South Carolina Code of Regulations
Chapter 69 - DEPARTMENT OF INSURANCE
69-34 - Individual Accident and Health Insurance Minimum Standards.

Universal Citation: SC Code Regs 69-34

69-34. Individual Accident and Health Insurance Minimum Standards.

(Statutory Authority: 1976 Code ยงยง 1-23-10 et seq., 38-3-110(2), 38-71-530, 38-71-540, 38-71-550)

A. Table of Contents: B......Purpose

C......Applicability and Scope

D .....Effective Date

E......Policy Definitions

F......Prohibited Policy Provisions

G .....Accident and Health Minimum Standards for Benefits

H.....Required Disclosure Provisions

I......Severability

B. Purpose: The purpose of this regulation is to implement Section 38-71-510, et seq., so as to provide reasonable standardization and simplification of terms and coverages of individual accident and health insurance policies and individual subscriber contracts of hospital, medical and dental service corporations in order to facilitate public understanding and comparison and to eliminate provisions contained in individual accident and health insurance policies and individual subscriber contracts of hospital, medical, and dental service corporations which may be misleading or confusing in connection either with the purchase of such coverages or with the settlement of claims and to provide for full disclosure in the sale of such coverages.

C. Applicability and Scope: This Regulation shall apply to all individual accident and health insurance policies and individual subscriber contracts of hospital and medical and dental service corporations delivered or issued for delivery in this State, except that it shall not apply to individual policies or contracts issued pursuant to a conversion privilege under a policy or contract of group or individual insurance when such group or individual policy or contract includes provisions which are inconsistent with this Regulation, nor shall it apply to Medicare Supplement policies issued in accordance with Regulation 69-46. The requirements contained in this Regulation shall be in addition to any other applicable regulations promulgated by the Commissioner.

D. Effective Date: This Regulation shall become effective July 13, 1981.

E. Policy Definitions: Except as provided hereafter, no individual accident or health insurance policy or hospital, medical, or dental service corporation subscriber contract delivered or issued for delivery to any person in this state shall contain definitions respecting the matters set forth below unless such definitions comply with the requirements of this section.

(1) "One period of confinement" means consecutive days of in-hospital service received as an in-patient, or successive confinements when discharge from and re-admission for the same or related causes to the hospital occurs within a period of time not more than the greater of 90 days or three times the maximum number of days of in-hospital coverage provided by the policy to a maximum of 180 days.

(2) "Hospital" may be defined in relation to its status, facilities and available services or to reflect its accreditation by the Joint Commission on Accreditation of Hospitals.

(a) The definition of the term "hospital" shall not be more restrictive than one requiring that the hospital:

1. be an institution operated pursuant to law; and

2. be primarily and continuously engaged in providing or operating, either on its premises or in facilities available to the hospital on a prearranged basis and under the supervision of a staff of duly licensed physicians, medical, diagnostic and major surgical facilities for the medical care and treatment of sick or injured persons on an in-patient basis for which a charge is made; and

3. provide 24 hour nursing service by or under the supervision of registered graduate professional nurses (R.N.'s).

(b) The definition of the term "hospital" may state that such term shall not be inclusive of:

1. convalescent homes, convalescent, rest, or nursing facilities; or

2. facilities primarily affording custodial, educational or rehabilitory care; or

3. facilities for the aged, drug addicts or alcoholics; or

4. any military or veterans hospital or soldiers home or any hospital contracted for or operated by any national government or agency thereof for the treatment of members or ex-members of the armed forces, except for services rendered where a legal liability exists for charges made to the individual for such services.

(3) "Convalescent Nursing Home," "Extended Care Facility," or "Skilled Nursing Facility" shall be defined in relation to its status, facilities, and available services.

(a) A definition of such home or facility shall not be more restrictive than one requiring that it:

1. be operated pursuant to law;

2. be approved for payment of Medicare benefits or be qualified to receive such approval, if so requested;

3. be primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under the supervision of a duly licensed physician;

4. provide continuous 24 hours a day nursing service by or under the supervision of a registered graduate professional nurse (R.N.); and

5. maintain a daily medical record of each patient.

(b) The definition of such home or facility may provide that such term shall not be inclusive of:

1. any home, facility or part thereof used primarily for rest;

2. a home or facility for the aged or for the care of drug addicts or alcoholics; or

3. a home or facility primarily used for the care and treatment of mental diseases, or disorders, or custodial or educational care.

(4) "Accident," "Accidental Injury," "Accidental Means;" shall be defined to employ "result" language and shall not include words which establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characterization.

The definition shall not be more restrictive than the following: Injury or injuries, for which benefits are provided, means accidental bodily injury sustained by the insured person which is the direct cause of the loss, independent of disease or bodily infirmity or any other cause and which occurs while the insurance is in force.

Such definition may provide that injuries shall not include injuries for which benefits are provided under workmen's compensation, employer's liability or similar laws, motor vehicle no-fault plans, unless prohibited by law, or injuries occurring while the insured person is engaged in any activity pertaining to any trade, business, employment, or occupation for wage or profit.

(5) Except as provided in F(1), "Sickness" shall not be defined to be more restrictive than the following: Sickness means sickness or disease of an insured person which first manifests itself after the effective date of insurance and while the insurance is in force. A definition of sickness may provide for a probationary period which will not exceed thirty (30) days from the effective date of the coverage of the insured person. The definition may be further modified to exclude sickness or disease for which benefits are provided under any workman's compensation, occupational disease, employer's liability or similar law.

(6) "Pre-existing condition" shall not be defined to be more restrictive than (a) or (b) as stated below. (a) shall apply where the insurer uses an application form designed to elicit the complete health history of a prospective insured and, on the basis of the answers on that application, underwrites in accordance with the insurer's established standards. (b) shall apply where the insurer elects to use a simplified application, with or without a question as to the applicant's health at the time of application, or elects not to use any application.

