No. 28044 (Repeal and Reenact): R590-126. Individual and Franchise Disability Insurance, Minimum Standards

DAR File No.: 28044
Filed: 06/28/2005, 07:42
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rule is being revised for a number of reasons: 1) it has been 10 years since substantive changes have been made to the rule; 2) the insurance industry has requested the update; 3) minimum benefit levels are being raised to correspond with rising health care costs; 4) the rule is being made to more closely correspond with the National Association of Insurance Commissioner's (NAIC) Model Regulation on minimum standards; and 5) the rule scope is being broadened to clarify that this rule encompasses more than just individual insurance plans.

 

Summary of the rule or change:

The original rule included major medical which is not included in the rewrite. The major changes being made in the new rule are: 1) minimum benefit levels are being raised to correspond to rising health care costs; 2) new definitions are being added, i.e., "scientific evidence," "medical necessity," "accident," and "accidental injury" based on industry input and other Insurance Department rules; 3) the probationary period for specific diseases and conditions has been revised to conform with the NAIC's Model Regulation; and 4) the new rule includes standards for dental and vision plans.

 

State statutory or constitutional authorization for this rule:

Sections 31A-2-201, 31A-2-202, 31A-23-312, 31A-22-605, 31A-22-623, 31A-22-626, 31A-23-302, and 31A-26-301

 

Anticipated cost or savings to:

the state budget:

The proposed changes to this rule will increase the department's workload due to the need to review policy forms that insurers will be required to refile with the department. Approximately 600 health insurers may be affected by the changes in the rule and will need to change and file policy forms, however, no filing fee is required.

 

local governments:

The changes to this rule will not affect local government since the rule only applies to the relationship between health insurers, consumers, and the department.

 

other persons:

Approximately 600 health insurers may be affected by the changes to this rule and will need to change and file policy forms, however, no filing fee is required. Some benefit requirements in the rule have been increased, but most health insurers have already been providing increased benefits to their insureds. As a result, there should be no significant increase in costs to the insurance companies or their insureds.

 

Compliance costs for affected persons:

Approximately 600 health insurers may be affected by the changes to this rule and will need to change and file policy forms, however, no filing fee is required. Some benefit requirements in the rule have been increased, but most health insurers have already been providing increased benefits to their insureds. As a result, there should be no significant increase in costs to the insurance companies or their insureds.

 

Comments by the department head on the fiscal impact the rule may have on businesses:

Benefit levels are being raised to correspond with rising health care costs. Most health insurers have already been providing these increased benefits to their insureds and as a result there should be no significant increased costs to health insurers. D. Kent Michie, Commissioner

 

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Insurance
Administration
Room 3110 STATE OFFICE BLDG
450 N MAIN ST
SALT LAKE CITY UT 84114-1201

 

Direct questions regarding this rule to:

Jilene Whitby at the above address, by phone at 801-538-3803, by FAX at 801-538-3829, or by Internet E-mail at [e-mail]

 

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

08/15/2005

 

Interested persons may attend a public hearing regarding this rule:

8/08/2005 at 9:00 AM, State Office Building (behind the Capitol), Room 3112, Salt Lake City, UT

 

This rule may become effective on:

08/16/2005

 

Authorized by:

Jilene Whitby, Information Specialist

 

 

RULE TEXT

R590. Insurance, Administration.

[R590-126. Individual and Franchise Disability Insurance, Minimum Standards.

R590-126-1. Authority.

This rule is issued by the Insurance Commissioner pursuant to Subsection 31A-2-201(3)(a) authorizing rules to implement the Insurance Code and Section 31A-22-605 requiring the commissioner to adopt rules to establish minimum standards for disclosure in the sale of, and benefits to be provided by, Individual and Franchise Disability Insurance.

 

R590-126-2. Purpose and Scope.

A. Purpose. The purpose of this rule is to provide reasonable standardization and simplification of terms and coverages of insurance policies in order to facilitate public understanding and comparison and to prohibit provisions 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 insurance.

B. Scope. This rule shall apply to all individual and franchise disability insurance policies, including health maintenance organization contracts, and subscriber contracts of hospital, medical and dental service corporations. Individual conversion policies shall be subject to this rule except where Section 31A-22-701, et. seq., U.C.A., requires otherwise. A policy or certificate characterized as "group insurance," but marketed to individuals, shall be subject to this rule. The rule shall apply only to coverage issued after the effective date of the rule.

 

R590-126-3. Definitions.

A. In addition to the definitions of Sections 31A-1-301 and 31A-22-605(2), U.C.A., the following definitions shall apply for the purposes of this rule:

1. "Accident" or "Accidental Injury."

a. The definition of these terms may 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 result of an accident, independent of disease or bodily infirmity or any other cause and occurs while insurance coverage is in force."

b. The definition shall employ "result" language and may not include the phrase "Accidental Means," or words which establish an accidental means test, or use words such as "external, violent, visible wounds" or similar words of description or characterization.

c. Unless otherwise prohibited by law, the definition may exclude injuries for which benefits are paid under worker's compensation, an employer's liability or similar law, or a motor vehicle no-fault plan.

2. "Adult Day Care" shall mean a licensed group program designed to meet the needs of functionally impaired adults for a period of fewer than 24 hours per day. Such care may be provided by persons without nursing skills or qualification.

3. "Certificate of Completion" shall mean a document issued by the Utah Board of Education to a person who completes an approved course of study not leading to a diploma, or to one who passes a challenge for that same course of study, or to one whose out-of-state credentials and certificate are acceptable to the Board.

4. "Cold-lead advertising" shall mean making use, directly or indirectly, of any method of marketing which fails to disclose, in a conspicuous manner, that a purpose of the method of marketing is solicitation of insurance and that contact will be made by an insurance agent or insurance company.

5. "Complications of pregnancy" shall mean diseases or conditions the diagnoses of which are distinct from pregnancy but are adversely affected or caused by pregnancy and not associated with a normal pregnancy.

a. "Complications of Pregnancy" include acute nephritis, nephrosis, cardiac decompensation, ectopic pregnancy which is terminated, a spontaneous termination of pregnancy when a viable birth is not possible, puerperal infection, eclampsia and toxemia.

b. This definition does not include false labor, occasional spotting, doctor-prescribed rest during the period of pregnancy, morning sickness, and conditions of comparable severity associated with management of a difficult pregnancy.

6. "Cosmetic Surgery" or "Reconstructive Surgery" shall mean any surgical procedure performed primarily to improve physical appearance.

a. This definition does not include surgery which is necessary:

i. To correct damage caused by injury or sickness;

ii. For reconstructive treatment following medically necessary surgery;

iii. To provide or restore normal bodily function; or

iv. To correct a congenital disorder that has resulted in a functional defect.

b. This provision does not require coverage for preexisting conditions otherwise excluded.

7. "Custodial Care" shall mean a Plan of Care which does not provide treatment for sickness or injury, but is only for the purpose of meeting personal needs and maintaining physical condition when there is no prospect of effecting remission or restoration of the patient to a condition in which care would not be required. Such care may be provided by persons without nursing skills or qualifications. If a Nursing Care Facility is only providing custodial or residential care, the level of care may be so characterized.

8. "Elimination Period" or "Waiting Period" shall mean the specified number of consecutive days at the start of each period of disability for which no benefits are payable.

9. "Experimental Treatment" is defined as medical treatment, services, supplies, medications, drugs, or other methods of therapy or medical practices which are not accepted as a valid course of treatment by your state's medical association, the U.S. Food and Drug Administration, the American Medical Association, or the Surgeon General.

10. "Health Care Expenses" shall mean expenses of health maintenance organizations associated with the delivery of health care services which are analogous to incurred losses of insurers. Such expenses may not include:

a. Home office and overhead costs;

b. Advertising costs;

c. Commissions and other acquisition costs;

d. Taxes;

e. Capital costs;

f. Administrative costs;

g. Claims processing costs.

11. "High-pressure tactics" shall mean employing any method of marketing which induces or attempts to induce the purchase of insurance through force, fright, threat, whether explicit or implied, or excessive pressure.

12. "Home Health Agency" shall mean a public agency or private organization, or subdivision of a health care facility, duly licensed and operating within the scope of such license.

13. "Home Health Aide" shall mean a person who obtains a Certificate of Completion, as required by law, which allows performance of health care and other related services under the supervision of a Registered Nurse from the Home Health Agency, or performance of simple procedures as an extension of physical, speech, or occupational therapy under the supervision of licensed therapists.

14. "Home Health Care" shall mean services provided by a Home Health Agency.

15. "Homemaker" shall mean a person who cares for the environment in the home through performance of duties such as housekeeping, meal planning and preparation, laundry, shopping and errands.

16. "Homemaker/Home Health Aide" shall mean a person who has obtained a Certificate of Completion, as required by law, which allows performance of both Homemaker and Home Health Aide services, and who provides health care and other related services under the supervision of a Registered Nurse from the Home Health Agency or under the supervision of licensed therapists.

17. "Hospice" shall mean a program of care for the terminally ill and their families which occurs in a home or in a health care facility and which provides medical, palliative, psychological, spiritual, or supportive care and treatment.

18. "Hospital" shall mean a facility duly licensed and operating within the scope of such license. This definition may not preclude the requirement of medical necessity of hospital confinement or other treatment.

19. "Intermediate Nursing Care" shall mean nursing services provided by, or under the supervision of, a Registered Nurse (R.N.). Such a Plan of Care shall be for the purpose of treating the condition for which confinement is required.

20. "Medically Necessary" shall mean treatment or services which are necessary and appropriate for the diagnosis or treatment of an illness or injury based on generally accepted current medical practice.

21. "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, and Amendments Thereto, Popularly Known as the Health Insurance for the Aged Act, as Enacted by the Eighty-Ninth Congress of the United States of America," or words of similar import.

22. "Medicare Supplement Policy" shall mean an individual, franchise, or group policy of disability insurance which is advertised, marketed, or primarily designed as a supplement to reimbursements under Medicare for hospital, medical, or surgical expenses of persons eligible for Medicare.

23. "Mental or Nervous Disorders" may not be defined more restrictively than a definition including neurosis, psychoneurosis, psychopathy, psychosis, or any other mental or emotional disease or disorder which does not have a demonstrable organic cause.

24. "Nurse" may be defined so that the description of nurse is restricted to a type of nurse, such as Registered Nurse (R.N.), or Licensed Practical Nurse (L.P.N.). If the words "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 applicable statutes or administrative rules.

25. "Nurse, Licensed Practical" shall mean a person who is registered and licensed to practice as a Practical Nurse.

26. "Nurse, Registered" shall mean any person who is registered and licensed to practice as a Registered Nurse.

27. "Nursing Care" shall mean assistance provided for the health care needs of sick or disabled individuals, by or under the direction of licensed nursing personnel.

28. "Nursing Care Facility," or "Nursing Home," shall mean a facility duly licensed and operating within the scope of such license.

29. "One Period of Confinement" shall mean consecutive days of in-hospital service received as an inpatient, or successive confinements when discharge from and readmission to the hospital occurs within a period of time of not more than 90 days or three times the maximum number of days of in-hospital coverage provided by the policy up to a maximum of 180 days.

30. "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.

31. "Personal Care" shall mean assistance, under a Plan of Care by a Home Health Agency, provided to persons in activities of daily living.

32. "Personal Care Aide" shall mean a person who obtains a Certificate of Completion, as required by law, which allows that person to assist in the activities of daily living and emergency first aid, and who must be supervised by a Registered Nurse from the Home Health Agency.

33. "Physician" may be defined by including words such as "duly qualified physician" or "duly licensed physician." The use of such terms requires an insurer to recognize and to accept, to the extent of its obligation under the contract, all providers of medical care and treatment when such services are within the scope of the provider's licensed authority and are provided pursuant to applicable laws as required by Section 31A-22-618, U.C.A.

34. "Plan of Care" shall mean a written plan based on assessment data or physician orders that identifies the patient's needs, who will provide needed services and how often, treatment goals, and anticipated outcomes.

35. "Preexisting Condition" may not be defined to be more restrictive than the following:

a. Specified Disease Insurance. "Preexisting condition" shall mean a condition which first manifested itself within six months prior to the effective date of coverage or which was diagnosed by a physician at any time prior to the effective date of coverage.

b. Other Health Coverage. "Preexisting condition" shall mean the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within a five-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-year period preceding the effective date of the coverage of the insured person.

36. "Probationary Period" shall mean the period of time following the date of issuance or effective date of the policy before coverage begins for all or certain conditions.

37. "Residential Health Care Facility" shall mean a publicly or privately operated and maintained facility providing personal care to residents who require protected living arrangements.

38. "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 shall 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.

39. "Respite Care" shall mean provision of temporary support to the primary caregiver of the aged, disabled, or handicapped individual insured, by taking over the tasks of that person for a limited period of time. The insured may receive care in the home, or other appropriate community location, or in an appropriate institutional setting.

