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Maine.gov > PFR Home > Insurance Regulation > Company Services > Review Checklists > Group Accidental Death & Dismemberment - H03G

Maine Bureau of Insurance
Form Filing Review Requirements Checklist
Group Accidental Death & Dismemberment

H03G
(Amended 11/2011)

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.

 

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.

 

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.

 

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.

 

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.

 

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.

 

 

 

 

 

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.

 

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.

 

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.

 

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.

 

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.

 

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.

 

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.

 

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."

 

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.

 

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.

 

Calculation of health benefits based on actual cost

24-A M.R.S.A. §2185

Policies must comply with the requirements of 24-A §2185 which requires calculation of health benefits based on actual cost.  All health insurance policies, health maintenance organization plans and subscriber contracts or certificates of nonprofit hospital or medical service organizations with respect to which the insurer or organization has negotiated discounts with providers must provide for the calculation of all covered health benefits, including without limitation all coinsurance, deductibles and lifetime maximum benefits, on the basis of the net negotiated cost and must fully reflect any discounts or differentials from charges otherwise applicable to the services provided. With respect to policies or plans involving risk-sharing compensation arrangements, net negotiated costs may be calculated at the time services are rendered on the basis of reasonably anticipated compensation levels and are not subject to retrospective adjustment at the time a cost settlement between a provider and the insurer or organization is finalized.

 

Explanations Regarding Deductibles

24-A M.R.S.A. §2413

All policies must include clear explanations of all of the following regarding deductibles:

  1. Whether it is a calendar or policy year deductible.
  2. Clearly advise whether non-covered expenses apply to the deductible.
  3. Clearly advise whether it is a per person or family deductible or both.

 

Explanations for any Exclusion of Coverage for work related sicknesses or injuries

24-A M.R.S.A. §2413

If the policy excludes coverage for work related sicknesses or injuries, clearly explain whether the coverage is excluded if the enrollee is exempt from requirements from state workers compensation requirements or has filed an exemption from the workers compensation laws.

 

Preventative Care Services

24-A M.R.S.A. §4320-A

Coverage of preventive health services

 

Last Updated: August 22, 2012