(a) A condition misrepresented or not revealed in the application and for which symptoms existed prior to the effective date of coverage that would cause an ordinarily prudent person to seek diagnosis, care or treatment or for which medical advice or treatment was recommended by or received from a physician.

(b) A condition for which symptoms existed which would cause an ordinarily prudent person to seek diagnosis, care or treatment within a one (1) year period preceding the effective date of the coverage of the insured person or a condition for which medical advice or treatment was recommended by a physician or received from a physician within a five (5) year period preceding the effective date of the coverage of the insured person.

(7) "Physician" may be defined by including words such as "duly qualified physician" or "duly licensed physician." However, the use of such terms may not exclude payment or reimbursement otherwise provided by the policy which is performed by a duly licensed podiatrist, chiropractor or oral surgeon when he is acting within his legal scope of practice.

(8) "Nurse" may be defined so that the description of nurse is restricted to a type of nurse, such as registered graduate professional nurse (R.N.), a licensed practical nurse (L.P.N.), or a licensed vocational nurse (L.V.N.). If the words "nurse," "trained nurse" or "registered nurse" are used without specific instruction, then the use of such terms requires the insurer to recognize the services of any individual who qualifies under such terminology in accordance with the applicable statutes or administrative rules of the licensing or registry board of the state.

(9) Total Disability:

(a) "Total Disability" shall not be defined more restrictively than the inability of the insured to engage in his own occupation during the first year of disability or for the length of the benefit period if less than one year. After the first year of disability, total disability may be defined as the complete inability of the insured to engage in any employment or occupation for which the insured is qualified by reason of education, training or experience. The definition of such word may allow the insurer to require reasonable conditions that the insured not be in fact engaged in any occupation for wage or profit.

(b) Total disability may be defined in relation to the inability of the person to perform duties but may not be based solely upon an individual's inability to: (a) Perform "any occupation whatsoever," "any occupational duty," or "any and every duty of his occupation," or (b) Engage in any training or rehabilitation program.

(c) An insurer may specify the requirement of the complete inability of the person to perform all of the substantial and material duties of his regular occupation or words of similar import. An insurer may require care by a physician (other than the insured or a member of the insured's immediate family).

(10) "Partial Disability" shall be defined in relation to the individual's inability to perform one or more but not all of the "major," "important," or "essential" duties of employment or occupation or may be related to a "percentage" of time worked or to a "specified number of hours" or to "compensation." Where a policy provides total disability benefits and partial disability benefits, only one elimination period may be required.

(11) "Residual Disability" shall be defined in relation to the individual's reduction in earnings and may be related either to the inability to perform some part of the "major," "important," or "essential duties" of employment or occupation, or to the inability to perform all usual business duties for as long as is usually required. A policy which provides for residual disability benefits may require a qualification period, during which the insured must be continuously totally disabled before residual disability benefits are payable. The qualification period for residual benefits may be longer than the elimination period for total disability. In lieu of the term "residual disability," the insurer may use "proportionate disability" or other term of similar import which in the opinion of the Commissioner adequately and fairly describes the benefit.

(12) "Medicare" shall be defined in any hospital, surgical or medical expense policy which relates its coverage to eligibility for Medicare or Medicare benefits. Medicare may be substantially defined as "The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended," or "Title I, Part I of Public Laws 89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act," as then constituted and any later amendments or substitutes thereof" or words of similar import.

(13) "Mental or Nervous Disorders" shall not be defined more restrictively than a definition including neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind.

F. Prohibited Policy Provisions and Practices.

(1) No policy shall contain provisions establishing a probationary or waiting period during which no coverage is provided under the policy subject to the further exception that a policy may specify a probationary or waiting period not to exceed six (6) months for specified diseases or conditions and losses resulting therefrom for hernia, disorder of reproduction organs, varicose veins, adenoids, appendix, tonsils, hemorrhoids and piles. However, the permissible six (6) months exception shall not be applicable where such specified diseases or conditions are treated on an emergency basis and if there is no previous medical history of the condition which predates the policy. Accident policies shall not contain probationary or waiting periods.

(2) No policy or rider for additional coverage may be issued as a dividend unless an equivalent cash payment or reduction in premium is offered to the policyholder as an alternative to such dividend policy or rider. No such dividend policy or rider shall be issued for an initial term of less than 6 months. This provision shall not be so construed as to prevent an insurer from voluntarily endorsing a policy so as to increase all future benefits without an increase in premium.

The initial renewal subsequent to the issuance of any policy or rider as a dividend shall clearly disclose that the policyholder is renewing the coverage that was provided as a dividend for the previous term and that such renewal is optional with the policyholder.

(3) A policy which is non-cancellable or guaranteed renewable may contain a "return of premium" or "cash value" benefit so long as: (1) such return of premium or cash value benefit is not reduced by an amount greater than the aggregate of any claims paid under the policy; and (2) the insurer demonstrates that the reserve basis for such policies is adequate. No other policy shall provide a return of premium or cash value benefit, except return of unearned premium upon termination or suspension of coverage, retroactive waiver of premium paid during disability, payment of dividends on participating policies, or experience rating refunds.

(4) Notwithstanding the permissible definition of hospital in Section E(2)(b)4., a hospital confinement indemnity policy shall not exclude coverage merely because of confinement in any government related hospital.

(5) A policy issued to a person eligible for Medicare by reason of age may not have limitations or exclusions more restrictive than those of Medicare for any type of coverage under such policies.