40. "Sickness."

a. The definition of this term may not be more restrictive than the following: "Sickness means sickness or disease of an insured person which manifests itself after the effective date of insurance and while the insurance is in force."

b. A definition of sickness may provide for a probationary period which may not exceed 30 days from the effective date of the coverage of the insured person.

c. The definition may be further modified to exclude sickness or disease for which benefits are paid under any worker's compensation, occupational disease, employer's liability or similar law.

41. "Skilled Nursing Care" shall mean nursing services provided by, or under the supervision of, a Registered Nurse (R.N.). Such a Plan of Care shall be for the purpose of treating the condition for which the confinement is required and not for the purpose of providing Intermediate or Custodial Care.

42. "Therapist" may be defined as a professionally trained or duly licensed or registered person, such as a physical therapist, occupational therapist, or speech therapist, who is skilled in applying treatment techniques and procedures under the general direction of a physician.

43. "Total Disability:"

a. A general definition of total disability may not be more restrictive than one requiring that the individual who is totally disabled not be engaged in any employment or occupation for which he is or becomes qualified by reason of education, training or experience; and not, in fact, engaged in any employment or 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:

i. Perform "any occupation whatsoever," "any occupational duty," or "any and every duty of his occupation," or

ii. 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.

d. An insurer may require care by a physician other than the insured or a member of the insured's immediate family.

44. "Twisting" shall mean knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policies or insurers for the purpose of inducing, or attempting to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on, or convert any insurance policy or to take out another policy of insurance.

45. "Usual and Customary" shall mean the reasonable, usual and customary charges for services and supplies in the community where such services and supplies were provided.

46. "Waiting Period" shall mean "Elimination Period."

 

R590-126-4. General Requirements.

A. Policy Definitions. No policy subject to this rule may contain definitions respecting the matters defined in Section R590-126-3 unless such definitions comply with the requirements of that section.

B. Rights of Spouse. The following provisions apply to policies which provide coverage to a spouse of the insured:

1. Termination of Spouse Limited. A policy may 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 for nonpayment of premium.

2. Spouse as Insured. A policy shall provide that in the event of the insured's death the spouse of the insured shall become the insured.

3. Age Determination. The age of the younger spouse shall be used as the basis for meeting the age and durational requirements of the noncancellation or renewal provisions of the policy. However, this requirement may 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.

C. Renewability.

1. Disclosure. The terms "noncancellable," "guaranteed renewable," "noncancellable and guaranteed renewable," "conditionally renewable," "collectively renewable," or "optionally renewable" may not be used without further explanatory language in accordance with the disclosure requirements of Subsection R590-126-6(B).

2. Disability Income - Effect of Employment Upon Right to Renew. Any accident and health or accident-only policy which provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from accident or sickness may provide that the insured has the right to continue the policy at least to age 60 if, at age 60, the insured has the right to continue the policy in force at least to age 65 while actively and regularly employed.

3. Cancellation and Renewal.

a. Noncancellable. The terms "noncancellable" or "noncancellable and guaranteed renewable" may be used only in a policy which the insured has the right to continue in force by the timely payment of premiums set forth in the policy at least to age 65 or to eligibility for Medicare, during which period the insurer has no right to make any unilateral change to the detriment of the insured while the policy is in force.

b. Guaranteed Renewable. Except as provided above, the term "guaranteed renewable" may be used only in a policy which the insured has the right to continue in force by the timely payment of premiums at least to age 65 or to eligibility for Medicare, during which period the insurer has no right to make any unilateral change to the detriment of the insured while the policy is in force, except that the insurer may make changes in premium rates by classes.

c. Conditionally Renewable. The term "conditionally renewable" may be used only in a policy which the insured may have the right to continue in force by the timely payment of premiums at least to age 65 or to eligibility for Medicare, during which period the insurer has no right to make any unilateral change to the detriment of the insured while the policy is in force. However, the insurer, at its option, and by timely notice, may decline renewal for reasons stated in the policy, or may make changes in premium rates by classes.

d. Collectively Renewable. The term "collectively renewable" may be used only in a policy which the insured may have the right to continue in force by the timely payment of premiums at least to age 65 or to eligibility for Medicare, during which period the insurer has no right to make any unilateral change in any provision of the policy while the policy is in force. However, the insurer, at its option, and by timely notice, may decline renewal of all policies of the same classification issued in this state, or may make changes in premium rates by classes.

e. Optionally Renewable. The term "optionally renewable" may be used only in a policy which the insured may have the right to continue in force by the timely payment of premiums at least to age 65 or to eligibility for Medicare, during which period the insurer has no right to make any unilateral change in any provision of the policy while the policy is in force. However, the insurer, at its option, and by timely notice, may decline renewal of the policy or may make changes in premium rates by classes.

f. Notice of nonrenewal or premium change. A notice of nonrenewal or change in premium shall be given no fewer than 30 days before the renewal date.

D. Optional insureds. 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.

E. Refund of Premium. 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 person on a pro rata basis.

F. Pregnancy Benefit Extension. In the event the insurer cancels or refuses to renew, except for nonpayment of premiums, policies providing pregnancy benefits shall provide for an extension of benefits for a pregnancy, including complications of pregnancy, commencing while the policy is in force and for which benefits would have been payable had the policy remained in force.

G. Post-hospital Admission Requirements. Policies providing convalescent or extended care benefits following hospitalization may not condition such benefits upon admission to the convalescent or extended care facility within a period of fewer than 14 days after discharge from the hospital.

H. Handicapped Dependent Coverage Extension. Family coverage shall continue for any dependent child who is incapable of self-sustaining employment due to mental retardation or physical handicap and is chiefly dependent on the insured for support and maintenance 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. The policy may require that within 31 days of such date the company receive due proof of such incapability 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.

I. Transplant Donor Coverage. Any policy providing 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.

J. Recurrent Disability. A policy may contain a provision relating to recurrent disabilities, but no such provision may specify that a recurrent disability be separated by a period greater than six months.

K. Time Limit for Occurrence of Loss. Accidental death and dismemberment benefits shall be payable if the loss occurs within 180 days from the date of the accident, irrespective of total disability. Disability income benefits, if provided, may not require the loss to commence fewer than 30 days after the date of accident, nor may 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.

L. Dismemberment Benefits. Specific dismemberment benefits may not be in lieu of other benefits unless the specific benefit equals or exceeds the other benefits.

M. Accident Benefits. Any accident-only policy providing benefits which vary according to the type of accidental cause shall prominently set forth, in both the policy and the outline of coverage, the circumstances under which benefits are payable which are less than the maximum amount payable under the policy.

N. Continuous Total Disability. Termination of a policy shall be without prejudice 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 total disability of the insured, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits.

O. Deterioration of Health. A policy may not be cancelled or nonrenewed by an insurer solely on the grounds of deterioration of health.

 

R590-126-5. Prohibited Policy Provisions.

A. Probationary periods. No policy may contain provisions establishing either a probationary or a waiting period during which coverage is not provided under the policy, except as follows in Subsections (1) and (2).

1. A probationary period of 30 days may apply under the definition of "sickness" contained in Subsection R590-126-3(A)(40) of this rule.

2. A probationary period of up to six months may be applied to the following specified diseases or conditions and losses resulting therefrom:

a. Hernia;

b. Disorder of reproductive organs;

c. Varicose veins;

d. Adenoids;

e. Appendix;

f. Tonsils.

3. The six month exception of Subsection R590-126-5(A)(2) may not be applicable where such specified diseases or conditions are treated on an emergency basis.

4. Accident policies may not contain either probationary or waiting periods.

B. "Dividend" coverage.

1. Cash Payment. No policy or rider for additional coverage may be issued as a dividend unless an equivalent cash payment is offered to the policyholder as an alternative to such dividend policy or rider. No such dividend policy or rider may be issued for an initial term of fewer than six months.

2. Optional Renewal. 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.

C. Preexisting Conditions. No policy may exclude coverage for a loss due to a preexisting condition for a period greater than 12 months (six months for specified disease policies) 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 preexisting condition is not specifically excluded by the terms of the policy.

D. "Return of Premium" or "Cash Value Benefit." A disability policy may contain a "return of premium" or "cash value benefit" so long as the insurer demonstrates that the reserve basis for such policies is adequate.

E. Hospital Indemnity. Policies providing hospital confinement indemnity coverage may not contain provisions excluding coverage because of confinement in a hospital operated by the federal government.

F. Limitations or Exclusions. No policy may limit or exclude coverage by type of illness, accident, treatment or medical condition, except as follows:

1. Preexisting conditions or diseases;

2. Mental or emotional disorders;

3. Alcoholism or drug addiction;

4. Pregnancy, but policies may not exclude complications of pregnancy;

5. Illness, treatment or medical condition arising out of:

a. 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;

b. Suicide (sane or insane), attempted suicide or intentionally self-inflicted injury;

c. Aviation;

d. Inter-scholastic sports, but only with respect to nonrenewable policies with a term of fewer than six months;

6. Cosmetic surgery, but policies may not exclude:

a. Reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part; or

b. Reconstructive surgery because of congenital disease or anomaly of a covered dependent child which has resulted in a functional defect;

7. Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, or symptomatic complaints of the feet;

8. Benefits for the following:

a. Treatment provided in a government hospital, but this exclusion may not apply to Hospital Confinement Indemnity Coverage, as defined in Subsection R590-126-7(E);

b. Services performed by a member of the covered person's immediate family;

c. Services for which no charge is normally made in the absence of insurance; or

d. Duplication of benefits paid under:

i. Medicare or other governmental program (except Medicaid); or

ii. Any state or federal worker's compensation, employer's liability or occupational disease law, or any motor vehicle no-fault coverage;

9. Dental care or treatment;

10. Corrective lenses, and examination for the prescription or fitting thereof, but policies may not exclude required lens implants following cataract surgery;

11. Hearing aids, and examination for the prescription or fitting thereof;

12. Rest cures;

13. Custodial care, except for long-term Care policies;

14. Transportation;

15. Routine physical examinations;

16. Territorial limitations outside the United States.

17. Others as may be approved by the commissioner.

G. Waivers.

1. No waiver may be used to exclude, limit, or reduce coverage or benefits unless:

a. Acceptance of the waiver is signed by the insured; or

b. The full text of the waiver, or a notice thereof, is contained on the first page or specification page of the policy.

H. Medicare Compliance. Except as otherwise provided in Subsection R590-126-6(L), the terms "Medicare Supplement," "Supplement to Medicare," "Medigap," and words of similar import may not be used unless the policy is issued in compliance with this rule and rule R590-146.

 

R590-126-6. Disclosure Requirements.

A. Coverage Description Statement. Each policy subject to this rule shall contain a statement, on the first page or specification page of the policy, which clearly identifies the type(s) of coverage offered.

B. Renewal or Nonrenewal Provisions. Each policy or contract subject to this rule shall include a renewal, continuation, or nonrenewal provision. The language or specifications of such provision shall be consistent with the type of contract issued. Such provision shall be appropriately captioned, shall appear on the first page, or schedule page, of the policy, and shall clearly state the duration, where limited, of renewability and the duration of the term of coverage for which the policy is issued and for which it may be renewed.

C. Rider or Endorsement Acceptance. 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 the date of policy issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term shall be agreed to in writing signed by the insured, unless the increased benefit or coverage is required by law.

D. Premium, Additional. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, such premium charge shall be set forth in the policy.

E. Benefit Payment Standard. 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.

F. Preexisting Conditions. If a policy contains any limitations with respect to preexisting conditions, such limitations shall appear as a separate paragraph of the policy and be labeled as "Preexisting Condition Limitations."

G. Accident-Only Disclosure. All accident-only policies shall contain a prominent statement on the first page of the policy, or attached thereto, in either contrasting color or in boldface type at least equal to the size of type used for policy captions, as follows: "This is an accident-only policy and it does not pay benefits for loss from sickness."

H. Age Limitation. 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 shall be prominently set forth in the outline of coverage and on the schedule page of the policy. However, benefits may not be reduced below levels otherwise required by this rule.

I. Conversion Privilege. If a policy contains a conversion privilege, it shall comply, in substance, with the following:

1. The caption of the provision shall be "Conversion Privilege," or words of similar import;

2. 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.

3. 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. Specified-Disease Insurance Buyer's Guide. Insurers, except direct response insurers, shall give any person applying for specified-disease insurance a Buyer's Guide, approved by the commissioner, at the time of application and shall obtain the recipient's written acknowledgment of the guide's delivery. Direct response insurers shall provide the Buyer's Guide upon request but not later than the time the policy is delivered.

K. Specified-Disease Insurance Disclosure. All specified-disease policies shall contain a prominent statement on the first page or schedule page of the policy or attached thereto in either contrasting color or in boldface type at least equal to the size type used for policy captions, a prominent statement as follows: "CAUTION: This is a limited policy. Read it carefully with the outline of coverage and the Buyer's Guide."

