New York Codes, Rules and Regulations
Title 11 - INSURANCE
Chapter XI - Prepaid Legal Services Plans And Legal Services Insurance
Part 261 - Prepaid Legal Services Plans
Section 261.3 - Prepaid legal services plan policy and certificate provisions

Universal Citation: 11 NY Comp Codes Rules and Regs ยง 261.3

Current through Register Vol. 46, No. 12, March 20, 2024

(a) Every policy and certificate shall be subject to the filing and approval requirements of article 23 of the Insurance Law and shall not qualify as a special risk pursuant to Part 16 of this Title (Regulation 86).

(b) Every policy and certificate shall be written in a readable and understandable manner in accordance with section 3102 of the Insurance Law.

(c) Every policy and certificate shall contain the provisions specified in section 1116 of the Insurance Law and shall be subject to the requirements of that section.

(d)

(1) Every policy and certificate shall contain a detailed list and description of the legal services to be supplied or the legal matters for which expenses are to be covered or reimbursed and any limits on the amounts covered or reimbursed.

(2) Every policy and certificate shall indicate the name of the insurer and the full address of its principal place of business, the telephone number of the place where services can be requested, and the full address and telephone number of the place where the insured may file a claim.

(3) Every policy and certificate shall contain a provision that nothing in the plan shall be construed to limit the right of an insured to retain any attorney admitted to practice in the state where the legal service is being provided. The policy shall state that compensation by the plan for attorneys not participating in the plan shall be subject to the schedule of benefits and fee structure set forth in the applicable contract. The policy shall not prohibit an attorney who is not participating in the plan from charging a fee for services provided in excess of the schedule of benefits or fee structure set forth in the applicable contract.

(4) Every policy and certificate shall provide a procedure for prompt resolution of grievances concerning benefits.

(5) Every policy and certificate shall provide that nothing in the plan shall be construed to prevent an insured from making a complaint to the appropriate Appellate Division or other body designated by the Appellate Division to investigate complaints in accordance with Judiciary Law section 90, or to the appropriate disciplinary body in the state where the legal service is being provided.

(e)

(1) Every policy and certificate shall state that coverage shall be provided for costs incurred during the policy term and shall exclude services rendered prior to the effective date of the insured's coverage.

(2) Coverage of services ongoing at the time that coverage terminates shall be provided for an additional 90 days, except that in regard to legal services insurance coverage provided under the plan, the policy shall provide coverage in accordance with the provisions of Part 262 of this Title (Regulation 162).

(f) The insured shall not be indemnified for a greater sum than that of the costs actually incurred.

(g) A prepaid legal services plan may include legal services insurance as part of the plan, in accordance with the provisions of Part 262 of this Title (Regulation 162).

(h)

(1) A policy or certificate may contain a coordination of benefits (COB) provision. If a policy or certificate includes a COB provision it must comply with this subdivision. A policy or certificate that does not include a COB provision shall be considered to be primary and may not take the benefits of another policy into account when it determines its benefits, except as provided in paragraph (5) of this subdivision.

(2) For the purposes of this subdivision the term benefits shall mean the schedule of benefits and the fee structure required pursuant to subdivision (d) of this section.

(3) Order of benefit determination rule. The benefits of a policy which covers the insured as a group member are primary and determined before those of a policy which covers the insured as an individual or as a family member, which are secondary. In all other circumstances, the benefits of the policy which covered the insured longer are determined before those of the policy which covered the insured for the shorter time.

(4) A secondary policy may reduce either the benefits it must pay or the services it must provide by the amount of benefits paid or the services provided by all policies to which it is secondary.

(5) No policy may contain a provision that its benefits are excess or always secondary to a policy unless such policy is designed to supplement either an existing prepaid legal services plan policy, as provided in this Part, or an existing liability insurance policy that includes legal services insurance as a part thereof, written pursuant to Part 262 of this Title (Regulation 162).

(i)

(1) An individual policy may also provide coverage for a family member.

(2) A group policy may also provide coverage for a family member under a certificate issued to a group member.

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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