(6) No policy shall limit or exclude coverage by type of illness, accident, treatment, or medical condition more stringent than the following:

(a) Pre-existing conditions or diseases, except for congenital anomalies of a covered dependent child;

(b) mental or emotional disorders, alcoholism and drug addiction;

(c) normal pregnancy and childbirth except for Disability Income policies defined in section G(6) of this regulation;

(d) illness, accident, treatment or medical condition arising out of:

1. war or act of war (whether declared or undeclared); participation in a felony, riot or insurrection; service in the armed forces or units auxiliary thereto,

2. suicide, sane or insane, attempted suicide or intentionally self-inflicted injury,

3. aviation,

4. with respect to short-term nonrenewable policies, interscholastic sports;

(e) cosmetic surgery, except that "cosmetic surgery" shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child which has resulted in a functional defect;

(f) foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, or symptomatic complaints of the feet;

(g) care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion, or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of, or in the vertebral column;

(h) treatment provided in a government hospital (except a hospital confinement policy); benefits provided under Medicare or other governmental program (except Medicaid), any state or federal workmen's compensation, employers liability or occupational disease law, any motor vehicle no-fault law; services rendered by employees of hospitals, laboratories or other institutions; services performed by a member of the covered person's immediate family; and services for which no charge is normally made in the absence of insurance;

(i) dental care or treatment

(j) eye glasses, hearing aids and examination for the prescription or fitting thereof; (k) rest cures, custodial care, transportation and routine physical examinations; (l ) territorial limitations.

(7) Other provisions of this regulation shall not impair or limit the use of waivers to exclude, limit or reduce coverage or benefits for specifically named or described pre-existing diseases, physical condition or extra hazardous activity. Where waivers are required as a condition of insurance, renewal or reinstatement, signed acceptance by the insured is required unless on initial issuance the full text of the waiver is contained either on the first page or specification page of the policy or unless notice of the waiver appears on the first page or specification page.

(8) Policy provisions precluded in this section shall not be construed as a limitation on the authority of the Commissioner to disapprove other policy provisions in accordance with Section 38-71-530(b) which, in the opinion of the Commissioner, are unjust, unfair, misleading, or unfairly discriminatory to the policyholder, beneficiary, or any person insured under the policy.

(9) No policy shall include a provision which gives the insurer an unconditional right of non-renewal.

(10) No policy shall exclude coverage for a loss due to a pre-existing condition for a period greater than 12 months following policy issue where the application for such insurance does not seek disclosure of prior illness, disease or physical conditions or prior medical care and treatment and such pre-existing condition is not specifically excluded by the terms of the policy.

G. Accident and Health Minimum Standards for Benefits.

The following minimum standards for benefits are prescribed for the categories of coverage noted in the following subsections. No individual policy of accident and health insurance or non-profit hospital, medical or dental service corporation contract shall be delivered or issued for delivery in this state which does not meet the required minimum standards for the specified categories unless the Commissioner finds that such policies or contracts serve a valid economic and social purpose and are approvable as Limited Benefit Health Insurance and the Outline of Coverage complies with the appropriate outline in section H(11) of this Regulation. Each such policy shall contain the words

"LIMITED BENEFITS" or "LIMITED OR SUPPLEMENTAL BENEFITS" prominently displayed on the first page of the policy in boldface type or contrasting color.

Nothing in this section shall preclude the issuance of any policy or contract combining two or more categories of coverage set forth in Section 38-71-540(a).

(1) General Rules

(a) A "noncancellable," "guaranteed renewable," or "noncancellable and guaranteed renewable" policy shall not provide for termination of coverage of the spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than nonpayment of premium. The policy shall provide that in the event of the insured's death the spouse of the insured, if covered under the policy, shall have the right to continue coverage previously afforded by the policy and exercise any rights previously vested in the insured.

(b) "Guaranteed renewable insurance" means all individual insurance which grants an insured the right to continue the policy in force by the timely payment of premiums until at least age 65 or to eligibility for Medicare during which period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force, except that the insurer may make changes in premium rates by classes except that the Commissioner may disapprove such increase in rates if he determines that the benefits provided in such policies are unreasonable in relation to the premium to be charged after the increase.

(c) "Noncancellable insurance" or "noncancellable and guaranteed renewable insurance" means all individual insurance which gives the insured the right to continue the insurance in force by the timely payment of premiums set forth in the policy until at least age 65 or to eligibility for Medicare during which period the insurer has no right to make unilaterally any change in any provision of the policy while it is in force.

(d) "Nonrenewable for stated reasons only" or "Conditionally Renewable" means all individual insurance which limits the insurer's right of nonrenewal to reasons stated in the policy. The following are acceptable reasons, except that reasons 2 and 3 shall not be included in the same policy:

1. overinsurance in accordance with insurer's standards on file with the Commissioner;

2. discontinuance of all policies in the same class;

3. discontinuance of all policies issued on the same form in this State;

4. change of the insured's occupation to an occupation classified as more hazardous than the original occupation.

5. any other factor which would qualify as a valid and generally accepted insurance underwriting basis.

(e) In a policy covering both husband and wife the age of the younger spouse must be used as the basis for meeting the age and durational requirements of the definitions of "noncancellable" or "guaranteed renewable." However, this requirement shall not prevent termination of coverage of the older spouse upon attainment of the stated age limit (e.g., age 65) so long as the policy may be continued in force as to the younger spouse to the age or for the durational period as specified in said definition.

(f) When accidental death and dismemberment coverage is part of the insurance coverage offered under the contract, the insured shall have the option to include all insureds under such coverage and not just the principal insured.

(g) If a policy contains a status type military service exclusion or a provision which suspends coverage during military service, the policy shall provide, upon receipt of written request, for refund of premiums as applicable to such persons on a pro rata basis.

(h) In the event the insurer cancels, or refuses to renew, policies providing pregnancy benefits, the policy shall provide for an extension of benefits as to pregnancy commencing while the policy is in force and for which benefits would have been payable had the policy remained in force.

(i) Policies providing convalescent or extended care benefits following hospitalization shall not condition such benefits upon admission to the convalescent or extended care facility within a period of less than fourteen (14) days after discharge from the hospital.

(j) Family coverage shall continue for any dependent child who is incapable of self sustaining employment due to intellectual disability or physical handicap on the date that such child's coverage would otherwise terminate under the policy due to the attainment of a specified age limit for children and is chiefly dependent on the insured for support and maintenance. The policy may require that within 31 days of such date the company receive due proof of such incapacity in order for the insured to elect to continue the policy in force with respect to such child, or that a separate converted policy be issued at the option of the insured or policyholder.