L. Notice Regarding Policies or Subscriber Contracts Which Are Not Medicare Supplement Policies. Any policy or subscriber contract, other than a Medicare Supplement policy, a policy issued pursuant to a contract under Section 1876 of the Federal Social Security Act, 42 U.S.C. Section 1395, et seq., or a Disability Income policy, which is issued for delivery to a person eligible by reason of age for Medicare, shall notify insureds under the policy or subscriber contract that the policy or subscriber contract is not a Medicare Supplement policy. Such notice shall either be printed on or attached to the first page of the outline of coverage delivered to insureds under the policy or subscriber contract, or if no outline of coverage is delivered, to the first page of the policy, certificate or subscriber contract delivered to insureds. Such notice shall be in no less than 12 point type and shall contain the following language:

"THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY OR CONTRACT. If you are eligible for Medicare, review the Medicare Supplement Buyer's Guide available from the company."

M. Medicare Supplement Buyer's Guide. Insurers issuing policies or certificates which provide hospital or medical expense coverage on an expense incurred or indemnity basis other than incidentally, to persons eligible for Medicare by reason of age, shall provide to the applicant a Medicare Supplement Buyer's Guide, in a form approved by the commissioner and entitled "Guide to Health Insurance For People With Medicare." Delivery of the Buyer's Guide shall be made whether or not the policy qualifies as a "Medicare Supplement Coverage" according to this rule or Rule R590-146. 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 obtained by the insurer. Direct response insurers shall deliver the Buyer's Guide upon request but not later than at the time the policy is delivered.

N. Emergency Care Limitation. A policy which limits treatment in an emergency room or similar facility shall disclose the existence of the limitation in the outline of coverage and on the schedule page of the policy.

 

R590-126-7. Disability, Minimum Standards for Benefits.

A. The following minimum standards for benefits are prescribed for the categories of coverage noted in the following subsections R590-126-7(C) through (K). A policy or contract subject to this rule which does not meet the required minimum standards contained herein may not be delivered or issued for delivery in this state.

B. Exception: A nonconforming policy may be issued only:

1. Upon approval by the commissioner as Limited Benefit Health Insurance under Subsection R590-126-7(K), and

2. With an Outline of Coverage which complies with the terms of Subsection R590-126-8(K) of this rule.

C. Basic Hospital Expense Coverage. This is a policy of disability insurance which provides coverage for a period of not fewer than 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:

1. Daily hospital room and board in an amount not less than 70% of the usual and customary charges for semiprivate room accommodations;

2. Miscellaneous hospital services for expenses incurred for 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 70% of the charges incurred or ten times the daily hospital room and board benefits, whichever is less; and

3. Hospital outpatient services consisting of:

a. Hospital services on the day surgery is performed;

b. Hospital services rendered within 72 hours after accidental injury, in an amount not less than $200 per accident;

c. X-ray and laboratory tests to the extent that benefits for such services would have been provided if rendered to an inpatient of the hospital to an extent not less than $200.

4. Benefits provided under (1) and (2) of R590-126-7(C) above, may be provided subject to a combined deductible amount not in excess of $200.

D. Basic Medical-Surgical Expense Coverage. This is a policy of disability 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:

1. Surgical services, of not less than 70% of the usual, reasonable and customary charges.

2. 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 physician or his assistant performing the surgical services, in an amount not less than the lesser of:

a. 70% of the reasonable charges; or

b. 15% of the surgical service benefit.

3. 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 70% of the reasonable charges for not fewer than 31 days during one period of confinement.

E. Hospital Confinement Indemnity Coverage. This is a policy of disability insurance which provides daily benefits for hospital confinement on an indemnity basis in an amount not less than $30 per day and for a period of not fewer than 31 days during any one period of confinement for each person insured under the policy.

F. Major Medical Expense Coverage. This is a disability insurance policy which provides hospital, medical and surgical expense coverage, to an aggregate maximum of not less than $25,000; copayment by the covered person not to exceed 30% of covered charges or up to five per cent of the aggregate maximum limit under the policy; an annual deductible stated on a per person, per family, or per calendar or policy year basis, or a combination of such bases not to exceed five per cent of the aggregate maximum limit under the policy. Benefits for each covered person shall be at least:

1. Daily hospital room and board expenses in an amount not less than 70% of the semiprivate room rate in the area where the insured resides, for a period of not fewer than 31 days during continuous hospital confinement;

2. Miscellaneous hospital services in an amount not less than 20 times the daily room and board rate;

3. Surgical services in an amount not less than 70% of the usual, reasonable and customary charges;

4. Anesthesia services in an amount not less than 15% of the covered surgical fees;

5. 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.

6. 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, and diagnostic x-ray, laboratory services, radiation therapy, chemotherapy, and hemodialysis ordered by a physician; and

7. Not fewer than three of the following additional benefits, for an aggregate maximum of such covered charges of not less than $2,500:

a. Private duty nursing services;

b. Nursing home care;

c. Physiotherapy;

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

e. Prosthetic devices, casts, splints, trusses or braces;

f. Treatment for functional nervous disorders, and mental and emotional disorders; or

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

G. Disability Income Protection Coverage. This 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:

1. 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.

2. Contains an elimination period no greater than:

a. In the case of a coverage providing a benefit of one year or less, 90 days;

b. In all other cases, 365 days.

3. Is payable during disability for at least six months, except in the case of a policy covering disability arising out of pregnancy, childbirth or miscarriage in which case the period may be for one month.

4. Does not reduce benefits because of an increase in Social Security or similar benefits during a benefit period.

5. The provisions of this Subsection R590-126-7(G) do not apply to policies providing business buyout coverage.

H. Accident-Only Coverage. This 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 and a single dismemberment amount shall be at least $500.

I. Specified Accident and Specified Disease Coverage.

1. "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 for accidental death, $1,000 for double dismemberment and $500 for single dismemberment.

2. "Specified Disease Coverage" pays benefits for the diagnosis and treatment of a specifically named disease or diseases. Any such policy shall meet the general rules set forth in Subsection R590-126-7(I)(2)(a). The policy shall also meet the minimum standards set forth in the applicable Subsections R590-126-7(I)(2)(b), (c), or (d).

a. General Rules. The following rules apply to specified disease coverage in addition to all other rules imposed by this rule. In cases of conflict with other rules, the following shall govern:

i. Preexisting Conditions. A specified disease policy, regardless of whether the basis of issuance is a detailed application form, a simplified application form, or an enrollment form, may not deny a claim for loss which occurs more than six months after the effective date of coverage due to a preexisting condition. Such policy may not define a preexisting condition more restrictively than a condition which first manifested itself within six months prior to the effective date of coverage or which was diagnosed by a physician at any time prior to the effective date of coverage.

ii. Policy Designation. 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.

iii. Medical Diagnosis. Any policy issued pursuant to this section which conditions payment upon pathological diagnosis of a covered disease, shall also provide that if a pathological diagnosis is medically inappropriate, a clinical diagnosis will be accepted.

iv. Related Conditions. Notwithstanding any other provision of this rule, 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).

v. Renewability. Specified disease coverage shall be at least Guaranteed Renewable.

vi. Probationary Period. No policy issued pursuant to Subsection R590-126-7(I) may contain either an elimination or a probationary period greater than 30 days.

vii. Medicaid Disclaimer. Any application for specified disease coverage shall contain a statement above the signature of the applicant that no person to be covered for specified disease is also covered by any Title XIX program, designated as Medicaid or any similar name. Such statement may be combined with any other statement for which the insurer may require the applicant's signature.

viii. Medical Care and Charges. Payments may be conditioned upon a covered person receiving medically necessary care, prescribed by a physician, given in a medically appropriate location, under a medically accepted Plan of Care. Payment may be limited to amounts not in excess of usual and customary charges.

ix. Other Insurance. Benefits for specified disease coverage shall be paid regardless of other coverage.

x. Retroactive Application of Coverage. After the effective date of the coverage, or the conclusion of an applicable waiting period, if any, subject to Subsection R590-126-7(I)(2)(a)(vi), 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.

b. Minimum Expense Incurred Benefits. The following minimum benefit standards apply to specified disease coverage on an expense incurred basis:

i. Policy Limits. A deductible amount not to exceed $250, an aggregate benefit limit of not less than $25,000 and a benefit period of not fewer than three years.

ii. Copayment. Covered services provided on an outpatient basis may be subject to a copayment which may not exceed 20%.

iii. Covered Services. Covered services shall include the following:

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

(B) Treatment by, or under the direction of, a legally qualified physician or surgeon;

(C) Private duty nursing services of a Registered Nurse (R.N.), or Licensed Practical Nurse (L.P.N.);

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

(E) Blood transfusions, and the administration thereof, including expense incurred for blood donors;

(F) Drugs and medicines prescribed by a physician;

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

(H) The rental of any respiratory or other mechanical apparatuses;

(I) Braces, crutches and wheelchairs 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;

(K) Home Health Care, as defined in Subsection R590-126-3(A)(14), which is provided by, or under the direction of, a Home Health Agency. The Plan of Care shall be prescribed in writing.

(L) Physical, speech, hearing and occupational therapy;

(M) Special equipment including hospital bed, toilette, pulleys, wheelchairs, aspirator, chux, oxygen, surgical dressings, rubber shields, colostomy and eleostomy appliances;

(N) Prosthetic devices including wigs and artificial breasts; and

(O) Nursing Home care for noncustodial services.

c. Minimum Per Diem Benefits. The following minimum benefit standards apply to coverages written on a per diem indemnity basis:

i. Hospital Confinement Benefit. A fixed-sum payment of at least $200 for each day of hospital confinement for at least 365 days, with no deductible amount permitted;

ii. Outpatient Benefit. A fixed-sum payment equal to one half the hospital inpatient benefits for each day of hospital or nonhospital outpatient surgery, radiation therapy and chemotherapy, for at least 365 days of treatment.

iii. Nursing Home/Home Health Care Benefit. Benefits tied to confinement in a Nursing Home or to receipt of Home Health Care are optional; if a policy offers these benefits, they must equal the following:

(A) A fixed-sum payment equal to one-half the hospital inpatient benefit for each day of Skilled Nursing Home confinement for at least 100 days.

(B) A fixed-sum payment equal to one-fourth the hospital inpatient benefit for each day of Home Health Care for at least 180 days.

(C) Notwithstanding any other provision of this rule, any restriction or limitation applied to the benefits in the above Subsections R590-126-7(I)(2)(c)(iii)((A)) and ((B)), whether by definition or otherwise, may not be more restrictive than those under Medicare.

d. Principal Sum Benefits. The following minimum benefit standards apply to principal sum indemnity coverage of any specified disease(s):

i. Benefits shall be payable as a fixed, one-time payment made within 30 days of submission to the insurer of proof of diagnosis of the specified disease(s). Dollar benefits shall be offered for sale only in even increments of $1,000.

ii. Where coverage is advertised or otherwise represented to offer generic coverage of a disease or diseases (e.g., "cancer insurance," "heart disease insurance"), the same dollar amounts shall be payable regardless of the particular subtype of the disease (e.g., lung or bone cancer), with one exception. In the case of clearly identifiable subtypes with significantly lower treatment costs (e.g., skin cancer), lesser amounts may be payable so long as the policy clearly differentiates that subtype and its benefits.

J. Catastrophic Coverage. This is a policy of disability insurance which:

1. provides benefits for medical expenses incurred by the insured to an aggregate maximum of not less than $1,000,000;

2. contains no separate internal dollar limits;

3. may be subject to a policy deductible which does not exceed the greater of .01% of the policy limit or the amount of other disability insurance coverage for the same medical expenses; and

4. contains no percentage participation or coinsurance clause for expenses which exceed the deductible.

K. Limited Benefit Health Insurance Coverage. This 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 Subsections R590-126-7(C), (D), (E), (F), (G), (H), (I) and (J). Such policies or contracts may be delivered or issued for delivery in this state only if the outline of coverage provided by Subsection R590-126-8(K) of this rule is completed and delivered as required by Subsection R590-126-8(A) of this rule. A policy covering a single specified disease or combination of diseases shall meet the requirements of Subsection R590-126-7(I) and may not be offered for sale as a "Limited Coverage" under this section. This subsection does not apply to policies designed to provide coverage for Long-Term Care, as governed by Rule R590-148, or Medicare Supplement, as governed by R590-146.

 

R590-126-8. Disability, Outlines of Coverage.

A. Outline of Coverage Requirements.

1. No policy or contract subject to this rule may be delivered or issued for delivery in this state unless an appropriate outline of coverage, as prescribed in Subsections R590-126-8(C) through (L), is completed and delivered to the applicant at the time application is made, with acknowledgement of receipt or certification of delivery provided to the insurer, or is delivered with the policy. In the case of direct response solicitation, the outline of coverage shall be delivered upon request, but no later than the time the policy is delivered.

2. Substitute Outline. 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 shall accompany the policy or contract when it is delivered and contain the following statement, in no less than 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."

