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.
| REVIEW REQUIREMENTS |
REFERENCE |
DESCRIPTION OF REVIEW
STANDARDS 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. |
|