(k) Any policy providing medical expense coverage for the recipient in a transplant operation shall also provide reimbursement of any medical expenses of a live donor to the extent that benefits remain and are available under the recipient's policy, after benefits for the recipient's own expenses have been paid.

(l ) A policy may contain a provision relating to recurrent disabilities; provided however, that no such provision shall specify that a recurrent disability be separated by a period greater than six (6) months.

(m) Accidental death and dismemberment benefits shall be payable if the loss occurs within ninety (90) days from the date of the accident, irrespective of total disability. Disability income benefits due to accident, if provided, shall not require the loss to commence less than thirty (30) days after the date of accident, nor shall any policy which the insurer cancels or refuses to renew require that it be in force at the time disability commences if the accident occurred while the policy was in force.

(n) Specific dismemberment benefits shall not be in lieu of other benefits unless the specific benefit equals or exceeds the other benefits.

(o) A company may not refuse to refund unearned premiums during a term for which premiums are paid. It may, however, base the amount of refund on a mode of premium payment more frequent than that of the term paid.

(p) Any accident-only policy providing benefits which vary according to the type of accidental cause shall prominently set forth in the outline of coverage the circumstances under which benefits are payable which are lesser than the maximum amount payable under the policy.

(q) Termination of the policy shall be without prejudice to losses incurred for "one period of confinement", as defined, or to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period the policy was in force may be predicated upon the continuous disability of the insured, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits.

(2) Basic Hospital Expense Coverage: "Basic Hospital Expense Coverage" is a policy of accident and health insurance which provides coverage for a period of not less than thirty-one (31) days during any continuous hospital confinement for each person insured under the policy, for expense incurred for necessary treatment and services rendered as a result of accident or sickness for at least the following:

(a) daily hospital room and board in an amount not less than the lesser of 80% of the charges for semi-private room accommodations or $30.00 per day;

(b) miscellaneous hospital services for expenses incurred for the charges made by the hospital for services and supplies which are customarily rendered by the hospital and provided for use only during any one period of confinement in an amount not less than the lesser of (i) 80% of the charges incurred up to at least $1,000.00 or (ii) ten times the daily hospital room and board benefits;

(c) hospital outpatient services consisting of hospital services on the day surgery is performed, hospital services rendered within 72 hours after accidental injury, in an amount not less than $50, and X-ray and laboratory tests to the extent that benefits for such services would have been provided if rendered to an in-patient of the hospital in an amount not less than $100; and

(d) benefits provided under (a) and (b) of (2) above, may be provided subject to a combined deductible amount not in excess of $100.00.

(3) Basic Medical-Surgical Expense Coverage: "Basic Medical-Surgical Expense Coverage" is a policy of accident and health insurance which provides coverage for each person insured under the policy for the expenses incurred for the necessary services rendered by a physician for treatment of an injury or sickness for at least the following:

(a) Surgical Services:

1. in amounts not less than those provided on a fee schedule based on the relative values contained in the state of New York certified surgical fee schedule, or the 1964 California Relative Value Schedule or other acceptable relative value scale or surgical procedures, up to a maximum of at least $500.00 for any one procedure; or

2. not less than 80% of the reasonable charges.

(b) Anesthesia services, consisting of administration of necessary general anesthesia and related procedures in connection with covered surgical service rendered by a physician other than the surgeon or the assistant surgeon performing the surgical services:

1. in an amount not less than 80% of the reasonable charges; or

2. 15% of the surgical service benefit.

(c) In-hospital medical services, consisting of physician services rendered to a person who is a bed patient in a hospital for treatment of sickness or injury other than that for which surgical care is required, in an amount not less than 80% of the reasonable charges; or $5.00 per day for not less than twenty-one (21) days during one period of confinement.

(4) Hospital Confinement Indemnity Coverage: "Hospital Confinement Indemnity Coverage" is a policy of accident and health insurance which provides daily benefits for hospital confinement on an indemnity basis in an amount not less than $30.00 per day and not less than thirty-one (31) days during any one period of confinement for each person insured under the policy.

(5) Major Medical Expense Coverage: ' 'Major Medical Expense Coverage" is an accident and health insurance policy which provides hospital, medical and surgical expense coverage, to an aggregate maximum of not less than $20,000.00; copayment by the covered person not to exceed 25% of covered charges; 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 5% of the aggregate 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 to the amount of the benefits provided by such underlying insurance, for each covered person for at least:

(a) Daily hospital room and board expenses, prior to application of the copayment percentage, for not less than $70.00 daily (or in lieu thereof the average daily cost of semiprivate room rate in the area where the insured resides) for a period of not less than 31 days during continuous hospital confinement;

(b) miscellaneous hospital services, prior to application of the copayment percentage, for an aggregate maximum of not less than $1,500 or 15 times the daily room and board rate if specified in dollar amounts;

(c) surgical services, prior to application of copayment percentage to a maximum of not less than $600 for the most severe operation with the amounts provided for other operations reasonably related to such maximum amount;

(d) anesthesia services prior to application of the copayment percentage, for a maximum of not less than 15 percent of the covered surgical fees or, alternatively, if the surgical schedule is based on relative values, not less than the amount provided therein for anesthesia services at the same unit value as used for the surgical schedule;

(e) in-hospital medical services, prior to application of the copayment percentage, as defined in subdivision (3)(c) of G.

(f) out-of-hospital care prior to application of the copayment percentage, 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, and diagnostic X-ray, laboratory services, radiation therapy, and hemodialysis ordered by a physician; and

(g) not fewer than three of the following additional benefits, prior to application of the copayment percentage, for an aggregate maximum of such covered charges of not less than $1,000:

1. In-hospital private duty graduate registered nurse services.

2. Convalescent nursing home care.

3. Diagnosis and treatment by a radiologist or physiotherapist.

4. Rental of special medical equipment, as defined by the insurer in the policy.

5. Artificial limbs or eyes, casts, splints, trusses or braces.

6. Treatment for functional nervous disorders, and mental and emotional disorders.

7. Out-of-hospital prescription drugs and medications.

(6) Disability Income Protection Coverage-This section does not apply to those policies providing business buyout coverage.