3. Changes in Outline. Appropriate changes in terminology may be made in the outline of coverage in the case of contracts of hospital, medical, or dental service corporations. In any other 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.

4. Outlines of Coverage for Combined Coverages. The outlines of coverage designated in Subsections R590-126-8(A)(4)(a) and (b) herein shall be appropriate for policies offering the combination coverages as listed:

a. Basic Hospital and Medical-Surgical Expense Outline (Outline (L)). The following combination coverages are included:

i. Basic Hospital Expense (Coverage (C)) and Basic Medical-Surgical Expense Coverage (Coverage (D)).

b. Major Medical Expense Outline (Outline (F)). The following combination coverages may be included:

i. Basic Hospital Expense (Coverage (C)) and Major Medical Expense Coverage (Coverage (F)); or

ii. Basic Medical-Surgical Expense (Coverage (D)) and Major Medical Expense Coverage (Coverage (F)); or

iii. Basic Hospital Expense (Coverage (C)), Basic Medical-Surgical Expense (Coverage (D)), and Major Medical Expense Coverage (Coverage (F)).

B. Outlines of Coverage Required; Sample Provisions. Insurance transacted under the provisions of this rule shall be disclosed as provided by this Section. Disclosure of the coverages listed in Subsections R590-126-7(C) through (K) shall include an Outline of Coverage which meets the requirements of the following corresponding Subsections R590-126-8(C) through (K), or an outline for a combination of coverages which meets the requirements of Subsection R590-126-8(A)(4) and either Subsection R590-126-8(F) or (L). These outlines are available from the Utah Insurance Department.

C. 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 Subsection R590-126-7(C) of this rule. The items included in the outline of coverage shall appear in the sequence prescribed: (Company Name) Basic Hospital Expense Coverage Outline of Coverage

1. 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!

2. 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 outpatient services, subject to any limitations, deductibles and copayment requirements set forth in the policy. Coverage is not provided for physician's or surgeon's fees or unlimited hospital expenses.

3. 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:

a. Daily hospital room and board;

b. Miscellaneous hospital services;

c. Hospital outpatient services;

d. Other benefits, if any;

e. 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.

4. 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.

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

D. 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 Subsection R590-126-7(D) of this rule. The items included in the outline of coverage shall appear in the sequence prescribed:

(Company Name) Basic Medical-Surgical Expense Coverage Outline of Coverage

1. 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!

2. 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 or unlimited medical-surgical expenses.

3. 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:

a. Surgical services;

b. Anesthesia services;

c. In-hospital medical services;

d. Other benefits, if any;

e. 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.

4. 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.

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

E. 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 Subsection R590-126-7(E) of this rule. The items included in the outline of coverage shall appear in the sequence prescribed:

(Company Name) Hospital Confinement Indemnity Coverage Outline of Coverage

1. 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!

2. 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.

3. A brief specific description of the benefits contained in this policy in the following order:

a. Daily benefit payable during hospital confinement;

b. Duration of such benefit described in (a), above.

c. The above description of benefits shall be stated clearly and concisely.

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

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

6. Any benefits provided in addition to the daily hospital benefit.

F. 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 Subsection R590-126-7(F) of this rule. An outline of coverage which meets these requirements shall also be issued in connection with a policy insuring a combination of the coverages under policies meeting the standards of Subsections R590-126-7(C) and (F), (D) and (F), or (C), (D) and (F), in accordance with the requirements of Subsection R590-126-8(A)(4). The items included in the outline of coverage shall appear in the sequence prescribed:

(Company Name) Major Medical Expense Coverage Outline of Coverage

1. 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!

2. 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 in this policy. (Note: If basic hospital and/or basic medical insurance coverage is provided, the inappropriate part of the last sentence may be omitted.)

3. A brief specific description of the benefits, including dollar amounts, contained in this policy, in the following order:

a. Daily hospital room and board;

b. Miscellaneous hospital services;

c. Surgical services;

d. Anesthesia services;

e. In-hospital medical services;

f. Out-of-hospital care;

g. Maximum dollar amount for covered charges;

h. Other benefits, if any;

i. 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.

4. 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.

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

G. 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 Subsection R590-126-7(G) of this rule. The items included in the outline of coverage shall appear in the sequence prescribed:

(Company Name) Disability Income Protection Coverage Outline of Coverage

1. 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!

2. 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.

3. A brief specific description of benefits shall be stated clearly and concisely.

4. 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.

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

H. 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 Subsection R590-126-7(H) of this rule. The items included in the outline of coverage shall appear in the sequence prescribed:

(Company Name) Accident Only Coverage Outline of Coverage

1. 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!

2. 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.

3. A brief specific description of the benefits contained in this policy. The description 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 R590-126-4(M) of this rule.

4. 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.

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

I. Specified Accident or Specified Disease Coverage (Outline of Coverage). An outline of coverage in the form prescribed below, shall be issued in connection with policies meeting the standards of Subsection R590-126-7(I) of this rule. The coverage shall be identified by the appropriate bracketed title. The items included in the outline of coverage shall appear in the sequence prescribed:

(Company Name) (Specified Accident) (Specified Disease) Coverage Outline of Coverage

1. This policy is designed only as a supplement for a comprehensive health insurance policy and should not be purchased unless you have this underlying coverage. It should not be purchased by persons covered under Medicaid. Read the Buyer's Guide discussion of the possible limits on benefits in this type of policy.

2. 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!

3. (Specified Accident) (Specified Disease) 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 accidents or specified diseases. Coverage is not provided for basic hospital, basic medical-surgical, or major medical expense.

4. A brief specific description of the benefits, including dollar amounts, contained in this policy. The description 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 R590-126-4(M) of this rule.

5. 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 (4) above.

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

J. Catastrophic Coverage. An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of Subsection R590-126-7(J) of this rule. The items included in the outline of coverage shall appear in the sequence prescribed:

(Company Name) Catastrophic Coverage Outline of Coverage

1. 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!

2. Catastrophic Coverage. Policies of this category are designed to provide, to persons insured, catastrophic coverage for losses resulting from a covered accident or sickness, subject to any limitations set forth in the policy.

3. A brief specific description of benefits shall be stated clearly and concisely.

4. 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.

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

K. 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 R590-126-7. The items included in the outline of coverage shall appear in the sequence prescribed:

(Company Name) Limited Benefit Health Coverage Outline of Coverage

1. 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!

2. Limited Benefit Health Coverage. Policies of this category are designed to provide, to persons insured, LIMITED OR SUPPLEMENTAL coverage.

3. A brief specific description of the benefits, including dollar amounts, contained in this policy. The description 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 R590-126-4(M) of this rule.)

4. 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.

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

L. 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 Subsections R590-126-7(C) and (D) of this rule. The items included in the outline of coverage shall appear in the sequence prescribed:

(Company Name) Basic Hospital and Medical-Surgical Expense Coverage Outline of Coverage

1. 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!

2. 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 outpatient 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.

3. 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:

a. Daily hospital room and board;

b. Miscellaneous hospital services;

c. Hospital outpatient services;

d. Surgical services;

e. Anesthesia services;

f. In-hospital medical services;

g. Other benefits, if any;

h. 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.

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

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

 

R590-126-9. Disability, Requirements for Replacement.

A. Application Information. Application forms shall include a question designed to elicit information as to whether the insurance to be issued is intended to replace any other disability policy or certificate presently in force. A supplementary application or other form to be signed by the applicant containing such a question may be used.

B. Notice to Existing Insurer. Where replacement is involved, the replacing insurer shall notify by written communication the existing insurer of the proposed replacement. Such existing insurance shall be identified by the name of the insurer, name of insured, and insured's address or contract number. The written communication shall be made within five working days of the date the application is received in the replacing insurer's home or regional office or the date the proposed policy or contract is issued, whichever is sooner.

C. Notice to Applicant.

1. Nondirect Response. Upon determining that a sale will involve replacement, an insurer, other than a direct response insurer, or its agent, shall furnish the applicant, prior to issuance or delivery of the policy or certificate, the notice described in R590-126-9(D) below. One copy of such notice shall be retained by the applicant and an additional copy, signed by the applicant, shall be retained by the insurer.

2. Direct Response. A direct response insurer shall deliver to the applicant, upon issuance of the policy or certificate, the notice described in R590-126-9(E) below.

D. Nondirect Response Notice Form. The notice required by Subsection R590-126-9(C)(1) above for an insurer, other than a direct response insurer, shall be in substantially the following form: "NOTICE TO APPLICANT REGARDING REPLACEMENT OF DISABILITY INSURANCE"

1. According to (your application) (information you have furnished), you intend to lapse or otherwise terminate existing insurance and replace it with a policy to be issued by (insert Company Name) Insurance Company. Your new policy provides (insert number of days) within which you may decide without cost whether you desire to keep the policy. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy.

a. Health conditions which you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy.

b. You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage.

c. If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical/health history.

d. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, re-read it carefully to be certain that all information has been properly recorded.

e. The above "Notice to Applicant" was delivered to me on ... (Date)...; ... (Signature)....

E. Direct Response Notice Form. The notice required by Subsection R590-126-9(C)(2) above for a direct response insurer shall be in substantially the following form: "NOTICE TO APPLICANT REGARDING REPLACEMENT OF DISABILITY INSURANCE"

1. According to (your application) (information you have furnished), you intend to lapse or otherwise terminate existing disability insurance and replace it with the policy delivered herewith issued by (insert Company Name) Insurance Company. Your new policy provides (insert number of days) within which you may decide without cost whether you desire to keep the policy. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy.

a. Health conditions which you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy.

b. You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage.

c. (To be included only if the application is attached to the policy). If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, read the copy of the application attached to your new policy and be sure that all questions are answered fully and correctly. Omissions or misstatements in the application could cause an otherwise valid claim to be denied. Carefully check the application and write to (insert company name and address) within the time allowed if any information is not correct and complete, or if any past medical history has been left out of the application.

F. Exception. The notices described in this section will not be required in the solicitation of accident only or single premium nonrenewable policies.

 

R590-126-10. Penalties.

Persons found, after hearing or other acceptable process, to be in violation of this rule shall be subject to penalties as provided under Section 31A-2-308, U.C.A.

 

R590-126-11. Severability.

If any provision of this rule or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the rule and the application of such provision to other persons or circumstances may not be affected thereby.

 

KEY: insurance law

1993

Notice of Continuation February 1, 2002

31A-2-201

31A-2-202

31A-21-101

31A-21-201

31A-22-605

31A-23-302

31A-23-312

31A-26-301]

R590-126. Accident and Health Insurance Standards.

R590-126-1. Authority.

This rule is issued by the insurance commissioner pursuant to the following provisions of the Utah Insurance Code:

(1) Subsection 31A-2-201(3)(a) authorizes rules to implement the Insurance Code;

(2) Sections 31A-2-202 and 31A-23a-412 authorize the commissioner to request reports, conduct examinations, and inspect records of any licensee;

(3) Subsection 31A-22-605(4) requires the commissioner to adopt rules to establish standards for disclosure in the sale of, and benefits to be provided by individual and franchise accident and health polices;

(4) Section 31A-22-623 authorizes the commissioner to establish by rule minimum standards of coverage for dietary products of inborn metabolic errors;

(5) Section 31A-22-626 authorizes the commissioner to establish by rule minimum standards of coverage for diabetes accident and health insurance;

(6) Subsection 31A-23a-402(8) authorizes the commissioner to define by rule acts and practices that are unfair and unreasonable; and

(7) Subsection 31A-26-301(1) authorizes the commissioner to set standards for timely payment of claims.

 

R590-126-2. Purpose and Scope.

(1) Purpose. The purpose of this rule is to provide reasonable standardization and simplification of terms and coverages of insurance policies in order to facilitate public understanding and comparison and to prohibit provisions 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 insurance.

(2) Scope.

(a) This regulation applies to:

(i) all individual accident and sickness insurance policies and group supplemental health policies and certificates, delivered or issued for delivery in this state on and after January 1, 2006, that are not specifically exempted from this regulation, regardless of:

(A) whether the policy is issued to an association; a trust; a discretionary group; or other similar grouping; or

(B) the situs of delivery of the policy or contract; and

(ii) all dental plans and vision plans.

(b) This rule shall not apply to:

(i) employer accident and health insurance, as defined in Section 31A-22-502;

(ii) policies issued to employees or members as additions to franchise plans in existence on the effective date of this regulation;

(iii) Medicare supplement policies subject to Section 31A-22-620; or

(iv) civilian Health and Medical Program of the Uniformed Services, Chapter 55, title 10 of the United States Code, CHAMPUS supplement insurance policies.

(3) The requirements contained in this regulation shall be in addition to any other applicable regulations previously adopted.

 

R590-126-3. Definitions.

In addition to the definitions of Section 31A-1-301 and Subsection 31A-22-605(2), the following definitions shall apply for the purpose of this rule.

(1) "Accident," "accidental injury," and "accidental means" shall be defined to employ result language and shall not include words that establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characterization.

