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 > Individual Accidental Death & Dismemberment - H03I

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

H03I
(Amended 11/2011)

REVIEW REQUIREMENTS

REFERENCE                                             

DESCRIPTION OF REVIEWSTANDARDS REQUIREMENTS

LOCATION OF STANDARD IN FILING

Note: These provisions do not apply to life or annuity policies on contracts supplemental thereto which contain only additional benefits in the case of death or dismemberment or loss of sight by accident or accidental means.

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.

 

Format of Policy

24-A M.R.S.A. §2703

Time, place, and amount of premium payment required
Effective and Termination Date required
Name of Insured(s) required

Each form, including riders and endorsements, which  comprise the contract, shall be identified by a form number in the lower left hand corner of the first page thereof.

 

Entire Contract Provision

24-A M.R.S.A.
§ 2705  

This policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid unless approved by an executive officer of the insurer and unless such approval be endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions.

 

Time Limit on Certain Defenses

24-A M.R.S.A.
§ 2706  

Provision as follows (a) After three (3) years from the date of issue of this policy no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or to deny a claim for loss incurred or disability, as defined in the policy, commencing after the expiration of such 3-year period. (Not applicable to misstatement of age or occ.)

 

Grace Period

24-A M.R.S.A.
§ 2707 

A grace period of not less than [7 days for weekly policies, 10 days for monthly policies, and 31 days for all other policies], will be granted for the payment of each premium falling due after the first premium, during which the policy shall continue in force.

 

Reinstatement

24-A M.R.S.A.
§ 2708

Provision as follows: Acceptance of premium by the insurer or by any agent duly authorized, without requiring an application for reinstatement, shall reinstate the policy. However, if the insurer requires an application for reinstatement and issues a conditional receipt, the policy will be reinstated upon approval of application, or lacking such approval, upon the 45th day following the date of conditional receipt unless the insurer has previously notified the insured in writing of its disapproval of the application. The reinstated policy shall only cover losses for accidental injury after the date of reinstatement and sickness beginning ten (10) days after the date of reinstatement.

 

Change of Beneficiary

24-A M.R.S.A.
§ 2716 

Unless the insured makes an irrevocable beneficiary, the right to change the beneficiary is reserved to the insured and the consent of the beneficiaries is not required to surrender, assign, or change the beneficiary, or to any other changes in the policy.

 

Right to Examine and Return

24-A M.R.S.A.
§ 2717

10-Day Free look. Policy may be returned to insurer or agent.

 

Notice of Claim

24-A M.R.S.A.
§ 2709

Written notice of claim to insurer within 20 days after covered loss. Notice to authorized agent is deemed notice to insurer.

 

Claim Forms

24-A M.R.S.A.
§ 2710 

Upon receipt of notice of claim, insurer will furnish claim forms. If such claim forms are not furnished within 15 days after giving notice, the claimant shall be deemed to have complied with the requirements of the policy as to proof of loss.

 

Proof of Loss

24-A M.R.S.A.
§ 2711
   

Written proof of loss must be furnished to the insurer in the case of a claim that provides periodic payment contingent upon continuing loss within 90 days after the termination of the period for which the insurer is liable. Failure to furnish within this timeframe does not invalidate or reduce any claim if it was not reasonably possible to give proof, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year form the time proof is otherwise required.

 

Time of Payment of Claims

24-A M.R.S.A.
§ 2712

Immediate and upon receipt of due written proof.

 

Payment of Claims

24-A M.R.S.A.
§ 2713

 

Loss of Life: In accordance with beneficiary designation. If no such designation is effective, benefit is payable to estate of the insured. insured. All other indemnities will be payable to the insured.

 

Physical Examination and Autopsy

24-A M.R.S.A.
§ 2714

Physical examination and autopsy: The insurer at its own expense shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law.

 

Legal Actions

24-A M.R.S.A. §2715 

No action at law or in equity shall be brought to recover on this policy prior to the expiration of sixty (60) days after written proof of loss has been furnished. No such action shall be brought after the expiration of three (3) years after the time written proof of loss is required to be furnished.

 

Optional Policy Provisions

24-A M.R.S.A.
§2718

The following optional policy provisions are allowed if such provisions are in the words in which the same appear in the applicable section (or in different wording approved by the superintendent which is not less favorable in any respect to the insured or the beneficiary):

 

§ 2719

Change of Occupation

 

§ 2720

Misstatement of Age

 

§ 2721-A

Overinsurance in Accident Policies

 

§ 2722

Insurance with other insurers, provision of service or expense incurred basis.

 

§ 2724

Relation of earnings to insurance

 

§ 2725

Unpaid premiums

 

§ 2726

Conformity with state statutes

 

§ 2727

Illegal occupation

 

§ 2728

Intoxicants and narcotics

 

Third Party Ownership

24-A M.R.S.A.
§ 2731 

A person other than the insured with proper insurable interest may make application for and own a policy covering the insured and may be entitled to any indemnities, benefits, and rights provided therein.

 

Age Limit

24-A M.R.S.A.
§ 2735
      

If policy contains a provision establishing, as an age limit or otherwise, a date after which the coverage provided by the policy will be not effective, and if such date falls within a period for which premium is accepted by the insurer or if the insurer accepts a premium after such date, the coverage provided by the policy will continue in force, subject to any right of termination, until the end of the period for which premium has been accepted. 
In the event that the age of the insured has been misstated and if, according to the correct age of the insured, the coverage provided by the policy would not have become effective, or would have ceased prior to the acceptance of such premium, then the liability of the insurer shall be limited to the refund, upon request, of all premiums paid for the period not covered by the policy.

 

Extension of coverage for dependent children with mental or physical illness

24-A M.R.S.A. §2742-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.

 

Last Updated: February 5, 2013