"Disability Income Protection Coverage" is a policy which provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from either sickness or injury or a combination thereof which:

(a) Provides that periodic payments which are payable at ages after 62 and reduced solely on the basis of age are at least 50% of amounts payable immediately prior to 62.

(b) Contains an elimination period no greater than:

1. Ninety (90) days in the case of a coverage providing a benefit of one (1) year or less;

2. One hundred and eighty (180) days in the case of coverage providing a benefit of more than one year but not greater than two (2) years; or

3. Three hundred sixty five (365) days in all other cases during the continuance of disability resulting from sickness or injury.

(c) Has a maximum period of time for which it is payable during disability of at least six (6) months except in the case of a policy covering disability arising out of pregnancy, childbirth, or miscarriage in which case the period for such disability may be one (1) month. No reduction in benefits shall be put into effect because of an increase in Social Security or similar benefits during a benefit period.

(7) Accident Only Coverage: "Accident Only Coverage" is a policy of accident insurance which provides coverage, singly or in combination, for death, dismemberment, disability, or hospital and medical care caused by accident. Accidental death and double dismemberment amounts under such a policy shall be at least $1,000.00 and a single dismemberment amount shall be at least $500.00.

(8) Specified Disease and Specified Accident Coverage

(a) "Specified disease coverage" pays benefits for the diagnosis and/or treatment of a specifically named disease or diseases. Any such policy must meet the following general rules of subsection 1. In addition, policies providing coverage on an expense-incurred basis must meet the standards of subsection 2, while policies providing coverage on an indemnity basis must meet the standards of subsection 3.

1. General Rules.

The following rules shall apply to specified-disease coverages in addition to all other rules imposed by this regulation; in cases of conflict between the following and other rules, the following ones shall govern:

(i) Policies covering a single specified disease or combination of specified diseases may not be sold or offered for sale other than as specified-disease coverage under this section.

(ii) Any policy issued pursuant to this section which conditions payment upon pathological diagnosis of a covered disease, shall also provide that if such a pathological diagnosis is medically inappropriate, a clinical diagnosis will be accepted in lieu thereof.

(iii) Notwithstanding any other provision of this regulation, specified-disease policies shall provide benefits to any covered person not only for the specified disease(s) but also for any other condition(s) or disease(s), directly caused or aggravated by the specified disease(s) or the treatment of the specified disease(s).

(iv) Policies containing specified disease coverage shall be at least Guaranteed Renewable.

(v) No policy issued pursuant to this section shall contain a waiting or probationary period greater than thirty (30) days.

(vi) Payments may be conditioned upon a covered person's receiving medically necessary care, given in a medically appropriate location, under a medically accepted course of diagnosis or treatment.

(vii) Except for the uniform provision regarding other insurance with this insurer, benefits for specified disease coverage shall be paid regardless of other coverage.

(viii) After the effective date of the coverage (or applicable waiting period, if any) benefits shall begin with the first day of care or confinement if such care or confinement is for a covered disease even though the diagnosis is made at some later date. The retroactive application of such coverage may not be less than forty-five (45) days prior to such diagnosis.

2. Expense-Incurred Policies.

(i) Coverage must be provided for each person insured under the policy for a specifically named disease (or diseases) with a deductible amount not in excess of $250.00 and an overall aggregate benefit limit of no less than $10,000 and a benefit period of not less than two (2) years for at least the following incurred expenses with no unreasonable inside limits:

(A) Hospital room and board and any other hospital furnished medical services or supplies;

(B) Treatment by a legally qualified physician or surgeon;

(C) Private duty services of a registered nurse (R.N.);

(D) X-ray, radium and other therapy procedures used in diagnosis and treatment;

(E) Professional ambulance for local service to or from a local hospital;

(F) Blood transfusions, including expense incurred for blood donors;

(G) Drugs and medicines prescribed by a physician;

(H) The rental of an iron lung or similar mechanical apparatus;

(I) Braces, crutches and wheel chairs as are deemed necessary by the attending physician for the treatment of the disease;

(J) Emergency transportation if in the opinion of the attending physician it is necessary to transport the insured to another locality for treatment of the disease.

(ii) The policy may include coverage of any other expenses necessarily incurred in the treatment of the disease.

3. Indemnity Policies.

Coverage must be provided for each person insured under the policy for a specifically named disease (or diseases) with no deductible amount, and an overall aggregate benefit limit of not less than $25,000 payable at a daily rate not expected to produce a claim payment less than that which would be produced by a policy paying $50 a day while confined in a hospital with a benefit period of 500 days.

(b) "Specified Accident Coverage" is an accident insurance policy which provides coverage for a specifically identified kind of accident (or accidents) for each person insured under the policy for accidental death or accidental death and dismemberment, combined with a benefit amount not less than $1,000.00 for accidental death, $1,000.00 for double dismemberment and $500.00 for single dismemberment.

(9) Limited Benefit Health Insurance Coverage: "Limited Benefit Health Insurance Coverage" is any policy or contract, other than a policy or contract covering only a specified disease or diseases, which provides benefits that are less than the minimum standards for benefits required under G(2), (3), (4), (5), (6), (7), and (8). A policy covering a single specified disease or combination of diseases shall meet the requirements of Section G(8) and shall not be offered for sale as a "Limited Coverage." Limited benefit policies or contracts may be delivered or issued for delivery in this state only if the outline of coverage required by Section H(11) of this Regulation is completed and delivered as required by Section H(2) of this Regulation.

