Language such as, “it must first manifest itself while the policy is in force,” should not be included, since it conflicts with the “Incontestability” clause and the “pre-existing condition” definitions
A. Except as provided in this rule, an
individual health insurance policy or
group health insurance policy or certificate delivered or issued for delivery to any person in this state and to which this rule applies shall contain definitions respecting the matters set forth below that comply with the requirements of this section. Definitions may need to be modified to comply with other requirements specified in Section 3(D).
C. “Accident,” “accidental injury,” and “accidental means” 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.
I. “Partial disability” shall be defined in relation to the individual’s inability to perform one or more, but not all, of the “major,” “important,” or “essential” duties of employment or occupation, or in relation to a percentage of time worked, to a specified number of hours worked, or to compensation earned.
J. “Physician” may be defined by including words such as “qualified physician” or “licensed physician.” The use of these terms requires an insurer to recognize and to accept, to the extent of its obligation under the contract, all providers of medical care and treatment when the services are within the scope of the provider’s licensed authority and are provided pursuant to applicable laws.
K. “Preexisting condition” shall not be defined more broadly than the following: “Preexisting condition means the existence of symptoms that would cause an ordinarily prudent person to seek diagnosis, care, or treatment within a 24-month period preceding the effective date of the coverage of the insured person or a condition for which medical advice or treatment was recommended by a physician or received from a physician within a 24-month period preceding the effective date of the coverage of the insured person.”
L. “Residual disability” shall be defined in relation to the individual’s reduction in earnings and may be related either to the inability to perform some part of the “major,” “important” or “essential duties” of employment or occupation, or to the inability to perform all usual business duties for as long as is usually required. A policy that provides for residual disability benefits may require a qualification period, during which the insured must be continuously totally disabled before residual disability benefits are payable. The qualification period for residual benefits may be longer than the elimination period for total disability. In lieu of the term “residual disability,” the insurer may use “proportionate disability” or other term of similar import that in the opinion of the Superintendent adequately and fairly describes the benefit.
M. “Sickness” shall not be defined to be more restrictive than the following: “Sickness means illness or disease of an insured person.”
N. “Total disability”
(1) A general definition of total disability shall not be more restrictive than one requiring that the insured, as a result of the covered sickness or accident, is unable to engage in any employment or occupation for which he or she is or becomes qualified by reason of education, training, or experience, and is not, in fact, engaged in any employment or occupation for wage or profit.
(2) Total disability may be defined in relation to the inability of the person to perform duties, but the definition must not require that an individual be unable to:
(a) Perform “any occupation whatsoever,” “any occupational duty,” or “any and every duty of his occupation”; or
(b) Engage in a training or rehabilitation program.
(3) An insurer may require the complete inability of the person to perform all of the substantial and material duties of his or her regular occupation or words of similar import, provided that “regular occupation” or similar words are clearly defined in the policy.
The restrictions set forth in this section are in addition to any other applicable restrictions as specified in Section 3(D).
A. A policy shall not contain provisions establishing a probationary or waiting period during which no coverage is provided under the policy, except:
(1) A policy may specify a probationary or waiting period for sickness not to exceed 30 days from the effective date of the coverage of the insured person; and
Accident policies shall not contain probationary or waiting periods. Nothing in this subsection is intended to restrict the use of elimination periods for disability income benefits.
B. A policy shall not exclude coverage for a loss, due to a preexisting condition, that occurs beyond the 12 months following the issuance of the policy or certificate where the application or enrollment form for the insurance does not seek disclosure of prior illness, disease, physical conditions, medical care, or treatment and where the preexisting condition is not specifically excluded by the terms of the policy or certificate.
E. A policy shall not limit or exclude coverage by type of illness, accident, treatment, or medical condition, except as provided in this subsection. Exclusions and limitations may be further limited by other applicable restrictions as specified in Section 3(D). A policy may contain coverage limitations or exclusions deemed reasonable by the Superintendent including but not limited to the following:
(1) Preexisting conditions, except for congenital anomalies of a dependent child covered at birth;
(2) Mental or emotional disorders, alcoholism, or drug addiction;
(3) Pregnancy, except for complications of pregnancy;
(4) Illness, treatment, or medical condition arising out of war or act of war (whether declared or undeclared), participation in a felony, riot, or insurrection, or service in the armed forces or units auxiliary to it;
(5) Illness or medical condition arising out of Suicide (sane or insane), attempted suicide or intentionally self-inflicted injury, except that this exclusion must not apply to benefits for medical expenses;
(6) Illness, treatment, or medical condition arising out of Aviation, other than as a ticketed passenger on a commercial airline;
(7) With respect to short-term nonrenewable policies, Illness, treatment, or medical condition arising out of interscholastic sports; or
(8) With respect to disability income protection policies, Illness, treatment, or medical condition arising out of incarceration.
