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 52.70 - Special rules for group, blanket and franchise insurance
Universal Citation: 11 NY Comp Codes Rules and Regs ยง 52.70
Current through Register Vol. 46, No. 39, September 25, 2024
(a) General rules for franchise insurance.
(1) The insurer may require evidence of
insurability as to each person to be insured.
(2) The insurer shall submit a statement as
to its rule, if any, with respect to the minimum participation requirement for
insuring all applicants without a statement of good health.
(3) The insurer's underwriting rules shall be
filed with the superintendent.
(4)
In the case of association franchise insurance, eligible members shall be
informed in writing of the sponsorship of the plan by the sponsoring
organization or by its representative, agent or trustee.
(5) Franchise policies approved prior to the
effective date of this Part may be used for new entrants to a franchise plan
existing prior to the effective date of this Part, provided that the
appropriate disclosure required by section
52.54(a) of this
Part is made with respect to such new entrant.
(b) Special Rules for employer-employee franchise.
(1) Eligible classes. The class or
classes of persons insured on the effective date of the plan shall consist of:
(i) not less than 2 nor more than 25
employees of an employer, except that in contributory cases 75 percent of the
number of eligible employees may not exceed 25. The term employees may include
officers and directors, partners, individual proprietors and retired
employees;
(ii) two or more
employees serving or employed in a governmental corporation, unit, department
or agency, including elected or appointed officials; or
(iii) groups of 25 or more employees where it
has been demonstrated to the satisfaction of the department that the franchise
insurance coverage actually supplements and does not substitute for group
coverage (including self-insurance).
(2) Participation requirements. All of the
employees or all of any class or classes thereof determined by conditions
pertaining to employment or such conditions, together with age or family
status, or both, or except those employees as to whom the evidence of
insurability submitted is not satisfactory to the insurer. If part or all of
the premium is contributed by the insured employees pursuant to payroll
deduction, such insurance may be provided if not less than 75 percent of all
eligible employees or not less than 75 percent of all eligible employees in any
class or classes are insured. However, with respect to the class of persons
insured under subparagraph (1)(ii) of this subdivision, where the employee pays
all of the premium, such insurance may be provided if not less than:
(i) 500 employees; or
(ii) 30 percent of the first 500 eligible
employees plus 10 percent of all eligible employees in excess of 500, whichever
is the lesser, participate unless the insurer individually underwrites all
applicants on the basis of either medical examination or a questionnaire
concerning the applicant's present health and medical history.
(c) Special rules for association franchise.
(1) Eligible classes.
The class or classes of persons insured on the effective date of the plan shall
consist of:
(i) 25 or more members of an
incorporated or unincorporated association having a constitution or bylaws,
where such association was formed and is maintained in good faith for purposes
other than that of obtaining insurance for its members, has been in active
existence for at least two years prior to the inception of the insurance of its
members, and consists of persons having the same or similar occupation or
profession;
(ii) not less than 4
nor more than 25 members of a labor union;
(iii) an association of civil service
employees, or employers of civil service employees;
(iv) groups of individuals, such as dairy
farmers, who supply or deliver materials, e.g., milk, to a central point of
collection.
(2)
Participation requirements.
(i) Not less than
500 members of an association of civil service employees, or 30 percent of the
first 500 eligible members thereof plus 10 percent of all eligible members in
excess of 500, whichever is the lesser, unless the insurer individually
underwrites all applicants on the basis of either medical examination or a
questionnaire concerning the applicant's present health and medical history,
but in no event shall the number of persons insured be less than 25.
(ii) Not less than 30 percent of the first
500 eligible suppliers plus 10 percent of the next 3,500 eligible suppliers,
unless the insurer individually underwrites all applicants on the basis of
either medical examination or a questionnaire concerning the applicant's
present health and medical history, but in no event shall the number of persons
insured be less than 25.
(3) Policies written on cases composed of
individuals who supply or deliver materials to a central point of collection
shall be predicated upon the deduction of premiums from the payments for the
materials supplied or delivered to the central point of collection and remitted
to the insurer by the person making such deductions.
(4) Premium payment may be on a contributory
or noncontributory basis.
(d) Blanket insurance.
(1) Blanket accident and blanket accident and
health insurance may be written for groups conforming to the requirements of
section
4237 (a)(3)(A) through
(F) of the Insurance Law. Blanket accident
and health insurance policies which provide hospital, surgical or medical
expense coverage shall insure all persons without evidence of insurability
provided that coverage is elected during an initial period of eligibility of at
least 30 days. Rules may be established limiting future enrollment to specified
time periods; however, such specified open enrollment time period for such
future enrollment must be provided at least once every 12 months for a period
of not less than 30 days. No enrollment limitation shall apply to enrollees who
apply for coverage under the conditions described in sections
3221
(q)(5) and
4305
(k)(5) of the Insurance Law.
(2) Blanket health insurance may be written
only for groups conforming to the requirements of section
4237 (a)(3)(C)
(E)-(F) of the Insurance Law.
(3) Common carriers, taxicab companies,
lessors of automobiles, innkeepers and other groups with a high degree of
potential customer liability shall be regarded under section
4237
(a)(3)(F)(i) of the Insurance Law as groups
substantially similar to groups specified under section
4237
(a)(3)(A) of the Insurance Law.
