All Rate and Form Filings submitted to the Bureau of Insurance for
review must be accompanied by the completed appropriate transmittal
Document as well as the completed appropriate rate/form review checklist.
The checklist must be completed by the company submitting the filing
and must reference, for each item on the checklist, the location of
each specific item in the filing. The transmittal Document takes the
place of the cover letter requirement. Blank transmittal documents are
attached here for your use.
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REVIEW REQUIREMENTS |
REFERENCE
|
DESCRIPTION OF REVIEW
STANDARDS REQUIREMENTS |
LOCATION OF
STANDARD IN FILING |
| Definition of “Accident”,
“Accidental Injury”, “Accidental Means” |
Rule
755, Sec. 4(C) |
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. The definition
shall not be more restrictive than the following: “accident,”
“accidental injury,” or “accidental means”
means accidental bodily injury sustained by the insured person that
is the direct cause of the condition for which benefits are provided
and that occurs while the insurance is in force. |
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| Probationary or Waiting Periods Not Allowed |
Rule
755, Sec. 5(A) |
Accident policies shall not contain probationary or
waiting periods. |
|
| Limitations and Exclusions |
Rule
755, Sec. 5(E) |
A policy shall not limit or exclude coverage except
as provided in this subsection. |
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| Designation of Classification of Coverage |
Rule
755, Sec. 6 |
The heading of the cover letter of any form filing
subject to this rule shall state the category of coverage set forth
in 24-A M.R.S.A. § 2694 that the form is intended to be in. |
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| General Rules for Minimum Standards |
Rule
755, Sec. 6(A) |
The requirements set forth in this section are in
addition to any other requirements contained in any other applicable
statutes and rules including, but not limited to, 24-A M.R.S.A. Chapters
27, 32, 33, 35, 36 and 56-A and Rules 140, 320, 330, 360, 530, 590,
600, 850 and 940. |
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| Minimum Standards for “Accident
Only Coverage” and “Specified Accident Coverage” |
Rule
755, Sec. 6(I) |
“Accident only coverage” is a policy 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 $2,000 and a single dismemberment amount shall be at least $1,000. |
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| REQUIRED DISCLOSURE
PROVISIONS INCLUDING, BUT NOT LIMITED TO: Renewal, Continuation,
or Nonrenewal Provisions
Required disclosure statements on policies/certificates
General Outline of Coverage Requirements
Accident-Only Coverage (Outline of Coverage)
|
Rule
755, Sec. 7
Rule
755, Sec. 7(A)(4)
Rule
755, Sec. 7(A)(9) and Sec. 7(A)(10)
Rule
755, Sec. 7(B)
Rule
755, Sec. 7(J)
|
Each policy shall contain
all appropriate provisions contained in this section including, but
not limited to the following:
Each policy of individual health insurance and group 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.
See this section for required disclosure statements to be placed
prominently on the first page of the policy/certificate.
This subsection contains general requirements and disclosures for
Outlines of Coverage.
This subsection describes the required provisions and disclosures
for the Outline of Coverage for Accident-Only coverage.
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| Employer
Groups |
24-A
M.R.S.A
§2804 |
This section contains requirements of an Employer
Group |
|
| Private
Purchasing Alliances |
24-A
M.R.S.A
§2804-A |
Private Purchasing Alliances meeting the requirements
of Chapter 18-A. |
|
| Debtor
Groups |
24-A
M.R.S.A
§2807 |
The lives of a group of individuals may be insured
under a policy issued to a creditor or its parent holding company,
trust, or trustee, or agent by 2 or more creditors, holding companies,
affiliates, trustees, or agent considered the policyholder to insure
debtors of the creditor.
The amount of credit life may not exceed the unpaid amount of the
debt plus earned interest.
Credit card holders are not an acceptable group. Copies of participation/joinder
agreements of 2 or more participating debtors must be submitted. |
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| Trustee
Groups |
24-A
M.R.S.A
§2806 |
The lives of a group of individuals may be insured
under a policy issued to a trust of a fund established by 2 or more
employers, labor unions, or similar employee organizations where the
trust is considered the policyholder.
Copies of participation/joinder agreements for 2 or more participants
must be submitted along with a copy of the trust document. |
|
| Labor Union Groups |
24-A
M.R.S.A
§2805 |
This section contains the requirements of Labor Union
Groups |
|
| Association
Groups |
24-A
M.R.S.A
§2805-A |
The association shall have at the outset a minimum
of 50 persons; shall have been organized and maintained in good faith
for purposes other than that of obtaining insurance; shall have been
in existence for at least 2 years; and shall have a constitution and
by-laws that provide:
That the association holds regular meetings not less than annually
to further the purposes of the members; that the association collects
dues or solicits contributions from members; and that the members
have voting privileges and representation on the governing board and
committees.
Copies of the constitution and by-laws must be submitted. Articles
of incorporation, etc. are also helpful. |
|
| Credit
Union Groups |
24-A
M.R.S.A
§2807-A |
§ 2807-A Credit Union Groups - The lives of a
group of individuals may be insured under a policy issued to a credit
union or to a trust, or agent designated by 2 or more credit unions.
