form is provided to the insurer.
The appropriate disclosure form for policies providing hospital coverage which
does not meet the standards of section
52.5 or
52.7 of this Part shall be that
statement contained in section
52.59 of this Part. The
appropriate disclosure form for policies providing coverage which meets the
standards of both sections
52.5 and
52.6 of this Part shall be the
statement contained in section
52.57 of this Part. The
appropriate disclosure form for policies providing coverage which meets the
standards of both sections
52.5 and
52.7 or sections
52.6 and
52.7 or sections
52.5,
52.6 and
52.7 shall be the statement
contained in section
52.58 of this Part.
(b) The expected benefit ratio required in
the statement contained in sections 52.55 through
52.61, 52.65 and
52.66 of this Part shall be:
(1) a number which is greater than or equal
to the applicable minimum loss ratio of section
52.45 of this Part, and is less
than or equal to the expected future loss ratio filed for the policy
form;
(2) where no expected future
loss ratio has been filed with a previously approved policy form, but an
anticipated loss ratio has been filed, a number which is greater than or equal
to the currently applicable minimum loss ratio and is less than or equal to the
anticipated loss ratio filed for the policy form;
(3) where no anticipated loss ratio or
expected future loss ratio has been filed with a previously approved policy
form, the minimum loss ratio permitted for the policy form as set forth in
section 52.45; and
(4) where different loss ratios are expected
for different classes within the same form, the limits specified in paragraphs
(1) through (3) of this subdivision, based on the expected aggregate premium of
all classes under the policy form.
(c) Except certificates providing coverage
under sections
52.12, 52.13 and
52.15 of this Part which are
subject to the disclosure requirements in sections 52.65 and
52.66 of this Part, no certificate
of insurance covering persons resident in this State shall be used in
conjunction with a group or blanket accident and health insurance policy
delivered or issued for delivery in this State unless incorporated in or
accompanied by:
(1) a synopsis of the
benefits, exclusions and limitations of the policy; and
(2) the appropriate disclosure statement or
statements as follows:
(i) Basic hospital
insurance. The insurance evidenced by this certificate meets the minimum
standards for basic hospital insurance as defined by the New York State
Insurance Department. It does NOT provide basic medical or major medical
insurance.
(ii) Basic medical
insurance. The insurance evidenced by this certificate meets the minimum
standards for basic medical insurance as defined by the New York State
Insurance Department. It does NOT provide basic hospital or major medical
insurance.
(iii) Major medical
insurance. The insurance evidenced by this certificate meets the minimum
standards for major medical insurance as defined by the New York State
Insurance Department. It does NOT provide basic hospital or basic medical
insurance.
(iv) Limited benefits
health insurance. The insurance evidenced by this certificate provides limited
benefits health insurance only. It does NOT provide basic hospital, basic
medical, major medical, Medicare supplement, long term care insurance, nursing
home insurance only, home care insurance only, or nursing home and home care
insurance as defined by the New York State Insurance Department.
(v) Disability income insurance. The
insurance evidenced by this certificate provides disability income insurance
only. It does NOT provide basic hospital, basic medical or major medical
insurance as defined by the New York State Insurance Department.
(vi) Accident insurance. The insurance
evidenced by this certificate provides ACCIDENT insurance only. It does NOT
provide basic hospital, basic medical or major medical insurance as defined by
the New York State Insurance Department.
IMPORTANT NOTICE - THIS POLICY DOES NOT PROVIDE COVERAGE
FOR SICKNESS.
(vii) Dental
insurance. The insurance evidenced by this certificate provides DENTAL
insurance only.
except that such statements may be made to conform to the
actual insurance provided where such insurance complies with more than one of
the definitions contained in sections 52.5 through
52.9 of this
Part.
(d)
(1) The
disclosure requirements in Insurance Law sections 3217-a(a)(1) through (6),
(9), (10), (15), (16), (17), (18), (19)(A) and (B), and (20); 3217-a(b)(1),
(2), (4), (5), (7), (8) if applicable, (10), (11), (13) and (14); 4324(a)(1)
through (6), (9), (10), (15), (16), (17), (19), (20)(A) and (B), and (21); and
4324-a(b)(1), (2), (4), (5), (7), (8) if applicable, (10), (11), (13) and (14)
shall apply to stand-alone dental insurance and standalone vision
insurance.
(2) In addition to the
disclosure requirements in paragraph (1) of this subdivision, the disclosure
requirements in Insurance Law section 3217-a(a)(7) and (11) through (13) and
Insurance Law section 4324(a)(7) and (11) through (13) shall apply to
stand-alone dental insurance and standalone vision insurance that meets the
definition of a "managed care product" in Insurance Law section
4801(c).
(3) This subdivision shall
apply to any policies issued, renewed, modified, or amended on or after one
year after the effective date of this section.
