Skip Maine state header navigation

Agencies | Online Services | Help

Skip First Level Navigation | Skip All Navigation

Maine.gov > PFR Home > Insurance Regulation > Company Services > Review Checklists > Group Disability Income - H11G

Maine Bureau of Insurance
Form Filing Review Requirements Checklist
Group Disability Income

H11G
(Amended 11/2011)

REVIEW REQUIREMENTS

REFERENCE

DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

LOCATION OF STANDARD IN FILING

Applicant's statements; waivers, amendments

24-A M.R.S.A.
§2817

There shall be a provision that no statement made by the applicant for insurance shall avoid the insurance or reduce benefits thereunder unless contained in the written application signed by the applicant; and a provision that no agent has authority to change the policy or to waive any of its provisions; and that no change in the policy shall be valid unless approved by an officer of the insurer and evidenced by endorsement on the policy, or by amendment to the policy signed by the policyholder and the insurer. 

 

Statements In Application

24-A M.R.S.A.
§2818

There shall be a provision that all statements contained in any such application for insurance shall be deemed representations and not warranties. 

 

New Employees, Members

24-A M.R.S.A.
§2819

There shall be a provision that all new employees or new members, as the case may be, in the groups or classes eligible for such insurance must be added to such groups or classes for which they are respectively eligible. 

 

Renewal of Policy

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.  

 

Individual Certificates

24-A M.R.S.A.
§ 2821

Except in the case of blanket health insurance, a provision that the insurer shall issue to the policyholder, for delivery to each member of the insured group, an individual certificate or printed information setting forth in summary form a statement of the essential features of the insurance coverage of such employee or such member and in substance the provisions of sections 2821 to 2828. The insurer shall also provide for distribution by the policyholder to each member of the insured group a statement, where applicable, setting forth to whom the benefits under such policy are payable.

 

Age Limits

24-A M.R.S.A.
§2822

There shall be a provision specifying the ages, if any there be, to which the insurance provided therein shall be limited; and the ages, if any there be, for which additional restrictions are placed on benefits and the additional restrictions placed on the benefits at such ages. 

 

Notice of Claim

24-A M.R.S.A.
§2823

There shall be a provision that written notice of sickness or of injury must be given to the insurer within 30 days after the date when such sickness or injury occurred. Failure to give notice within such time shall not invalidate nor reduce any claim, if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible. 

 

Proof of Loss

24-A M.R.S.A.
§2824

There shall be a provision that in the case of claim for loss of time for disability, written proof of such loss must be furnished to the insurer within 30 days after the commencement of the period for which the insurer is liable, and that subsequent written proofs of the continuance of such disability must be furnished to the insurer at such intervals as the insurer may reasonably require, and that in the case of claim for any other loss, written proof of such loss must be furnished to the insurer within 90 days after the date of such loss. Failure to furnish such proof within such time shall not invalidate nor reduce any claim, if it shall be shown not to have been reasonably possible to furnish such proof and that such proof was furnished as soon as was reasonably possible. 

 

Forms for Proof of Loss

24-A M.R.S.A.
§2825

There shall be a provision that the insurer will furnish to the policyholder such forms as are usually furnished by it 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 fixed in the policy for filing proof of loss, written proof covering the occurrence, character and extent of the loss for which claim is made. 

 

Examination, Autopsy

24-A M.R.S.A.
§2826

There shall be a provision that the insurer shall have the right and opportunity to examine the person of the insured when and so often as it may reasonably require 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 for Payment of Benefits

24-A M.R.S.A.
§2827

There shall be a provision, subject to due proof of loss, all accrued benefits payable under the policy for loss of time will be paid not later than at 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 will be paid immediately upon receipt of such proof. 

 

Time for Suits

24-A M.R.S.A.
§2828

There shall be a 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 has been filed in accordance with the requirements of the policy and that no such action shall be brought at all, unless brought within 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

Any portion of any such policy, delivered or issued for delivery in this State, which purports, by reason of the circumstances under which a loss is incurred, to reduce any benefits promised thereunder to an amount less than that provided for the same loss occurring under ordinary circumstances, shall be printed in such policy and in each certificate issued thereunder, in bold face type and with greater prominence than any other portion of the rest of such policy or certificate, respectively; and all other exceptions of the policy shall be printed in the policy and certificate with the same prominence as the benefits to which they apply.

 

Disclosure of Benefit Offsets

24-A M.R.S.A.
§2829-A

If the benefits under the policy or contract are subject to reduction due to other sources of income, the insurer shall include in the enrollment material and certificate of coverage a clear and conspicuous notice that accurately explains all types of other sources of income that may result in a reduction of benefits.

 

Work Related Disabilities

Rule Chapter 530

     24-A M.R.S.A.
§2413-B

     24-A M.R.S.A.
§2413-C

     24-A M.R.S.A.
§2413-D

If an STD policy excludes benefits for a work-related disability, provisional payments must be offered. Such policies should include a notice following the exclusion explaining provisional payments.

STD policies that exclude benefits for a work-related disability should indicate on the face page that the plan is a non-occupational plan.

 It is recommended that LTD plans do not include an exclusion of benefits for work related disabilities.

 

Specific Treatment

24-A M.R.S.A.
§2413(B)(D)

It is inappropriate if a policy requires the claimant to receive specific treatment above what the claimant is receiving, when:
   -- The claimant is receiving regular and appropriate treatment from a practitioner operating within the scope of his/her license.  

 

Pre-X

24-A M.R.S.A.
§2413-D 

Pre-existing conditions exclusions should be relative to the disabling condition.

 

Pregnancy

5-M.R.S.A. §4572-A(3)

A group DI policy that excludes benefits for pregnancy may be in violation of the Maine Human Rights Act: "Disabilities caused or contributed to by pregnancy, miscarriage, abortion, childbirth, or related medical conditions, and recovery therefrom, for all job-related purposes, shall be treated the same as disabilities caused or contributed to by other medical conditions, under any health or disability insurance or sick leave plan available in connection with employment."

 

Definition of Sickness

Case Law and
24-A M.R.S.A.
§2413(B)(D)

A definition of "sickness" should not include language such as, “condition(s) first  manifesting themselves while the contract is inforce.”
Such language conflicts with the incontestability clause as well as the pre-existing condition definition, since these clauses, when satisfied, can include benefits for known manifested conditions prior to the effective date of the policy.

 

 

 

 

 

 

 

Third Party Notice Cancellation and
Reinstatement

Rule 580
24-A M.R.S.A.
§2847-C

Third party notice of cancellation and reinstatement for cognitive impairment or functional incapacity.

 

 

 

Definition of Dependent

 

 

 

  24-A M.R.S.A.
§2833

Children (including stepchildren adopted children or children placed for adoption) under the age of 19.  Cannot use financial dependency as a requirement for eligibility.  Adopted or placed for adoption children are to be provided the same benefits as natural dependent children and stepchildren.

 

 

Subrogation/Limits on priority liens

  24-A M.R.S.A.
§2836
24-A M.R.S.A. §4243
24-A M.R.S.A. §2729-A

Does this policy have subrogation provisions? If yes see provisions below:
Subrogation requires prior written approval of the insured and allows such payments only on a just and equitable basis and not on the basis of a priority lien. 

 

Yes   Please provide citation for section in policy ________________________

No  

Last Updated: August 22, 2012