(9) Cosmetic surgery, except that “cosmetic surgery” shall not include reconstructive surgery when the service is incidental to or follows surgery resulting from trauma, infection, or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child that has resulted in a functional defect;
(10) Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, or symptomatic complaints of the feet;
(11) Care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion, or subluxation in the human body for purposes of removing nerve interference and the effects of it, where the interference is the result of or related to distortion, misalignment, or subluxation of, or in the vertebral column;
(12) Treatment provided in a government hospital, benefits provided under Medicare or other governmental program (except Medicaid or MaineCare), a state or federal workers’ compensation, or employers liability or occupational disease law, services performed by a member of the covered person’s immediate family, and services for which no charge is normally made in the absence of insurance;
(13) Dental care or treatment;
(14) Eye glasses, hearing aids, and examinations for the prescription or fitting of them;
(15) Rest cures, custodial care, transportation, and routine physical examinations;
(16) Territorial limitations;
(17) Injuries from accidents occurring while the insured person is engaged in any activity pertaining to a trade, business, employment, or occupation for wage or profit.
F. This rule shall not impair or limit the use of waivers to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases, physical conditions, or hazardous activities. Where waivers are required as a condition of issuance, renewal, or reinstatement, signed acceptance by the insured is required unless on initial issuance the full text of the waiver is contained either on the first page or specification page.
G. Policy provisions precluded in this section shall not be construed as a limitation on the authority of the Superintendent to disapprove other policy provisions that in the opinion of the Superintendent are unjust, unfair, or unfairly discriminatory to the policyholder, beneficiary, or a person insured under the policy.
The following minimum standards for benefits are prescribed for the categories of coverage noted in the following subsections. An individual health insurance policy or group health insurance policy or certificate shall not be delivered or issued for delivery in this state unless it meets the required minimum standards for the specified categories or the Superintendent finds that the policies or certificates are approvable as supplemental health insurance and the outline of coverage complies with the outline of coverage in Section 7(M) of this rule.
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.
This section shall not preclude the issuance of any policy or contract combining two or more categories set forth in 24-A M.R.S.A. § 2694.
The requirements set forth in this section are in addition to any other applicable requirements as specified in Section 3(D).
A. General Rules
(1) A “noncancellable,” “guaranteed renewable,” or “noncancellable and guaranteed renewable” individual health insurance policy shall not provide for termination of coverage of the spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than nonpayment of premium. In addition, the policy shall provide that in the event of the insured’s death, the spouse of the insured, if covered under the policy, shall become the insured.
(2) (a) The terms “noncancellable,” “guaranteed renewable,” or “noncancellable and guaranteed renewable” shall not be used without further explanatory language in accordance with the disclosure requirements of Section 7A(4).
(b) The terms “noncancellable” or “noncancellable and guaranteed renewable” may be used only in an individual health insurance policy that the insured has the right to continue in force by the timely payment of premiums set forth in the policy at least until the age of 65 or until eligibility for Medicare, during which period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force.
(c) An individual health insurance policy that provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from accident or sickness must provide that the insured has the right to continue the policy in force at least to age 60. The policy must further provide that if the insured is actively and regularly employed at age 60, the insured has the right to continue the policy in force at least until the earlier of the date the insured ceases to be actively and regularly employed or the insured’s normal retirement age under social security. If the insured is ineligible for social security benefits, age 65 may be substituted for the insured’s normal retirement age under social security.
(d) A policy that is subject to the renewal requirements of 24-A M.R.S.A. § 2850-B and that permits the insurer to nonrenew for any reason other than nonpayment of premiums must be labeled “guaranteed renewable with limited exceptions.”
