REVIEW REQUIREMENTS

REFERENCE

DESCRIPTION OF REVIEW

STANDARDS REQUIREMENTS

LOCATION OF

STANDARD IN FILING

Requirements for Documents External to Policy or Certificate

24-A M.R.S.A. §2816
24-A M.R.S.A. §2755

Re application; notice of claim; proof of loss; and assignment of benefits (last document mandated by 24-A M.R.S.A. §2755).

Designation of Product Category

24-A M.R.S.A. §2694
Rule 755, Sec. 6

Heading of form filer’s cover letter shall designate intended coverage category.

Definitions, Disclosures, Prohibitions, Minimum Standards, Outline of Coverage

Rule 755, Secs. 4 through 7

Must comply with Rule 755, including but not limited to § 4 (policy definitions); § 5 (prohibited provisions); § 6(L) (scope of “supplemental health” plans); § 7(A) (disclosures, font size and related protections); § 7(B) (mandatory outline of coverage and disclosures); and § 7(M) (outline of coverage content).

Right to Internal Review of Insurer’s Claim and Other Denials

24-A M.R.S.A. §2847

The policy or certificate shall provide the insured with an opportunity to seek insurer review of the latter’s denial of benefits and of other claims. The right of appeal must be prominently set forth in every written notice to the insured pertaining to the denial.

Warning Imminent Lapse 10 Days Before Cancellation; Right to Reinstate in Certain Circumstances

24-A M.R.S.A. §2847-C
 Rule 580

Policy or certificate must affirm that insurer, at least 10 days prior to lapse date, shall give insured written notice of imminent cancellation arising from failure to pay premium, and that coverage will be reinstated if insured has cognitive impairment or functional incapacity which leads to unintended lapse.

Renewal Provision, Including Guaranty of Lifetime Renewal

24-A M.R.S.A. §2738

Policy or certificate must contain the terms under which the policy can or cannot be renewed.

Notice That Policy or Certificate Is Not Long Term Care

24-A M.R.S.A.
§5072 (4)
§5074 (3)
 

For prominent display on first page: "THIS [POLICY OR CERTIFICATE] IS NOT A LONG TERM CARE CONTRACT” and “IS NOT INTENDED TO BE QUALIFIED FOR INCOME TAX INCENTIVES UNDER FEDERAL OR MAINE LAW.”

Notice That Policy or Certificate Is Not Medicare Supplement

24-A M.R.S.A.§5013
Rule 275, Sec. 17(E)

For prominent display on first page: "THIS [POLICY OR CERTIFICATE] IS NOT A MEDICARE SUPPLEMENT CONTRACT. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company."

Coordination of Benefits Between Insurer and Medicaid (MaineCare)

24-A M.R.S.A. §2844

Disclosure that Medicaid (MaineCare) is always secondary payer to the insurer.

Representations in Application for Insurance Are Not Warranties

24-A M.R.S.A. §2818

Insurer must acknowledge that the insured’s statements in an application, including answers given in any medical questionnaire, are deemed to constitute representations and not warranties.