H. Required Disclosure Provisions.

(1) General Rules

(a) Each individual policy of accident and health insurance or hospital, medical or dental service corporation subscriber contract shall include a renewal, continuation, or nonrenewal provision. The language or specifications of such provision must be consistent with the type of contract to be issued. Such provision shall be appropriately captioned, shall appear on the first page of the policy, and shall clearly state the duration of renewability and the duration of the term of coverage for which the policy is issued and for which it may be renewed.

(b) Except for riders or endorsements by which the insurer effectuates a request made in writing by the policyholder or exercises a specifically reserved right under the policy, all riders or endorsements added to a policy after date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require signed acceptance by the policyholder. After date of policy issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term must be agreed to in writing signed by the insured, unless the increased benefits or coverage is required by law.

(c) Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, such additional premium charge shall be clearly set forth separately in the policy or on the rider.

(d) A policy which provides for the payment of benefits based on standards described as "usual and customary," "reasonable and customary," or words of similar import shall include a definition of such terms and an explanation of such terms in its accompanying outline of coverage.

(e) If a policy contains any limitations with respect to pre-existing conditions such limitations must appear as a separate paragraph of the policy and be labeled as "Pre-existing Condition Limitations."

(f) Each accident only policy or a policy providing benefits for a specified disease only shall contain an appropriate prominent statement on the first page of the policy in boldface type or in contrasting color similar to the following, whichever is appropriate:

1. This is an accident only policy which does not pay benefits for a loss from sickness.

2. This is a specified disease policy which only provides benefits for a loss due to__It does not provide benefits for any other sickness or condition.

(g) All policies, except trip or travel ticket policies and as otherwise provided in this paragraph, shall have a notice prominently printed on the first page of the policy or attached thereto stating in substance that the policyholder shall have the right to return the policy within ten (10) days of its delivery and to have the premium refunded if, after examination of the policy, the policyholder is not satisfied for any reason. With respect to policies issued pursuant to a direct response solicitation, the policy shall have a notice prominently printed on the first page of the policy or attached thereto stating in substance that the policyholder shall have the right to return the policy within thirty (30) days of its delivery and to have the premium refunded if, after examination of the policy, the policyholder is not satisfied for any reason.

(h) If age is to be used as a determining factor for reducing the maximum aggregate benefits made available in the policy as originally issued, such fact must be prominently set forth in the outline of coverage.

(i) If a policy contains a conversion privilege, it shall comply, in substance, with the following: the caption of the provision shall be "Conversion Privilege," or words of similar import. The provision shall indicate the persons eligible for conversion, the circumstances applicable to the conversion privilege, including any limitations on the conversion, and the person by whom the conversion privilege may be exercised. The provision shall specify the benefits to be provided on conversion or may state that the converted coverage will be as provided on a policy form then being used by the insurer for that purpose.

(j) Insurers issuing policies which provide hospital or medical expense coverage on either an expense incurred or indemnity basis to person(s) eligible for Medicare by reason of age, shall provide to the policyholder a medicare supplement buyer's guide in a form approved by the Commissioner. Delivery of the buyer's guide shall be made whether or not the policy qualifies as a medicare supplement coverage under Regulation 69-46. Except in the case of direct response insurers, delivery of the buyer's guide shall be made at the time of application, and acknowledgment of receipt or certification of delivery of the buyer's guide shall be provided to the insurer. Direct response insurers shall deliver the buyer's guide upon prior request but not later than at the time the policy is delivered. (NOTE: The NAIC Model Buyer's Guide is acceptable. Any substantially equivalent Buyer's Guide which has been approved by the Insurance Department of any other state may be used upon prior approval by the Commissioner.)

(k) Outlines of coverage delivered in connection with policies defined in this Regulation as Hospital Confinement Indemnity (G(4)), Specified Disease (G(8)), or Limited Benefit Health Insurance Coverages (G(9)) to persons eligible for Medicare by reason of age shall contain, in addition to the requirements of subsections H(6), H(10), and H(11), the following language which shall be printed on or attached to the first page of the outline of coverage:

This policy IS NOT A MEDICARE SUPPLEMENT policy. If you are eligible for Medicare, review the Medicare Supplement Buyer's Guide furnished by the company. (2) Outline of Coverage Requirements for Individual Coverages: No individual accident and health insurance policy or non-profit hospital, medical or dental service corporation subscriber contract subject to this regulation shall be delivered or issued for delivery in this State unless an appropriate outline of coverage, as prescribed in Section H(3) through (11) is completed as to such policy or contract, and the outline is either: (a) delivered with the policy; or (b) delivered to the applicant at the time application is made and acknowledgment of receipt or certification of delivery of such outline of coverage is provided to the insurer.

(a) for policies offered for sale as Medicare Supplement Coverage the outline is delivered to the applicant at the time application is made and, except for the direct response policy, acknowledgment of receipt or certification of delivery of such outline of coverage is provided to the insurer; and

(b) for all other policies, the outline is either:

1. delivered with the policy; or

2. delivered to the applicant at the time application is made and acknowledgment of receipt or certification of delivery of such outline of coverage is provided to the insurer.

If an outline of coverage was delivered at the time of application and the policy or contract is issued on a basis which would require revision of the outline, a substitute outline of coverage properly describing the policy or contract must accompany the policy or contract when it is delivered and contain the following statement, in no less than twelve (12) point type, immediately above the company name: "NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued."

The appropriate outline of coverage for policies or contracts providing hospital coverage which only meets the standards of section G(2) shall be that statement contained in section H(3). The appropriate outline of coverage for policies providing coverage which meets the standards of both sections G(2) and (3) shall be the statement contained in section H(5). The appropriate outline of coverage for policies providing coverage which meets the standards of both sections G(2) and (5) or sections G(3) and (5) or sections G(2), (3), and (5) shall be the statement contained in section H(7).

An appropriate outline of coverage will be filed with each policy submitted for approval. In any case where the prescribed outline of coverage is inappropriate for the coverage provided by the policy or contract, an alternate outline of coverage shall be submitted to the Commissioner for prior approval.