(e) Except as provided in subparagraph (c) and (d) above, the term “guaranteed renewable” may be used only in a policy that the insured has the right to continue in force by the timely payment of premiums at least until the age of 65 or until eligibility for Medicare, during which period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force, except that the insurer may make changes in premium rates on a class basis.
(3) In an individual health insurance policy covering both husband and wife, the age of the younger spouse shall be used as the basis for meeting the age and durational requirements of the definitions of “noncancellable” or “guaranteed renewable.” However, this requirement shall not prevent termination of coverage of the older spouse upon attainment of the stated age so long as the policy may be continued in force as to the younger spouse to the age or for the policy duration period specified in the policy.
(4) When accidental death and dismemberment coverage is part of the individual health insurance coverage offered under the contract, the insured shall have the option to include all insureds under the coverage and not just the principal insured.
- If a policy contains a status-type military service exclusion or a provision that suspends coverage during military service, the policy shall provide, upon written request of the payer, for refund of unearned premiums as applicable to the person on a pro rata basis beginning with the first day of military service. The policy must also provide for coverage to resume without penalty to the owner upon receipt of a written request within 30 days of the end of military service.
(7) A policy may contain a provision relating to recurrent disabilities, but a provision relating to recurrent disabilities shall not specify that a recurrent disability be separated by a period greater than six months.
(8) Accidental death and dismemberment benefits shall be payable if the loss occurs within 90 days from the date of the accident, irrespective of total disability. Disability coverage for loss due to an accident that occurs while the policy is in force may impose a time limit not to exceed 30 days on the time between the accidental event and commencement of the loss, but the limit must be waived if there is a clear cause and effect relationship between the accident and the subsequent loss.
(9) Specific dismemberment benefits shall not be in lieu of other benefits unless the specific benefit equals or exceeds the other benefits.
(10) If a continuous loss commences while a policy or certificate providing disability income benefits is in force, termination of the policy will not relieve the insurer of liability for that loss. The continuous total disability of the insured may be a condition for the extension of benefits beyond the period the policy was in force, limited to the duration of the benefit period, if any, or payment of the maximum benefits.
(13) A short-term nonrenewable policy shall be classified in one of the categories specified in Subsections B through I, K, or L based on its benefits.
(14) For a Sickness first manifested before the policy effective date, that was fraudulently not disclosed or fraudulently misrepresented in answer to a question in an application for coverage, an insurer may void or contest the policy or deny a claim at any time.
H. Individual Disability Income Protection Coverage
“Individual disability income protection coverage” provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from either sickness or injury or a combination of them. The requirements of this subsection do not apply to policies providing business buy-out coverage.
(1) Policies shall not contain an elimination period greater than:
(a) 90 days in the case of a coverage providing a benefit of one year or less;
(b) 180 days in the case of coverage providing a benefit of more than one year but not greater than two (2) years; or
(c) 730 days in all other cases during the continuance of disability resulting from sickness or injury;
(2) The maximum benefit period shall be at least three months except a maximum benefit period of one month is permitted for normal pregnancy and normal childbirth or for miscarriage.
(3) No reduction in benefits shall be put into effect because of an increase in Social Security or similar benefits during a benefit period.
(4) An insurer may condition total disability benefits on care by a physician other than the insured or a member of the insured’s immediate family.
I. Accident Only Coverage
“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.
The requirements set forth in this section are in addition to any other applicable requirements as specified in Section 3(D).
A. General Rules
(1) All applications for coverages specified in Sections 6B, C, D, E, G, I, J, K and L shall contain a prominent statement by type, stamp or other appropriate means in either contrasting color or in boldface type at least equal to the size type used for the headings or captions of sections of the application and in close conjunction with the applicant’s signature block on the application as follows:
“The [policy] [certificate] provides limited benefits. Review your [policy][certificate] carefully.”
(4) 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.
(6) Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charge shall be set forth in the policy or certificate.
(8) If a policy or certificate contains any limitations with respect to preexisting conditions, the limitations shall appear as a separate paragraph of the policy or certificate and be labeled as “Preexisting Condition Limitations.”