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

(b) Unless otherwise prohibited by law, the definition may exclude injuries for which benefits are paid under worker's compensation, any employer's liability or similar law, or a motor vehicle no-fault plan.

(2) "Adult Day Care" shall mean a facility duly licensed and operating within the scope of such license. Adult Day Care facility may not be defined more restrictively than providing continuous care and supervision for three or more adults 18 years of age and over for at least four but less than 24 hours a day, that meets the needs of functionally impaired adults through a comprehensive program that provides a variety of health, social, recreational, and related support services in a protective setting.

(3) "Certificate of Completion" shall mean a document issued by the Utah Board of Education to a person who completes an approved course of study not leading to a diploma, or to one who passes a challenge for that same course of study, or to one whose out-of-state credentials and certificate are acceptable to the Board.

(4) "Complications of Pregnancy" shall mean diseases or conditions the diagnoses of which are distinct from pregnancy but are adversely affected or caused by pregnancy and not associated with a normal pregnancy.

(a) "Complications of Pregnancy" include acute nephritis, nephrosis, cardiac decompensation, ectopic pregnancy which is terminated, a spontaneous termination of pregnancy when a viable birth is not possible, puerperal infection, eclampsia, pre-eclampsia and toxemia.

(b) This definition does not include false labor, occasional spotting, doctor prescribed rest during the period of pregnancy, morning sickness, and conditions of comparable severity associated with management of a difficult pregnancy.

(5) "Conditionally Renewable" means renewal can be declined by class, by geographic area or for stated reasons other than deterioration of health.

(6) "Convalescent Nursing Home," "extended care facility," or "skilled nursing facility" shall mean a facility duly licensed and operating within the scope of such license.

(7) "Cosmetic Surgery" or "Reconstructive Surgery" shall mean any surgical procedure performed primarily to improve physical appearance.

(a) This definition does not include surgery, which is necessary:

(i) to correct damage caused by injury or sickness;

(ii) for reconstructive treatment following medically necessary surgery;

(iii) to provide or restore normal bodily function; or

(iv) to correct a congenital disorder that has resulted in a functional defect.

(b) This provision does not require coverage for preexisting conditions otherwise excluded.

(8) "Custodial Care" shall mean a Plan of Care, which does not provide treatment for sickness or injury, but is only for the purpose of meeting personal needs and maintaining physical condition when there is no prospect of effecting remission or restoration of the patient to a condition in which care would not be required. Such care may be provided by persons without nursing skills or qualifications. If a nursing care facility is only providing custodial or residential care, the level of care may be so characterized.

(9) "Disability Income" shall mean income replacement as defined in Section 31A-1-301.

(10) "Elimination Period" or "Waiting Period" means the length of time an insured shall wait before benefits are paid under the policy.

(11) "Enrollment Form" shall mean application as defined in Section 31A-1-301.

(12) "Experimental Treatment" is defined as medical treatment, services, supplies, medications, drugs, or other methods of therapy or medical practices which are not accepted as a valid course of treatment by the Utah Medical Association, the U.S. Food and Drug Administration, the American Medical Association, or the Surgeon General.

(13) "Group Supplemental Health Insurance" means group accident and sickness insurance policies and certificates providing hospital confinement indemnity, accident only, specified disease, specified accident or limited benefit health coverage.

(14) "Guaranteed Renewable" means renewal cannot be declined by the insurance company for any reasons, but the insurance company can revise rates on a class basis.

(15) "Home Health Agency" shall mean a public agency or private organization, or subdivision of a health care facility, licensed and operating within the scope of such license.

(16) "Home Health Aide" shall mean a person who obtains a Certificate of Completion, as required by law, which allows performance of health care and other related services under the supervision of a registered nurse from the home health agency, or performance of simple procedures as an extension of physical, speech, or occupational therapy under the supervision of licensed therapists.

(17) "Home Health Care" shall mean services provided by a home health agency.

(18) "Homemaker" shall mean a person who cares for the environment in the home through performance of duties such as housekeeping, meal planning and preparation, laundry, shopping and errands.

(19) "Homemaker/Home Health Aide" shall mean a person who has obtained a Certificate of Completion, as required by law, which allows performance of both homemaker and home health aide services, and who provides health care and other related services under the supervision of a registered nurse from the home health agency or under the supervision of licensed therapists.

(20) "Hospice" shall mean a program of care for the terminally ill and their families which occurs in a home or in a health care facility and which provides medical, palliative, psychological, spiritual, or supportive care and treatment and is licensed and operating within the scope of such license.

(21) "Hospital" means a facility that is licensed and operating within the scope of such license. This definition may not preclude the requirement of medical necessity of hospital confinement or other treatment.

(22) "Intermediate Nursing Care" shall mean nursing services provided by, or under the supervision of, a registered nurse. Such care shall be for the purpose of treating the condition for which confinement is required.

(23) "Medical Necessity" means:

(a) health care services or products that a prudent health care professional would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is:

(i) in accordance with generally accepted standards of medical practice in the United States;

(ii) clinically appropriate in terms of type, frequency, extent, site, and duration;

(iii) not primarily for the convenience of the patient, physician, or other health care provider; and

(iv) covered under the contract;

(b) when a medical question-of-fact exists medical necessity shall include the most appropriate available supply or level of service for the individual in question, considering potential benefits and harms to the individual, and known to be effective.

(i) For interventions not yet in widespread use, the effectiveness shall be based on scientific evidence.

(ii) For established interventions, the effectiveness shall be based on:

(A) scientific evidence;

(B) professional standards; and

(C) expert opinion.

(24) "Medicare" means the "Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended."

(25) "Medicare Supplement Policy" shall mean an individual, franchise, or group policy of accident and health insurance, other than a policy issued pursuant to a contract under section 1876 of the federal Social Security Act, 42 U.S.C. section 1395 et seq., or an issued policy under a demonstration project specified in 41 U.S.C. section 1395ss(g)(1), that is advertised, marketed, or primarily designed as a supplement to reimbursements under Medicare for hospital, medical, or surgical expenses of persons eligible for Medicare.

(26) "Mental or Nervous Disorders" may not be defined more restrictively than a definition including neurosis, psychoneurosis, psychosis, or any other mental or emotional disease or disorder which does not have a demonstrable organic cause.

(27) "Non-Cancelable" means renewal cannot be declined nor can rates be revised by the insurance company.

(28) "Nurse" may be defined so that the description of nurse is restricted to a type of nurse, such as registered nurse, or licensed practical nurse. If the words "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 applicable statutes or administrative rules.

(29) "Nurse, Licensed Practical" shall mean a person who is registered and licensed to practice as a practical nurse.

(30) "Nurse, Registered" shall mean any person who is registered and licensed to practice as a registered nurse.

(31) "Nursing Care" shall mean assistance provided for the health care needs of sick or disabled individuals, by or under the direction of licensed nursing personnel.

(32) "One Period of Confinement" shall mean consecutive days of in-hospital service received as an inpatient, or successive confinements when discharge from and readmission to the hospital occurs within a period of time of not more than 90 days or three times the maximum number of days of in-hospital coverage provided by the policy up to a maximum of 180 days.

(33) "Optionally Renewable" means renewal is at the option of the insurance company.

(34) "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; customary duties of a homemaker or dependent; or may be related to a percentage of time worked or to a specified number of hours or to compensation.

(35) "Personal Care" shall mean assistance, under a plan of care by a home health agency, provided to persons in activities of daily living.

(36) "Personal Care Aide" shall mean a person who obtains a Certificate of Completion, as required by law, which allows that person to assist in the activities of daily living and emergency first aid, and who must be supervised by a registered nurse from the home health agency.

(37) "Physician" may be defined by including words such as qualified physician or licensed physician. The use of such terms requires an insurer to recognize and to accept, to the extent of its obligation under the contract, all providers of medical care and treatment when such services are within the scope of the provider's licensed authority and are provided pursuant to applicable laws.

(38) "Preexisting Condition."

(a) Except as provided in Section (b), a preexisting condition shall not be defined more restrictively than the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within a two 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 two year period preceding the effective date of the coverage of the insured person.

(b) A specified disease insurance policy shall not define preexisting condition more restrictively than a condition which first manifested itself within six months prior to the effective date of coverage or which was diagnosed by a physician at any time prior to the effective date of coverage.

(39) "Probationary Period" shall mean the period of time following the date of issuance or effective date of the policy before coverage begins for all or certain conditions.

(40) "Residential Health Care Facility" shall mean a publicly or privately operated and maintained facility providing personal care to residents who require protected living arrangements which is licensed and operating within the scope of such license.

(41) "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 duties for as long as is usually required.

(42) "Respite Care" shall mean provision of temporary support to the primary caregiver of the aged, disabled, or handicapped individual insured, by taking over the tasks of that person for a limited period of time. The insured may receive care in the home, or other appropriate community location, or in an appropriate institutional setting.

(43)(a) "Scientific evidence" means:

(i) scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff; or

(ii) findings, studies or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes.

(b) Scientific evidence shall not include published peer-reviewed literature sponsored to a significant extent by a pharmaceutical manufacturing company or medical device manufacturer or a single study without other supportable studies.

(44) "Sickness" means illness, disease, or disorder of an insured person.

(45) "Skilled Nursing Care" shall mean nursing services provided by, or under the supervision of, a registered nurse. Such care shall be for the purpose of treating the condition for which the confinement is required and not for the purpose of providing intermediate or custodial care.

(46) "Therapist" may be defined as a professionally trained or duly licensed or registered person, such as a physical therapist, occupational therapist, or speech therapist, who is skilled in applying treatment techniques and procedures under the general direction of a physician.

(47)(a) "Total Disability" shall mean an individual who:

(i) is not engaged in employment or occupation for which he is or becomes qualified by reason of education, training or experience; and

(ii) is unable to perform all of the substantial and material duties of his or her regular occupation or words of similar import.

(b) An insurer may require care by a physician other than the insured or a member of the insured's immediate family.

(c) The definition may not exclude benefits based on the individual's:

(i) ability to engage in any employment or occupation for wage or profit;

(ii) inability to perform any occupation whatsoever, any occupational duty, or any and every duty of his occupation; or

(iii) inability to engage in any training or rehabilitation program.

(48)(a) "Usual and Customary" shall mean the most common charge for similar services, medicines or supplies within the area in which the charge is incurred.

(b) In determining whether a charge is usual and customary, insurers shall consider one or more of the following factors:

(i) the level of skill, extent of training, and experience required to perform the procedure or service;

(ii) the length of time required to perform the procedure or services as compared to the length of time required to perform other similar services;

(iii) the severity or nature of the illness or injury being treated;

(iv) the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged for the same or comparable services, medicines or supplies in other parts of the country;

(v) the cost to the provider of providing the service, medicine or supply; and

(vi) other factors determined by the insurer to be appropriate.

(49) "Waiting Period" shall mean "Elimination Period."

 

R590-126-4. Prohibited Policy Provisions.

(1) Probationary periods.

(a) A policy shall not contain provisions establishing a probationary period during which no coverage is provided under the policy, subject to the further exception that a policy may specify a probationary period not to exceed six months for specified diseases or conditions and losses resulting from disease or condition related to:

(i) adenoids;

(ii) appendix;

(iii) disorder of reproductive organs;

(iv) hernia;

(v) tonsils; and

(vi) varicose veins.

(b) The six-month period in Subsection (1)(a) may not be applicable where such specified diseases or conditions are treated on an emergency basis.

(c) Accident policies may not contain probationary or waiting periods.

(d) A probationary or waiting period for a specified disease policy shall not exceed 30 days.

(2) Preexisting conditions.

(a) Except as provided in Subsections (b) and (c), a policy shall not exclude coverage for a loss due to a preexisting condition for a period greater than 12 months following the issuance of the policy or certificate where the application or enrollment form for the insurance does not seek disclosure of prior illness, disease or physical conditions or prior medical care and treatment and the preexisting condition is not specifically excluded by the terms of the policy or certificate.

(b) A specified disease policy shall not exclude coverage for a loss due to a preexisting condition for a period greater than six months following the issuance of the policy or certificate, unless the preexisting condition is specifically excluded.

(c) A hospital confinement indemnity policy shall not exclude a preexisting condition for a period greater than 12 months following the effective date of coverage of an insured person unless the preexisting condition is specifically and expressly excluded.

(d) Any preexisting condition elimination period must be reduced by any applicable creditable coverage.

(3) Hospital indemnity. Policies providing hospital confinement indemnity coverage shall not contain provisions excluding coverage because of confinement in a hospital operated by the federal government.

(4) Limitations or exclusions. A policy shall not limit or exclude coverage or benefits by type of illness, accident, treatment or medical condition, except as follows:

(a) abortion;

(b) acupuncture and acupressure services;

(c) administrative charges for completing insurance forms, duplication services, interest, finance charges, or other administrative charges, unless otherwise required by law;

(d) administrative exams and services;

(e) allergy tests and treatments;

(f) aviation;

(g) axillary hyperhidrosis;

(h) benefits provided under:

(A) Medicare or other governmental program, except Medicaid;

(B) state or federal worker's compensation; or

(C) employer's liability or occupational disease law.