(3) Basic Hospital Expense Coverage (Outline of Coverage): An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of section G(2) of this Regulation. The items included in the outline of coverage must appear in the sequence prescribed:

COMPANY NAME AND ADDRESS

LOCAL TELEPHONE NUMBER: _(if available)_

BASIC HOSPITAL EXPENSE COVERAGE Policy Form Number_

OUTLINE OF COVERAGE

(a) Read Your Policy Carefully-This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!

(b) Basic Hospital Expense Coverage-Policies of this category are designed to provide, to persons insured, coverage for hospital expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, and hospital out-patient services, subject to any limitations, deductibles and copayment requirements set forth in the policy. Coverage is not provided for physicians or surgeons fees or unlimited hospital expenses.

(c) (A brief specific description of the benefits, including dollar amounts and number of days duration where applicable, contained in this policy, in the following order:

1. daily hospital room and board;

2. miscellaneous hospital services;

3. hospital out-patient services; and

4. other benefits, if any.)

(Note: The above description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provision applicable to the benefits described.)

(d) (A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described in (c) above.)

(e) (A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.)

(4) Basic Medical-Surgical Expense Coverage (Outline of Coverage): An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of section G(3) of this Regulation. The items included in the outline of coverage must appear in the sequence prescribed:

COMPANY NAME AND ADDRESS

LOCAL TELEPHONE NUMBER: _(if available)_

BASIC MEDICAL-SURGICAL EXPENSE COVERAGE Policy Form Number_

OUTLINE OF COVERAGE

(a) Read Your Policy Carefully-This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control your policy. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!

(b) Basic Medical-Surgical Expense Coverage-Policies of this category are designed to provide, to persons insured, coverage for medical-surgical expenses incurred as a result of a covered accident or sickness. Coverage is provided for surgical services, anesthesia services, and in-hospital medical services, subject to any limitations, deductibles and copayment requirements set forth in the policy. Coverage is not provided for hospital expenses in unlimited medical-surgical expenses.

(c) (A brief specific description of the benefits, including dollar amounts and number of days duration where applicable, contained in this policy, in the following order:

1. surgical services;

2. anesthesia services;

3. in-hospital medical services; and

4. other benefits, if any.)

(Note: The above description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provisions applicable to the benefits described.)

(d) (A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described in (3) above.)

(e) (A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.)

(5) Basic Hospital and Medical Surgical Expense Coverage (Outline of Coverage): An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of section G(2) and (3) of this Regulation. The items included in the outline of coverage must appear in the sequence prescribed.

COMPANY NAME AND ADDRESS

LOCAL TELEPHONE NUMBER: _(if available)_

BASIC HOSPITAL AND MEDICAL SURGICAL EXPENSE COVERAGE

Policy Form Number_

OUTLINE OF COVERAGE

(a) Read Your Policy Carefully-This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOU POLICY CAREFULLY!

(b) Basic Hospital and Medical Surgical Expense Coverage-Policies of this category are designed to provide, to persons insured, coverage for hospital and medical-surgical expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, hospital out-patient services, surgical services, anesthesia services, and in-hospital medical services, subject to any limitations, deductibles and copayment requirements set forth in the policy. Coverage is not provided for unlimited hospital or medical-surgical expenses.

(c) A brief specific description of the benefits, including dollar amounts and number of days duration where applicable, contained in this policy, in the following order:

1. daily hospital room and board;

2. miscellaneous hospital services;

3. hospital out-patient services;

4. surgical services;

5. anesthesia services;

6. in-hospital medical services; and

7. other benefits, if any.)

(Note: The above description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provision applicable to the benefits described.)

(d) (A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described in (c) above.)

(e) (A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.)

(6) Hospital Confinement Indemnity Coverage (Outline of Coverage): An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of section G(4) of this Regulation. The items included in the outline of coverage must appear in the sequence prescribed:

COMPANY NAME AND ADDRESS LOCAL TELEPHONE NUMBER: _(if available)_

HOSPITAL CONFINEMENT INDEMNITY COVERAGE

Policy Form Number_

OUTLINE OF COVERAGE

(a) Read Your Policy Carefully-This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY

CAREFULLY!

(b) Hospital Confinement Indemnity Coverage-Policies of this category are designed to provide, to persons insured, coverage in the form of a fixed daily benefit during periods of hospitalization resulting from a covered accident or sickness, subject to any limitations set forth in the policy. Such policies do not provide any benefits other than the fixed daily indemnity for hospital confinement and any additional benefit described below.

(c) (A brief specific description of the benefits contained in this policy, in the following order:

1. daily benefit payable during hospital confinement; and

2. duration of benefit described in (a).)

(Note: The above description of benefits shall be stated clearly and concisely.)

(d) (A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described in (c) above.)

(e) (A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.)

(f) (Any benefits provided in addition to the daily hospital benefit.)

(7) Major Medical Expense Coverage (Outline of Coverage): An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of Section G(5) of this Regulation. The items included in the outline of coverage must appear in the sequence prescribed:

COMPANY NAME AND ADDRESS

LOCAL TELEPHONE NUMBER_(if available)_

MAJOR MEDICAL EXPENSE COVERAGE

Policy Form Number_

OUTLINE OF COVERAGE

(a) Read Your Policy Carefully-This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY

CAREFULLY!

(b) Major Medical Expense Coverage-Policies of this category are designed to provide, to persons insured, coverage for major hospital, medical, and surgical expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-hospital medical services, and out-of-hospital care, subject to any deductibles, copayment provisions, or other limitations which may be set forth in the policy. Basic hospital or basic medical insurance coverage is not provided.

(c) (A brief specific description of the benefits, including dollar amount, contained in this policy, in the following order:

1. daily hospital room and board;

2. miscellaneous hospital services;

3. surgical services;

4. anesthesia services;

5. in-hospital medical services;

6. out-of-hospital care;

7. maximum dollar amount for covered charges; and

8. other benefits, if any.)

(Note: The above description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provision applicable to the benefits described.)

(d) (A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described in (c) above.)