(9) All accident-only policies and certificates shall contain a prominent statement on the first page of the policy or certificate, in either contrasting color or in boldface type at least equal to the size of type used for headings or captions of sections in the policy or certificate, a prominent statement as follows:
“Notice to Buyer: This is an accident-only [policy][certificate] and it does not pay benefits for loss from sickness. Review your [policy][certificate] carefully.”
(10) All individual policies, except nonrenewable accident policies, shall have a notice prominently printed on the first page of the policy or certificate or attached to it stating in substance that the policyholder or certificateholder shall have the right to return the policy or certificate within ten days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the policyholder or certificateholder is not satisfied for any reason. Ten days is a minimum; longer periods are permitted.
(11) If age is to be used as a determining factor for reducing the maximum aggregate benefits made available in the policy or certificate as originally issued, that fact shall be prominently set forth in the outline of coverage.
(12) If a policy or certificate contains a conversion privilege, it shall comply, in substance, with the following: The caption of the provision shall be “Conversion Privilege” or words of similar import. The provision shall indicate the persons eligible for conversion, the circumstances applicable to the conversion privilege, including any limitations on the conversion, and the person by whom the conversion privilege may be exercised. The provision shall specify the benefits to be provided on conversion or may state that the converted coverage will be as provided on a policy form then being used by the insurer for that purpose.
I. Individual Disability Income Protection Coverage (Outline of Coverage)
An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of Section 6(H) of this rule. The items included in the outline of coverage must appear in the sequence prescribed:
[COMPANY NAME]
DISABILITY INCOME PROTECTION COVERAGE
OUTLINE OF COVERAGE
(1) Read Your Policy Carefully—This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!
(2) Disability income protection is designed to replace part of your earned income every month if you become unable to work due to a covered accident or sickness, subject to any limitations set forth in the policy. No coverage is provided for medical expenses.
(3) [A brief specific description of the benefits contained in this policy. The description of benefits shall be stated clearly and concisely.]
(4) [A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or, in any other manner, operate to qualify payment of the benefits described in Paragraph (3) above.]
(5) [A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.]
J. Accident-Only Coverage (Outline of Coverage)
An outline of coverage in the form prescribed below shall be issued in connection with policies meeting the standards of Section 6(I) of this rule. The items included in the outline of coverage must appear in the sequence prescribed:
[COMPANY NAME]
ACCIDENT-ONLY COVERAGE
THIS [POLICY][CERTIFICATE] PROVIDES LIMITED BENEFITS
BENEFITS PROVIDED ARE SUPPLEMENTAL AND NOT INTENDED TO COVER ALL MEDICAL EXPENSES
OUTLINE OF COVERAGE
(1) Read Your [Policy][Certificate] Carefully—This outline of coverage provides a very brief description of the important features of the coverage. This is not the insurance contract, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR [POLICY][CERTIFICATE] CAREFULLY!
(2) Accident-only coverage is designed to provide coverage for certain losses resulting from a covered accident ONLY, subject to any limitations contained in the policy. Coverage is not provided for medical expenses.
(3) [A brief specific description of the benefits. The description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provision applicable to the benefits described. If benefits vary according to the type of accidental cause, the outline of coverage shall prominently set forth the circumstances under which benefits are payable that are less than the maximum amount payable under the policy.]
(4) [A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or, in any other manner, operate to qualify payment of the benefits described in Paragraph (3) above.]
(5) [A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservations of right to change premiums.]
A. An application form for individual health insurance shall include a question designed to elicit information as to whether the insurance to be issued is intended to replace any other health insurance presently in force. A supplementary application or other form to be signed by the applicant containing the question may be used.
The following requirements apply to any form approved prior to the effective date of this rule that the carrier intends to offer in this state on or after January 1, 2005.
A. On or before October 1, 2004, the carrier must submit to the Superintendent a list of previously approved forms that the carrier intends to continue offering and that are in compliance with this rule.
B. For previously approved forms that the carrier intends to continue offering and that do not comply with this rule, the carrier must submit, on or before October 1, 2004, for approval by the Superintendent, any amendments needed to bring the forms into compliance with this rule.
C. On or before December 31, 2004, the carrier must submit to the Superintendent, for each form on the list specified in Subsection A and each form amended pursuant to Subsection B, outlines of coverage that comply with Section 7 of this rule. Outlines of coverage submitted pursuant to this subsection do not require approval and may be used unless disapproved by the Superintendent. |