(4) Independent contractors engaged as
theatrical groups on tour, orchestras or bands on special engagements, and
professional athletes in specific events shall be regarded under section
4237
(a)(3)(F)(i) of the Insurance Law as
substantially similar to employee-employer groups under section
4237
(a)(3)(B) of the Insurance Law.
(5) Exceptional hazards under section
4237
(a)(3)(B) of the Insurance Law shall include
travel policies and policies covering hazardous sports. Coverage for dependents
may be included only where the dependent actually participates in the hazards
incident to the employment of the employee, as, for example, dependents
accompanying the employee on special trips associated with his
occupation.
(6) Under section
4237
(a)(3)(C) of the Insurance Law, a policy may
be issued to a school, school district, board of education or school principal
covering students and employees, and dependents (optional). Policies issued to
camps, covering campers, organizations sponsoring youth programs, covering
youth groups (e.g., boy scouts, girl scouts), youth sports groups or students
participating in special events, such as tours, shall be regarded as
substantially similar to the listed groups pursuant to section
4237
(a)(3)(F)(i) of the Insurance Law.
(7) Under section
4237
(a)(3)(D) of the Insurance Law, groups of
fire departments, auxiliaries, ambulance corporations, first aid rescue squads
and volunteer police departments will be considered as substantially similar to
the listed groups pursuant to section
4237
(a)(3)(F)(i) of the Insurance Law. Coverage
may be provided for any work connected with the activity for which the
organization was founded, including fund-raising drives and participation in
volunteer fire meets. Coverage for bystanders drafted into emergency service,
and members of other departments volunteering for emergency service may be
included.
(8) Nothing contained
herein shall preclude an application under section
4237
(a)(3)(F) of the Insurance Law for a
discretionary ruling of the superintendent regarding a substantially similar
group other than as described herein.
(9) Every insurer issuing school blanket
insurance policies pursuant to Insurance Law section 3221 shall send written
notice of the enactment of chapter 748 of the Laws of 2006 (commonly referred
to as "Timothy's Law") to all affected policyholders, certificateholders and
members. If permitted by the school blanket policy, insurers may provide notice
to the group policyholder for distribution to individual certificateholders but
shall be responsible for providing the notice. The notice shall be provided no
later than February 15, 2007. The notice shall:
(i) describe the key features of the benefits
required under chapter 748 of the Laws of 2006;
(ii) state that a formal contract or
certificate amendment shall be forthcoming that will explain the new benefits
in greater detail;
(iii) provide a
toll-free customer service telephone number that insureds may call to contact
the insurer with questions concerning the new law; and
(iv) advise the policyholders that their
premiums may be adjusted.
(e) Group insurance.
(1) No group policy replacing a plan of
similar benefits of another insurer or self-insurer shall be written unless all
persons of the same class insured under the prior plan are eligible without
evidence of individual insurability or restrictions as to preexisting
conditions, except those contained in the policy from which transfer is made to
the extent of the lesser of the prior coverage or the coverage provided under
the replacing plan.
(2) Except for
dental insurance, disability income insurance subject to section
3234 of the
Insurance Law as added by the Laws of 1993, chapter 650, insurance written
under section
4235
(c)(1)(H) of the Insurance Law (unless such
insurance is as described in paragraph [3] of this subdivision), and to the
extent that insurance written under section
4235 (c)(1)(B) and
(D) of the Insurance Law insures employees of
an employer with less than 300 employees (unless such insurance is as described
in paragraph [3] of this subdivision), any group policy insuring 300 or more
persons, excluding dependents, shall insure all persons without evidence of
individual insurability, provided that coverage is elected during an initial
period of eligibility of at least 30 days.
(3) Any group hospital, surgical or medical
expense insurance policy shall insure all persons without evidence of
insurability, provided that coverage is elected during an initial period of
eligibility of at least 30 days. Rules may be established limiting future
enrollment to specified time periods; however, such specified open enrollment
time period for such future enrollment must be provided at least once every 12
months for a period of not less than 30 days. No enrollment limitation shall
apply to enrollees who apply for coverage under the conditions described in
sections
3221
(q)(5) and
4305
(k)(5) of the Insurance Law.
(4) Where a group offers more than one health
care plan to its employees or members, rules may be established controlling the
transfer between the health care plans so long as transfer is permitted no less
than once each calendar year.
(5)
Every insurer, article 43 corporation and health maintenance organization (HMO)
shall send written notice of the enactment of chapter 748 of the Laws of 2006
to all affected group policyholders, certificateholders, and members. If
permitted by the group contract, an insurer, article 43 corporation or HMO may
provide notice to the group policyholder for distribution to individual
certificateholders and members, but such insurer, article 43 corporation or HMO
ultimately shall be responsible for providing the notice. The notice shall be
provided no later than February 15, 2007. The notice shall:
(i) describe the key features of the benefits
required pursuant to chapter 748 of the Laws of 2006;
(ii) state that a formal contract or
certificate amendment will be forthcoming that will explain the new benefits in
greater detail;
(iii) provide a
toll-free customer service telephone number that insureds may call to contact
the insurer, article 43 corporation, or HMO with questions concerning the new
law; and
(iv) advise the
policyholders that their premiums may be adjusted.
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.
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