(i) cardiopulmonary fitness training, exercise equipment, and membership fees to a spa or health club;

(j) charges for appointments scheduled and not kept;

(k) chiropractic;

(l) complementary and alternative medicine;

(m) corrective lenses, and examination for the prescription or fitting thereof, but policies may not exclude required lens implants following cataract surgery;

(n) cosmetic surgery including gastric bypass; reversal, revision, repair or treatment related to a non-covered cosmetic surgery, except that cosmetic surgery shall not include reconstructive surgery when the 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 that has resulted in a functional defect;

(o) custodial care;

(p) dental care or treatment, except dental plans;

(q) dietary products, except as required by R590-194;

(r) educational and nutritional training, except as required by R590-200;

(s) experimental and/or investigational services;

(t) felony, riot or insurrection, when the insured is a voluntary and active participant;

(u) foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain or symptomatic complaints of the feet, including orthotics. The exclusion of routine foot care does not apply to cutting or removal of corns, calluses, or nails when provided to a person who has a systemic disease, such as diabetes with peripheral neuropathy or circulatory insufficiency, of such severity that unskilled performance of the procedure would be hazardous;

(v) gene therapy;

(w) genetic testing;

(x) hearing aids, and examination for the prescription or fitting thereof;

(y) illegal activities, limited to losses related directly to the insured's voluntary participation;

(z) incarceration, with respect to disability income policies;

(aa) infertility services, except as required by R590-76;

(bb) interscholastic sports, with respect to short-term nonrenewable policies;

(cc) mental or emotional disorders, alcoholism and drug addictions;

(dd) motor vehicle no-fault law, except when the covered person is required by law to have no-fault coverage, the exclusion applies to charges up to the minimum coverage required by law whether or not such coverage is in effect;

(ee) nuclear release;

(ff) preexisting conditions or diseases as allowed under Subsection R590-126-4(2), except for coverage of congenital anomalies as required by Section 31A-22-610;

(gg) pregnancy, except for complications of pregnancy;

(hh) refractive eye surgery;

(ii) rehabilitation therapy services (physical, speech, and occupational), unless required to correct an impairment caused by a covered accident or illness;

(jj) respite care;

(kk) rest cures;

(ll) routine physical examinations;

(mm) service in the armed forces or units auxiliary to it;

(nn) services rendered by employees of hospitals, laboratories or other institutions;

(oo) services performed by a member of the covered person's immediate family;

(pp) services for which no charge is normally made in the absence of insurance;

(qq) sexual dysfunction;

(rr) shipping and handling, unless otherwise required by law;

(ss) suicide, sane or insane, attempted suicide, or intentionally self-inflicted injury;

(tt) telephone/electronic consultations;

(uu) territorial limitations outside the United States;

(vv) terrorism, including acts of terrorism;

(ww) transplants;

(xx) transportation;

(yy) treatment provided in a government hospital, except for hospital indemnity policies; or

(zz) war or act of war, whether declared or undeclared.

(5) Waivers. This rule shall not impair or limit the use of waivers to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases, physical condition or extra hazardous activity. Where waivers are required as a condition of issuance, renewal or reinstatement, signed acceptance by the insured is required.

(6) Commissioner authority. Policy provisions precluded in this section shall not be construed as a limitation on the authority of the commissioner to prohibit other policy provisions that in the opinion of the commissioner are unjust, unfair or unfairly discriminatory to the policyholder, beneficiary or a person insured under the policy.

 

R590-126-5. General Requirements.

(1) Policy definitions. No policy subject to this rule may contain definitions respecting the matters defined in Section R590-126-3 unless such definitions comply with the requirements of that section.

(2) Rights of spouse. The following provisions apply to policies that provide coverage to a spouse of the insured:

(a) A policy may 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 for nonpayment of premium.

(b) A policy shall provide that in the event of the insured's death the spouse of the insured shall become the insured.

(c) The age of the younger spouse shall be used as the basis for meeting the age and durational requirements of the noncancellation or renewal provisions of the policy. However, this requirement may not prevent termination of coverage of the older spouse upon attainment of stated age limit in the policy, so long as the policy may be continued in force as to the younger spouse to the age or for durational period as specified in said definition.

(3) Cancellation, Renewability, and Termination.

The terms "conditionally renewable," "guaranteed renewable," "noncancellable," or "optionally renewable" shall not be used without further explanatory language in accordance with the disclosure requirements of Subsection R590-126-6(2).

(a) Conditionally renewable. The term "conditionally renewable" may be used only in a policy which the insured may have the right to continue in force by the timely payment of premiums at least to age 65, during which period the insurer has no right to make any unilateral change to the detriment of the insured while the policy is in force. However, the insurer, at its option, and by timely notice, may decline renewal for reasons stated in the policy, or may make changes in premium rates by classes.

(b) Guaranteed renewable. The term "guaranteed renewable" may be used only in a policy which the insured has the right to continue in force by the timely payment of premiums at least to age 65, during which period the insurer has no right to make any unilateral change to the detriment of the insured while the policy is in force, except that the insurer may make changes in premium rates by classes.

(c) Noncancellable. The term "noncancellable" may be used only in a policy that the insured has the right to continue in force by the timely payment of premiums until the age of 65, during which period the insurer has no right to make unilaterally any change in any provision of the policy to the detriment of the insured.

(d) Optionally renewable. The term "optionally renewable" may be used only in a policy which the insured may have the right to continue in force by the timely payment of premiums at least to age 65, during which period the insurer has no right to make any unilateral change in any provision of the policy while the policy is in force. However, the insurer, at its option, and by timely notice, may decline renewal of the policy or may make changes in premium rates by classes.

(e) Notice of nonrenewal shall be given 90 days prior to nonrenewal.

(f) A policy may not be cancelled or nonrenewed solely on the grounds of deterioration of health.

(g) Termination of the policy shall be without prejudice to a continuous loss that commenced while the policy or certificate was in force. The continuous total disability of the insured may be a condition for the extension of benefits beyond the period the policy was in force, limited to the duration of the benefit period, if any, or payment of the maximum benefits.

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

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

(6) Pregnancy benefit extension. In the event the insurer cancels or refuses to renew a policy providing pregnancy benefits, the policy shall provide an extension of benefits for a pregnancy commencing while the policy is in force and for which benefits would have been payable had the policy remained in force. This requirement does not apply to a policy that is canceled for the following reasons:

(a) the insured fails to pay the required premiums in accordance with the terms of the plan; or

(b) the insured person performs an act or practice that constitutes fraud in connection with the coverage or makes an intentional misrepresentation of material fact under the terms of the coverage.

(7) Post hospital admission requirement. A policy providing convalescent or extended care benefits following hospitalization shall not condition the benefits upon admission to the convalescent or extended care facility within a period of less than 14 days after discharge from the hospital.

(8) Transplant donor coverage. A policy providing 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 or certificate, after benefits for the recipient's own expenses have been paid.

(9) Recurrent disability. A policy may contain a provision relating to recurrent disabilities, but a provision relating to recurrent disabilities shall not specify that a recurrent disability be separated by a period greater than 6 months.

(10) Time limit for occurrence of loss.

(a) Accidental death and dismemberment benefits shall be payable if the loss occurs within 180 days from the date of the accident, irrespective of total disability.

(b) Disability income benefits, if provided, shall not require the loss to commence less than 30 days after the date of accident, nor shall any policy that the insurer cancels or refuses to renew require that it be in force at the time disability commences if the accident occurred while the coverage was in force.

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

(12) A policy providing coverage for fractures or dislocations may not provide benefits only for "full or complete" fractures or dislocations.

(13) Specified disease, also known as critical illness, dread disease, etc., insurance sold in conjunction with another insurance product, including but not limited to life insurance or annuities, shall be in the form of a separate endorsement complying with all provisions of this rule. Specified Disease insurance shall not be incorporated into a life insurance policy or annuity contract.

(14) Notice of premium change. A notice of change in premium shall be given no fewer than 45 days before the renewal date.

 

R590-126-6. Required Provisions.

(1) Applications.

(a) Questions used to elicit health condition information may not be vague and must reference a reasonable time frame in relation to the health condition.

(b) Completed applications shall be attached and made part of the policy.

(c) All applications shall contain a prominent statement by type, stamp or other appropriate means in either contrasting color or in boldface type at least equal to the size type used for the headings or captions of sections of the application and in close conjunction with the applicant's signature block on the application as follows:

"The (policy) (certificate) provides limited benefits. Review your (policy) (certificate) carefully."

(d) Application forms shall disclose the pre-existing waiting period and the requirements to receive any applicable credit for previous coverage.

(e) An application form shall include a question designed to elicit information as to whether the insurance to be issued is intended to replace any other accident and health insurance presently in force. A supplementary application or other form to be signed by the applicant containing the question may be used.

(f) All applications for dental and vision plans shall contain a prominent statement by type, stamp or other appropriate means in either contrasting color or in boldface type at least equal to the size type used for the headings or captions of sections of the application and in close conjunction with the applicant's signature block on the application as follows:

"The (policy) (certificate) provides (dental) (vision) benefits only. Review your (policy) (certificate) carefully."

(2) Renewal and nonrenewal provisions. Accident and health insurance shall include a renewal, continuation or nonrenewal provision. The language or specification of the provision shall be consistent with the type of contract to be issued. The provision shall be appropriately captioned, shall appear on the first page of the policy, and shall clearly state the duration, where limited, of renewability and the duration of the term of coverage for which the policy is issued and for which it may be renewed.

(3) Endorsement acceptance.

(a) Except for endorsements by which the insurer effectuates a request made in writing by the policyholder or exercises a specifically reserved right under the policy, all endorsements added to a policy after date of issue or at reinstatement or renewal that reduce or eliminate benefits or coverage in the policy shall require signed acceptance by the policyholder.

(b) After the date of policy issue, any endorsement that increases benefits or coverage with a concurrent increase in premium during the policy term, must be agreed to in writing signed by the policyholder, except if the increased benefits or coverage is required by law.

(4) Additional premium. Where a separate additional premium is charged for benefits provided in connection with endorsements, the premium charge shall be set forth in the policy or certificate.

(5) Benefit payment standard. A policy or certificate that 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 the terms and an explanation of the terms in its accompanying outline of coverage.

(6) Preexisting conditions. If a policy or certificate contains any limitations with respect to preexisting conditions, the limitations shall appear as a separate paragraph of the policy or certificate and be labeled as "Preexisting Condition Limitations."

(7)(a) An accident only policy or certificate shall contain a prominent statement on the first page of the policy or certificate, in either contrasting color or in boldface type at least equal to the size of type used for headings or captions of sections in the policy or certificate, as follows:

Notice to Buyer: This is an accident only (policy)(certificate) and it does not pay benefits for loss from sickness. Review your (policy)(certificate) carefully.

(b) Accident only policies or certificates that provide coverage for hospital or medical care shall contain the following statement in addition to the notice above:

This (policy)(certificate) provides limited benefits. Benefits provided are supplemental and are not intended to cover all medical expenses.

(8) Age limitation. If age is to be used as a determining factor for reducing the maximum aggregate benefits made available in the policy or certificate as originally issued, that fact shall be prominently set forth in the outline of coverage and schedule page.

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

(10) Conversion privilege. If a policy or certificate contains a conversion privilege, it shall comply, in substance, with the following: The caption of the provision shall read "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.

(11) Specified Disease Insurance Buyers Guide. An insurer, except a direct response insurer, shall give a person applying for specified disease insurance, a buyer's guide filed with the commissioner at the time of enrollment and shall obtain recipient's written acknowledgement of the guide's delivery. A direct response insurer shall provide the buyer's guide upon request, but not later than the time that the policy or certificate is delivered.

(12) Specified disease policies or certificates shall contain on the first page or attached to it in either contrasting color or in boldface type, at least equal to the size type used for headings or captions of sections in the policy or certificate, a prominent statement as follows:

Notice to Buyer: This is a specified disease (policy) (certificate). This (policy) (certificate) provides limited benefits. Benefits provided are supplemental and are not intended to cover all medical expenses. Read your (policy) (certificate) carefully with the outline of coverage and the buyer's guide.

(13) Hospital confinement indemnity and limited benefit health policies or certificates shall display prominently by type, stamp or other appropriate means on the first page of the policy or certificate, or attached to it, in either contrasting color or in boldface type at least equal to the size type used for headings or captions of sections in the policy or certificate the following:

Notice to Buyer: This is a (hospital confinement indemnity) (limited benefit health) (policy) (certificate). This (policy) (certificate) provides limited benefits. Benefits provided are supplemental and are not intended to cover all medical expenses.

