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 52.7 - Major medical insurance
Current through Register Vol. 46, No. 39, September 25, 2024
Major medical insurance is an insurance policy which provides coverage for each covered person, to a maximum of not less than $100,000; copayment by the covered person not to exceed 25 percent; a deductible stated on a per-person, per-family, per-illness, per-benefit period, or per- year basis, or a combination of such bases, not to exceed five percent of the lowest overall maximum limit under the policy, unless the policy is written to complement underlying hospital and medical insurance, in which case such deductible may be increased by the amount of the benefits provided by such underlying insurance, for at least:
(a) daily room and board, as defined in section 52.5(a) of this Part;
(b) miscellaneous hospital services, as defined in section 52.5(b) of this Part; provided, however, that the maximum amount limitation shall not apply;
(c) surgical services, as defined in section 52.6(a) of this Part;
(d) anesthetic services, as defined in section 52.6(b) of this Part;
(e) in-hospital medical services, as defined in section 52.6(c) of this Part;
(f) mental health care consisting of coverage for diagnosis and treatment of mental illness for at least:
(g) out-of-hospital care, consisting of physicians' services rendered on an ambulatory basis, where coverage is not provided elsewhere in the policy, for diagnosis and treatment of sickness or injury, including the cost of drugs and medications available only on the prescription of a physician, and diagnostic X-ray, laboratory services, radiation therapy, chemotherapy and hemodialysis ordered by a physician; and
(h) prosthetic appliances, meaning artificial limbs or other prosthetic appliances (including replacements thereof which are functionally necessary), and rental or purchase (at insurer's option) of durable medical equipment required for therapeutic use, including repairs and necessary maintenance of purchased equipment, not otherwise provided for under a manufacturer's warranty or purchase agreement.