(e) (A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.)

(8) Disability Income Protection Coverage (Outline of Coverage): An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of section G(6) of this Regulation. The items included in the outline of coverage must appear in the sequence prescribed:

COMPANY NAME AND ADDRESS

LOCAL TELEPHONE NUMBER: _(if available)_

DISABILITY INCOME PROTECTION COVERAGE

Policy Form Number_

OUTLINE OF COVERAGE

(a) Read Your Policy Carefully-This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY

CAREFULLY!

(b) Disability Income Protection Coverage-Policies of this category are designed to provide, to persons insured, coverage for disabilities resulting from a covered accident or sickness, subject to any limitations set forth in the policy. Coverage is not provided for basic hospital, basic medical-surgical, or major medical expenses.

(c) (A brief specific description of the benefits contained in this policy). (Note: The above description of benefits shall be stated clearly and concisely.)

(d) (A description of any policy provisions which exclude, eliminate, restrict, reduce limit, delay, or in any other manner operate to qualify payment of the benefits described in (c) above.)

(e) (A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.)

(9) Accident Only Coverage (Outline of Coverage): An outline of coverage in the form prescribed below, shall be issued in connection with policies meeting the standards of section G(7) of this Regulation. The items included in the outline of coverage must appear in the sequence prescribed:

COMPANY NAME AND ADDRESS LOCAL TELEPHONE NUMBER: _(if available)_

ACCIDENT ONLY COVERAGE

Policy Form Number_

OUTLINE OF COVERAGE

(a) Read Your Policy Carefully-This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY

CAREFULLY!

(b) Accident Only Coverage-Policies of this category are designed to provide, to persons insured, coverage for certain losses resulting from a covered accident ONLY, subject to any limitations contained in the policy. Coverage is not provided for basic hospital, basic medical-surgical, or major medical expenses due to sickness.

(c) (A brief specific description of the benefits contained in this policy.)

(Note: The above description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provision applicable to the benefits described. Proper disclosure of benefits which vary according to accidental cause shall be made in accordance with subsection (1)(o) of section G of this Regulation.)

(d) (A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described in (c) above.)

(e) (A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.)

(10) Specified Disease or Specified Accident Coverage (Outline of Coverage): An outline of coverage in the form prescribed below, shall be issued in connection with policies meeting the standards of section G(8) of this Regulation. The coverage shall be identified by the appropriate bracketed title. The items included in the outline of coverage must appear in the sequence prescribed:

COMPANY NAME AND ADDRESS

LOCAL TELEPHONE NUMBER: _(if available)_

(SPECIFIED DISEASE) (SPECIFIED ACCIDENT) COVERAGE

Policy Form Number_

OUTLINE OF COVERAGE

(a) Read Your Policy Carefully-This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY

CAREFULLY!

(b) (Specified Disease) (Specified Accident) Coverage-Policies of this category are designed to provide, to persons insured, restricted coverage paying benefits ONLY when certain losses occur as a result of (Specified diseases) or (specified accidents). Coverage is not provided for basic hospital, basic medical-surgical, or major medical expenses.

(c) (A brief specific description of the benefits, including dollar amounts, contained in this policy.)

(Note: The above description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provisions applicable to the benefits described. Proper disclosure of benefits which vary according to accidental cause shall be made in accordance with subsections (1)(o) of section G of this Regulation.)

(d) (A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described in (c) above.)

(e) (A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.)

(11) Limited Benefit Health Coverage (Outline of Coverage): An outline of coverage, in the form prescribed below, shall be issued in connection with policies which do not meet the minimum standards of section G(2), (3), (4), (5), (6), (7), and (8) of this Regulation. The items included in the outline of coverage must appear in the sequence prescribed:

COMPANY NAME AND ADDRESS

LOCAL TELEPHONE NUMBER: _(if available)_

LIMITED BENEFIT HEALTH COVERAGE

Policy Form Number_

OUTLINE OF COVERAGE

(a) Read Your Policy Carefully-This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore important that you READ YOUR POLICY CAREFULLY!

(b) Limited Benefit Health Coverage-Policies of this category are designed to provide, to persons insured, limited or supplemental coverage.

(c) (A brief specific description of the benefits, including dollar amounts, contained in this policy.)

(Note: The above description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provisions applicable to the benefits described. Proper disclosure of benefits which vary according to accidental cause shall be made in accordance with subsection (1)(o) of section G of this Regulation.)

(d) (A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described in (c) above.)

(e) (A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.)

(12) Limited Benefit Health Coverage (Outline of Coverage): An outline of coverage, in the form prescribed below, shall be issued in connection with policies which do not meet the minimum standards of section G(2), (3), (4), (5), (6), (7), and (8) of this Regulation. The items included in the outline of coverage must appear in the sequence prescribed:

COMPANY NAME AND ADDRESS

LOCAL TELEPHONE NUMBER: _(if available)_

LIMITED BENEFIT HEALTH COVERAGE

Policy Form Number_

OUTLINE OF COVERAGE

(a) Read Your Policy Carefully-This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore important that you READ YOUR POLICY CAREFULLY!

(b) Limited Benefit Health Coverage-Policies of this category are designed to provide, to persons insured, limited or supplemental coverage.

(c) (A brief specific description of the benefits, including dollar amounts, contained in this policy.)

(Note: The above description of benefits shall be stated clearly a description of any deductible or copayment provisions applicable to the benefits described. Proper disclosure of benefits which vary according to accidental cause shall be made in accordance with subsection (1)(o) of section G of this Regulation.)

(d) (A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described in (c) above.)

(e) (A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.)

I. Severability: Each provision of this Regulation is deemed to be severable and the determination that any provision is invalid for any reason shall not invalidate the remaining provisions of the Regulation.

HISTORY: Amended by State Register Volume 13, Issue No. 4, eff April 28, 1989.

Editor's Note

This regulation was adopted May 14, 1980.

Disclaimer: These regulations may not be the most recent version. South Carolina 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.