(14) Basic hospital, basic medical-surgical, and basic hospital-medical surgical expense policies and certificates shall display prominently by type, stamp or other appropriate means on the first page of the policy or certificate, or attached to it, in either contrasting color or in boldface type at least equal to the size type used for headings or captions of sections in the policy or certificate the following:

Notice to Buyer: This is a (basic hospital) (basic medical-surgical) (basic hospital/medical-surgical) expense (policy)(certificate). This (policy) (certificate) provides limited benefits and should not be considered a substitute for comprehensive health insurance coverage.

(15) Dental and vision coverage policies and certificates shall display prominently by type or stamp on the first page of the policy or certificate, or attached to it, in either contrasting color or in boldface type at least equal to the size type used for headings or captions of sections in the policy or certificate the following:

Notice to Buyer: This (policy) (certificate) provides (dental) (vision) coverage only.

 

R590-126-7. Accident and Health Standards for Benefits.

The following standards for benefits are prescribed for the categories of coverage noted in the following subsections. An accident and health insurance policy or certificate subject to this rule shall not be delivered or issued for delivery unless it meets the required standards for the specified categories. This section shall not preclude the issuance of any policy or contract combining two or more categories set forth in Subsection 31A-22-605(5).

Benefits for coverages listed in this section shall include coverage of inborn metabolic errors as required by Section 31A-22-623 and Rule R590-194, and benefits for diabetes as required by Section 31A-22-626 and Rule R590-200, if applicable.

(1) Basic Hospital Expense Coverage.

Basic hospital expense coverage is a policy of accident and health insurance that provides coverage for a period of not less than 31 days during a 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, and shall include at least the following:

(a) daily hospital room and board in an amount not less than:

(i) 80% of the charges for semiprivate room accommodations; or

(ii) $100 per day;

(b) miscellaneous hospital services for expenses incurred for the charges made by the hospital for services and supplies that are customarily rendered by the hospital and provided for use only during any one period of confinement in an amount not less than either:

(i) 80% of the charges incurred up to at least $3000; or

(ii) ten times the daily hospital room and board benefits; and

(c) hospital outpatient services consisting of:

(i) hospital services on the day surgery is performed;

(ii) hospital services rendered within 72 hours after injury, in an amount not less than $250 per accident; and

(iii) x-ray and laboratory tests to the extent that benefits for the services would have been provided if rendered to an in-patient of the hospital to an extent not less than $200;

(d) benefits provided under Subsections (a) and (b) may be provided subject to a combined deductible amount not in excess of $200.

(2) Basic Medical-Surgical Expense Coverage.

Basic medical-surgical expense coverage is a policy of accident and health insurance that 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 and shall include at least the following:

(a) surgical services:

(i) in amounts not less than those provided on a current procedure terminology based relative value fee schedule, up to at least $1000 for one procedure; or

(ii) 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 physician, or the physician assistant, performing the surgical services:

(i) in an amount not less than 80% of the reasonable charges; or

(ii) 15% of the surgical service benefit; and

(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:

(i) 80% of the reasonable charges; or

(ii) $100 per day.

(3) Basic Hospital/Medical-Surgical Expense Coverage.

Basic hospital/medical-surgical expense coverage is a policy of accident and health which combines coverage and must meet the requirements of both Subsections R590-126-7(1) and (2).

(4) Hospital Confinement Indemnity Coverage.

(a) Hospital confinement indemnity coverage is a policy of accident and health insurance that provides daily benefits for hospital confinement on an indemnity basis.

(b) Coverage includes an indemnity amount of not less than $50 per day and not less than 31 days during each period of confinement for each person insured under the policy.

(c) Benefits shall be paid regardless of other coverage.

(5) Income Replacement Coverage.

Income replacement coverage is a policy of accident and health insurance that 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 of both that:

(a) contains an elimination period no greater than:

(i) 90-days in the case of a coverage providing a benefit of one year or less;

(ii) 180 days in the case of coverage providing a benefit of more than one year but not greater than two years; or

(iii) 365 days in all other cases during the continuance of disability resulting from sickness or injury;

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

(c) where a policy provides total disability benefits and partial disability benefits, only one elimination period may be required;

(d) a policy which provides for residual disability benefits may require a qualification period, during which the insured shall 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;

(e) the provisions of this subsection do not apply to policies providing business buyout coverage.

(6) Accident Only Coverage.

Accident only coverage is a policy of accident and health insurance that 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 the policy shall be at least $1,000 and a single dismemberment amount shall be at least $500.

(7) Specified Accident Coverage.

Specified accident coverage is a policy of accident and health insurance that 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 for accidental death, $1,000 for double dismemberment and $500 for single dismemberment.

(8) Specified Disease Coverage.

Specified disease coverage is a policy of accident and health insurance that provides coverage for the diagnosis and treatment of a specifically named disease or diseases, and includes critical illness coverages. Any such policy shall meet these general provisions. The policy shall also meet the standards set forth in the applicable Subsections R590-126-7(8)(b), (c) or (d).

(a) General Provisions.

(i) Policy designation. 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 Subsection (8).

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

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

(iv) Renewability. Specified disease coverage shall be at least guaranteed renewable.

(v) Probationary period. No policy issued pursuant to this section may contain a probationary period greater than 30 days.

(vi) Medicaid disclaimer. Any application for specified disease coverage shall contain a statement above the signature of the applicant that no person to be covered for specified disease is also covered by any Title XIX program, designated as Medicaid or any similar name. Such statement may be combined with any other statement for which the insurer may require the applicant's signature.

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

(viii) Other insurance. Benefits for specified disease coverage shall be paid regardless of other coverage.

(ix) Retroactive application of coverage. After the effective date of the coverage, or the conclusion of an applicable probationary 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.

(x) Hospice. Hospice care is an optional benefit, but if offered it shall meet the following minimum standards:

(i) eligibility for payment of benefits when the attending physician of the insured provides a written statement that the insured person has a life expectance of six months or less;

(ii) fixed-sum payment of at least $50 per day; and

(iii) lifetime maximum benefit of at least $10,000.

(b) Expense Incurred Benefits. The following benefit standards apply to specified disease coverage on an expense-incurred basis.

(i) Policy limits. A deductible amount not to exceed $250, an aggregate benefit limit of not less than $25,000 and a benefit period of not fewer than three years.

(ii) Copayment. Covered services provided on an outpatient basis may be subject to a copayment which may not exceed 20%.

(iii) Covered Services. Covered services shall include the following:

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

(B) treatment by, or under the direction of, a legally qualified physician or surgeon;

(C) private duty nursing services of a registered nurse, or licensed practical nurse;

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

(E) blood transfusions, and the administration thereof, including expense incurred for blood donors;

(F) drugs and medicines prescribed by a physician;

(G) professional ambulance for local service to or from a local hospital;

(H) the rental of any respiratory or other mechanical apparatuses;

(I) braces, crutches and wheelchairs 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;

(K) home health care with a written prescribed plan of care;

(L) physical, speech, hearing and occupational therapy;

(M) special equipment including hospital bed, toilette, pulleys, wheelchairs, aspirator, chux, oxygen, surgical dressings, rubber shields, colostomy and eleostomy appliances;

(N) prosthetic devices including wigs and artificial breasts;

(O) nursing home care for non-custodial services; and

(P) reconstructive surgery when deemed necessary by the attending physician.

(c) Per Diem Benefits. The following benefit standards apply to specified disease coverage on a per diem basis.

(i) Covered services shall include the following:

(A) hospital confinement benefit with a fixed-sum payment of at least $200 for each day of hospital confinement for at least 365 days, with no deductible amount permitted;

(B) outpatient benefit with a fixed-sum payment equal to one half the hospital inpatient benefits for each day of hospital or non-hospital outpatient surgery, radiation therapy and chemotherapy, for at least 365 days of treatment; and

(C) blood and plasma benefit with a fixed-sum benefit of at least $50 per day for blood and plasma, which includes their administration whether received as an inpatient or outpatient for at least 365 days of treatment.

(ii) Benefits tied to confinement in a skilled nursing home or home health care are optional. If a policy offers these benefits, they must equal the following:

(A) fixed-sum payment equal to one-half the hospital inpatient benefit for each day of skilled nursing home confinement for at least 180 days; and

(B) fixed-sum payment equal to one-fourth the hospital inpatient benefit for each day of home health care for at least 180 days.

(C) Any restriction or limitation applied to the benefits may not be more restrictive than those under Medicare.

(d) Lump Sum Benefits. The following benefit standards apply to specified disease coverage on a lump sum basis.

(i) Benefits shall be payable as a fixed, one-time payment, made within 30 days of submission to the insurer, of proof of diagnosis of the specified disease. Dollar benefits shall be offered for sale only in even increments of $1,000.

(ii) Where coverage is advertised or otherwise represented to offer generic coverage of a disease or diseases, e.g., "cancer insurance," "heart disease insurance," the same dollar amounts shall be payable regardless of the particular subtype of the disease, e.g., lung or bone cancer, with one exception. In the case of clearly identifiable subtypes with significantly lower treatment costs, e.g., skin cancer, lesser amounts may be payable so long as the policy clearly differentiates that subtype and its benefits.

(9) Limited Benefit Health Coverage.

Limited benefit health coverage is a policy of accident and health insurance, other than a policy covering only a specified disease or diseases, that provides benefits that are less than the standards for benefits required under this Section. These policies or contracts may be delivered or issued for delivery with the outline of coverage required by Section R590-126-8.

 

R590-126-8. Outline of Coverage Requirements.

(1) Basic Hospital Expense Coverage.

An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of Subsection R590-126-7(1). The items included in the outline of coverage must appear in the sequence prescribed:

 

TABLE I

(COMPANY NAME)



BASIC HOSPITAL EXPENSE COVERAGE



THIS (POLICY)  (CERTIFICATE)  PROVIDES LIMITED BENEFITS AND

SHOULD NOT BE CONSIDERED A SUBSTITUTE FOR

COMPREHENSIVE HEALTH INSURANCE COVERAGE



OUTLINE OF COVERAGE



Read Your (Policy)(Certificate)  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)(CERTIFICATE)  CAREFULLY!

Basic hospital expense coverage is 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 outpatient 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.

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: daily hospital room and

board; miscellaneous hospital services; hospital out-patient

services; and other benefits, if any.

A description of any policy provisions that exclude,

eliminate, restrict, reduce, limit, delay or in any other manner

operate to qualify payment of the benefits.

A description of policy provisions respecting renewability or

continuation of coverage, including age restrictions or any

reservation of right to change premiums.

 

(2) Basic Medical-Surgical Expense Coverage.

An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of Subsection R590-126-7(2). The items included in the outline of coverage must appear in the sequence prescribed:

 

TABLE II

(COMPANY NAME)



BASIC MEDICAL-SURGICAL EXPENSE COVERAGE



THIS (POLICY)(CERTIFICATE)  PROVIDES LIMITED BENEFITS AND

SHOULD NOT BE CONSIDERED A SUBSTITUTE FOR

COMPREHENSIVE HEALTH INSURANCE COVERAGE



OUTLINE OF COVERAGE



Read Your (Policy)(Certificate)  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)  (CERTIFICATE)  CAREFULLY!

Basic medical-surgical expense coverage is 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

or unlimited medical-surgical expenses.

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:

surgical services;

anesthesia services;

in-hospital medical services; and

other benefits, if any.

A description of any policy provisions that exclude, eliminate,

restrict, reduce, limit, delay, or in any other manner operate

to qualify payment of the benefits.

A description of policy provisions respecting renewability or

continuation of coverage, including age restrictions or any

reservation of right to change premiums.

 

(3) Basic Hospital/Medical-Surgical Expense Coverage.

An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of Subsections R590-126-7(3). The items included in the outline of coverage must appear in the sequence prescribed.

 

TABLE III

(COMPANY NAME)



BASIC HOSPITAL/MEDICAL-SURGICAL EXPENSE COVERAGE



THIS (POLICY)(CERTIFICATE)  PROVIDES LIMITED BENEFITS AND

SHOULD NOT BE CONSIDERED A SUBSTITUTE FOR

COMPREHENSIVE HEALTH INSURANCE COVERAGE



OUTLINE OF COVERAGE



Read Your (Policy)(Certificate)  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)  (CERTIFICATE)  CAREFULLY!

Basic hospital/medical-surgical expense coverage is 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

outpatient 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.

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:

daily hospital room and board;

miscellaneous hospital services;

hospital outpatient services;

surgical services;

anesthesia services;

in-hospital medical services; and

other benefits, if any.

A description of any policy provisions that exclude, eliminate,

restrict, reduce, limit, delay, or in any other manner operate

to qualify payment of the benefits.

A description of policy provisions respecting renewability or

continuation of coverage, including age restrictions or any

reservation of right to change premiums.

 

(4) Hospital Confinement Indemnity Coverage.