Copies of participation/joinder agreements for 2 or more credit unions
must be submitted.
|
|
| Other Groups |
24-A
M.R.S.A
§2808 |
(other than those groups as described above) No group
life insurance shall be delivered in this State unless:
A. The policyholder is a bona fide group formed for purposes other
than the procurement of insurance;
B. The insurance of the group policy would be actuarially sound;
C. The issuance of the group policy would result in economies of acquisition
or administration; and
D. The benefits are reasonable in relation to the premiums charged.
Note: All four above-listed conditions must be met. Actuarial memorandums
and rates are required for review. |
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| Dependent Coverage |
24-A
M.R.S.A.
§2809 |
Any policy issued pursuant to 2804, 2805, 2805-A, 2806,
and 2087-A may include coverage for dependents. |
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| Representations |
24-A
M.R.S.A.
§2818 |
All statements contained in applications shall be deemed
representations and not warranties. |
|
| New Employees |
24-A
M.R.S.A.
§2819 |
All new employees or new members in groups must be
added to such groups in which they are eligible |
|
| Renewability |
24-A
M.R.S.A.
§2820 |
There shall be a provision stating the conditions under
which the insurer may decline to renew the policy. |
|
| Certificates |
24-A
M.R.S.A.
§2821 |
Except for blanket health, the insurer shall issue
to the policyholder, for delivery to each member of the group, an
individual certificate. |
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| Age Limits |
24-A
M.R.S.A.
§2822 |
There shall be a provision specifying the ages, if
any, to which insurance provided shall be limited or restricted. |
|
Notice of Claim
Proof of Loss |
24-A
M.R.S.A.
§2823, 2824 |
Provision that written notice of sickness or of injury
must be given to the insurer within 30 days Failure to provide notice
shall not invalidate nor reduce any claim, if it was not reasonably
possible to give such notice. |
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| Forms for Proof of Loss |
24-A
M.R.S.A.
§2825 |
Provision that the insurer will furnish forms required
for filing proof of loss. If such forms are not furnished before the
expiration of 15 days after the insurer received notice of any claim
under the policy, the person making such claim shall be deemed to
have complied with the requirements of the policy as to proof of loss
upon submitting within the time frame fixed in the policy. |
|
| Examination, autopsy |
24-A
M.R.S.A.
§2826
24-A
M.R.S.A.
§2714 |
There shall be a provision that the insurer shall have
the right to an opportunity to examine the person when and so often
as it may reasonably required during the pendency of claim under the
policy and also the right and opportunity to make an autopsy in case
of death where it is not prohibited by law. |
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| Time Payment of Benefits |
24-A
M.R.S.A.
§2827 |
Provision that all benefits payable under the policy,
other than benefits payable for loss of time, will be payable not
more than 60 days after receipt of proof and that all accrued benefits
payable will be paid no later than the expiration of each period of
30 days during the continuance of the period for which the insurer
is liable and that any balance remaining unpaid at the termination
of such period shall be paid immediately upon receipt of such proof. |
|
| Time for Suits |
24-A
M.R.S.A.
§2828 |
Provision that no action at law or in equity shall
be brought to recover on the policy prior to the expiration of 60
days after proof of loss in accordance with the requirements of the
policy and that no such action shall be brought at all, unless brought
within two (2) years from the expiration of the time within which
proof of loss is required by the policy. |
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| Exceptions |
24-A
M.R.S.A.
§2829 |
If any benefits of policy are reduced, by reason of
circumstances under which a loss is incurred, it shall be printed
in the policy and in each certificate in bold face and with greater
prominence than any other portion of the rest of the policy. If any
such policy contains any provision which affects the liability of
the insurer, because of any violation of the law by the insured or
because of the insured's use of intoxicating liquor, narcotics or
hallucinogenic drugs, during the term of the policy, there shall be
a statement in the following form: "The insurer shall not be
liable for death or injury incurred to which a contributing cause
was the insured's commission of or attempt to commit a felony, or
which occurs while the insured is engaged in an illegal occupation;
while the insured is intoxicated; or under the influence of narcotics
or hallucinogenic drugs, unless administered on the advice of a physician." |
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| AIDS/ARC |
24-A
M.R.S.A.
§2846 |
No insurance policy may provide more restrictive coverage
for death resulting from AIDS, ARC, or HIV-related diseases that the
death resulting from any other disease or sickness or exclude coverage
for death resulting from AIDS, ARC, or HIV-related diseases, except
through an exclusion under which deaths resulting from all sicknesses
and diseases are treated the same.
See also 24-A M.R.S.A. § 2159(4) for further information on unfair
discrimination. |
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| Extension of coverage for dependent children with
mental or physical illness |
24-A
M.R.S.A. §2833-A |
Requires health insurance policies to continue coverage for dependent
children up to 24 years of age who are unable to maintain enrollment
in college due to mental or physical illness if they would otherwise
terminate coverage due to a requirement that dependent children of
a specified age be enrolled in college to maintain eligibility. |
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