An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of Subsection R590-126-7(4). The items included in the outline of coverage must appear in the sequence prescribed:

 

TABLE IV

(COMPANY NAME)



HOSPITAL CONFINEMENT INDEMNITY COVERAGE



THIS (POLICY)(CERTIFICATE)  PROVIDES LIMITED BENEFITS

BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT

INTENDED TO COVER ALL MEDICAL EXPENSES



OUTLINE OF COVERAGE



Read Your (Policy)(Certificate)  Carefully-This outline of

coverage provides a very brief description of the important

features of coverage.  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)  (CERTIFICATE)  CAREFULLY!

Hospital confinement indemnity coverage is 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.  Coverage is not provided for any benefits

other than the fixed daily indemnity for hospital confinement

and any additional benefit described below.

A brief specific description of the benefits in the following

order:

daily benefit payable during hospital confinement; and

duration of benefit.

A description of any policy provisions that exclude, eliminate,

restrict, reduce, limit, delay or in any other manner operate

to qualify payment of the benefit.

A description of policy provisions respecting renewability or

continuation of coverage, including age restrictions or any

reservation of right to change premiums.

Any benefits provided in addition to the daily hospital

benefit.

 

(5) Income Replacement Coverage.

An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of Subsection R590-126-7(5). The items included in the outline of coverage must appear in the sequence prescribed:

 

TABLE V

(COMPANY NAME)



INCOME REPLACEMENT COVERAGE



THIS (POLICY)  (CERTIFICATE)  PROVIDES LIMITED BENEFITS

BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED

TO COVER ALL EXPENSES



OUTLINE OF COVERAGE



Read Your (Policy)(Certificate)  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)(CERTIFICATE)  CAREFULLY!

Income replacement coverage is 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.

A brief specific description of the benefits contained in the

policy.

A description of any policy provisions that exclude, eliminate,

restrict, reduce, limit, delay or in any other manner operate to

qualify payment of the benefits.

A description of policy provisions respecting renewability or

continuation of coverage, including age restrictions or any

reservation of right to change premiums.

 

(6) Accident Only Coverage.

An outline of coverage in the form prescribed below shall be issued in connection with policies meeting the standards of Subsection R590-126-7(6). The items included in the outline of coverage must appear in the sequence prescribed:

 

TABLE VI

(COMPANY NAME)



ACCIDENT ONLY COVERAGE



THIS (POLICY)(CERTIFICATE)  PROVIDES LIMITED BENEFITS

BENEFITS PROVIDED ARE SUPPLEMENTAL AND NOT INTENDED

TO COVER ALL MEDICAL EXPENSES



OUTLINE OF COVERAGE



Read Your (Policy) (Certificate)  Carefully-This outline

of coverage provides a very brief description of the important

features of the coverage.  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)(CERTIFICATE)  CAREFULLY!

Accident only coverage is 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.

A brief specific description of the benefits.

A description of any policy provisions that exclude, eliminate,

restrict, reduce, limit, delay, or in any other manner operate

to qualify payment of the benefits.

A description of policy provisions respecting renewability or

continuation of coverage, including age restrictions or any

reservations of right to change premiums.

 

(7) Specified Accident Coverage.

An outline of coverage, in the form prescribed below, shall be issued in connection with policies or certificates meeting the standards of R590-126-7(7). The items included in the outline of coverage must appear in the sequence prescribed:

 

TABLE VII

(COMPANY NAME)



SPECIFIED ACCIDENT COVERAGE



THIS (POLICY)  (CERTIFICATE)  PROVIDES LIMITED BENEFITS

BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED

TO COVER ALL MEDICAL EXPENSES



OUTLINE OF COVERAGE



Read Your (Policy)(Certificate)  Carefully-This outline of

coverage provides a very brief description of the important

features of coverage.  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)  (CERTIFICATE)  CAREFULLY!

Specified accident coverage is designed to provide, to persons

insured, restricted coverage paying benefits ONLY when certain

losses occur as a result of specified accidents.  Coverage

is not provided for basic hospital, basic medical-surgical, or

major medical expenses.

A brief specific description of the benefits, including dollar

amounts.

A description of any policy provisions that exclude, eliminate,

restrict, reduce, limit, delay, or in any other manner operate

to qualify payment of the benefits.

A description of policy provisions respecting renewability or

continuation of coverage, including age restrictions or any

reservations of right to change premiums.

 

(8) Specified Disease Coverage.

An outline of coverage, in the form prescribed below, shall be issued in connection with policies or certificates meeting the standards of Subsection R590-126-7(8). The items included in the outline of coverage must appear in the sequence prescribed:

 

TABLE VIII

(COMPANY NAME)



SPECIFIED DISEASE COVERAGE



THIS (POLICY)  (CERTIFICATE)  PROVIDES LIMITED BENEFITS

BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED

TO COVER ALL MEDICAL EXPENSES



OUTLINE OF COVERAGE



Specified disease coverage is designed only as a supplement

to a comprehensive health insurance policy and should not

be purchased unless you have this underlying coverage.

Persons covered under Medicaid should not purchase it.  Read

the Buyer's Guide to Specified Disease Insurance to review

the possible limits on benefits in this type of coverage.

Read Your (Policy) (Certificate) Carefully--This outline

of coverage provides a very brief description of the

important features of coverage.  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)

(CERTIFICATE) CAREFULLY!

Specified disease coverages designed to provide, to

persons insured, restricted coverage paying benefits

ONLY when certain losses occur as a result of

specified diseases.  Coverage is not provided for basic

hospital, basic medical-surgical, or major medical expenses.

A brief specific description of the benefits, including dollar

amounts.

A description of any policy provisions that exclude, eliminate,

restrict, reduce, limit, delay, or in any other manner operate

to qualify payment of the benefits.

A description of policy provisions respecting renewability or

continuation of coverage, including age restrictions or any

reservations of right to change premiums.

 

(9) Limited Benefit Health Coverage.

Except for dental or vision plans, an outline of coverage, in the form prescribed below, shall be issued in connection with policies or certificates which do not meet the standards of Subsections R590-126-7(1) through (8). The items included in the outline of coverage must appear in the sequence prescribed:

 

TABLE IX

(COMPANY NAME)



LIMITED BENEFIT HEALTH COVERAGE



BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED

TO COVER ALL MEDICAL EXPENSES



OUTLINE OF COVERAGE



Read Your (Policy) (Certificate)  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) (CERTIFICATE)

CAREFULLY!

Limited benefit health coverage is designed to provide, to

persons insured, limited or supplemental coverage.

A brief specific description of the benefits, including

amounts.

A description of any provisions that exclude, eliminate,

restrict, reduce, limit, delay, or in any other manner

operate to qualify payment of the benefits.

A description of provisions respecting renewability or

continuation of coverage, including age restrictions or any

reservations of right to change premiums.

 

(10) Dental Coverage.

An outline of coverage, in the form prescribed below, shall be issued in connection with dental plan policies and certificates. The items included in the outline of coverage must appear in the sequence prescribed:

 

TABLE X

(COMPANY NAME)



DENTAL COVERAGE



BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED

TO COVER ALL DENTAL EXPENSES



OUTLINE OF COVERAGE



Read Your (Policy) (Certificate)  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) (CERTIFICATE) CAREFULLY!

A brief specific description of the benefits.

A description of any policy provisions that exclude,

eliminate, restrict, reduce, limit, delay, or in any

other manner operate to qualify payment of the benefits.

A description of policy provisions respecting renewability

or continuation of coverage, including age restrictions or

any reservations of right to change premiums.

 

(11) Vision Coverage.

An outline of coverage in the form prescribed below shall be issued in connection with vision plan policies and certificates. The items included in the outline of coverage must appear in the sequence prescribed:

 

TABLE XI

(COMPANY NAME)



VISION COVERAGE



BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED

TO COVER ALL VISION EXPENSES



OUTLINE OF COVERAGE



Read Your (Policy) (Certificate) 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) (CERTIFICATE) CAREFULLY!

A brief specific description of the benefits.

A description of any policy provisions that exclude, eliminate,

restrict, reduce, limit, delay or in any other manner operate

to qualify payment of the benefits.

A description of policy provisions respecting renewability or

continuation of coverage, including age restrictions or any

reservations of right to change premiums.

 

(12) An insurer shall deliver an outline of coverage to an applicant or enrollee upon the sale of an individual accident and health insurance policy as required in this rule.

(13) If an outline of coverage was delivered at the time of application or enrollment and the policy or certificate is issued on a basis which would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate must accompany the policy or certificate when it is delivered and contain the following statement in no less than 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.

(14) Outlines of coverage for hospital confinement indemnity, specified disease, or limited benefit policies, which are to be delivered to persons eligible for Medicare by reason of age shall contain the following language, which shall be printed on or attached to the first page of the outline of coverage:

THIS IS NOT A MEDICARE SUPPLEMENT POLICY. If you are eligible for Medicare, review the Guide to Health Insurance for People With Medicare available from the company.

(15) Where the prescribed outline of coverage is inappropriate for the coverage provided by the policy or certificate, an alternate outline of coverage shall be submitted to the commissioner for prior approval.

(16) Advertisements may fulfill the requirements for outlines of coverage if they satisfy the standards specified for outlines of coverage in this rule.

 

R590-126-9. Replacement of Accident and Health Insurance Requirements.

(1) Upon determining that a sale will involve replacement, an insurer, other than a direct response insurer, or its producer, shall furnish the applicant, prior to issuance or delivery of the policy, the notice described in Subsection (2). The insurer shall retain a copy of the notice. A direct response insurer shall deliver to the applicant, upon issuance of the policy, the notice described in Subsection (3). In no event, however, will the notices be required in the solicitation of the following types of policies: accident-only and single-premium nonrenewable policies.

(2) The notice required by Subsection (1) for an insurer, other than a direct response insurer, shall provide, in substantially the following form:

 

TABLE XII

NOTICE TO APPLICANT REGARDING REPLACEMENT

OF ACCIDENT AND HEALTH INSURANCE



According to (your application) (information you have

furnished), you intend to lapse or otherwise terminate

existing accident and health insurance and replace it with

a policy to be issued by (insert company name)  Insurance

Company.  For your own information and protection, you should

be aware of and seriously consider certain factors that may

affect the insurance protection available to you under the

new policy.

Health conditions which you may presently have, (preexisting

conditions) may not be immediately or fully covered under

the new policy.  This could result in denial or delay of a

claim for benefits under the new policy, whereas a similar

claim might have been payable under your present policy.

You may wish to secure the advice of your present insurer

or its producer regarding the proposed replacement of your

present policy.  This is not only your right, but it is

also in your best interests to make sure you understand all

the relevant factors involved in replacing your present

coverage.

If, after due consideration, you still wish to terminate

your present policy and replace it with new coverage, be

certain to truthfully and completely answer all questions

on the application concerning your medical/health history.

Failure to include all material medical information on an

application may provide a basis for the company to deny any

future claims and to refund your premium as though your policy

had never been in force.  After the application has been

completed and before you sign it, reread it carefully to be

certain that all information has been properly recorded.

The above "Notice to Applicant" was delivered to me on:

...........................

(Date)

...........................

(Applicant's Signature)

 

(3) The notice required by Subsection (1) for a direct response insurer shall be as follows:

 

TABLE XII

NOTICE TO APPLICANT REGARDING REPLACEMENT

OF ACCIDENT AND HEALTH INSURANCE



According to (your application) (information you have

furnished), you intend to lapse or otherwise terminate

existing accident and health insurance and replace it

with the policy delivered herewith issued by (insert

company name) Insurance Company.  Your new policy provides

30 days within which you may decide without cost whether you

desire to keep the policy.  For your own information and

protection, you should be aware of and seriously consider

certain factors that may affect the insurance protection

available to you under the new policy.

Health conditions that you may presently have, (preexisting

conditions) may not be immediately or fully covered under

the new policy.  This could result in denial or delay of a

claim for benefits under the new policy, whereas a similar

claim might have been payable under your present policy.

You may wish to secure the advice of your present insurer

or its producer regarding the proposed replacement of your

present policy.  This is not only your right, but it is

also in your best interests to make sure you understand all

the relevant factors involved in replacing your present

coverage.

(To be included only if the application is attached to the

policy).  If, after due consideration, you still wish to

terminate your present policy and replace it with new

coverage, read the copy of the application attached to

your new policy and be sure that all questions are answered

fully and correctly.  Omissions or misstatements in the

application could cause an otherwise valid claim to be denied.

Carefully check the application and write to (insert company

name and address) within ten days if any information is not

correct and complete, or if any past medical history has been

left out of the application.

COMPANY NAME

 

R590-126-10. Existing Contracts.

Contracts issued prior to the effective date of this rule must be amended to comply with the revised provisions.

 

R590-126-11. Enforcement Date.

The commissioner will begin enforcing the revised provision of this rule January 1, 2006.

 

R590-126-12. Severability.

If any provision of this rule or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the rule and the application of the provision to other persons or circumstances shall not be affected thereby.

 

KEY: health insurance

2005

31A-2-201

31A-2-202

31A-21-201

31A-22-605

31A-22-623

31A-22-626

31A-23a-402

31A-26-301