31.10.01.03

.03 Filing of Health Insurance Forms for Approval.

A. The filing of a form shall be accompanied by the filing of premium rates for it. Subsequent changes in premium rates shall be filed with supporting data at least 90 days before the date any change in the rate is proposed to become effective.

A-1. A carrier submitting forms for approval, or premiums for forms pending approval or previously approved, shall print or type in a conspicuous manner immediately below the name of the carrier on the letter of transmittal the carrier’s National Association of Insurance Commissioners (NAIC) company code number.

B. Any name or title of a policy should be printed in a size of type smaller than that used for the name of the carrier.

C. Reference to a standard of time shall specify time at the place the insured resides, or at the place the accident or illness occurs, or at the place the policy is delivered.

D. A form will not be approved for issuance at any age which does not provide a reasonable period of full coverage before the age at which benefits terminate or are substantially reduced.

E. If a rider or endorsement reduces or eliminates coverage of a policy, signed acceptance by the policyowner at the time of or before delivery of the policy is required.

F. Any form which by its terms provides that only one of several benefits will be payable as a result of any one accident or sickness shall state that the largest of the benefits will be payable.

G. If the claimant has the right to elect alternative benefits, the time allowed for the election shall be not less than 90 days from the date of the accident or commencement of the loss.

H. If payment of benefits is related to the first visit of a physician or the date of the first medical attendance, this stipulation shall appear in the benefit provision to which it applies.

I. Payment of benefits may be limited in duration to the time the insured is under the care of a physician, but may not be conditioned upon any specified frequency of visits or attendance by the physician.

J. Except in the case of group health insurance, if any policy provision terminates upon entry of the insured into military service, or if the policy excludes any coverage while the insured is in military service, the policy shall provide for a refund upon request of the policyowner of pro rata unearned premium for any period during which the insured is not covered. However, if coverage is excluded only for loss resulting from military service while in military service, a refund is not required. In policies of noncancellable or guaranteed renewable health insurance, when the coverage is automatically reinstated upon discharge from military service or within a stated period not exceeding 6 months after discharge, a refund is not required.

K. In lieu of the definitions contained in §§L, M, and N of this regulation, the policy may contain a definition which, in the opinion of the Commissioner, is not less favorable to the policyholder.

L. During at least the first 12 months, or the first 52 weeks, of disability, total disability for which benefits may become due and payable shall be defined as "inability by reason of injury or sickness to perform each and every duty pertaining to the insured's occupation". After the first 12 months, or the first 52 weeks, of disability, total disability may be defined as "inability to perform each and every duty of any business or occupation for which the insured is reasonably fitted by education, training and experience".

M. Partial disability shall be defined as "inability to perform one or more, but not all, of the important daily duties of the insured's occupation".

N. If a form provides coverage due to the wrecking or disablement of, or material damage to, an automobile, elevator, or other conveyance in which the insured is a passenger at the time of the accident, the wrecking, disablement, or material damage shall be defined substantially as damage which necessitates repair in order to place the conveyance in as good a condition as it was before the accident.

O. An exception excluding liability for chronic or organic disease will not be permitted. Any disease to be excluded from coverage shall be stated with sufficient clarity so as to be readily identifiable.

P. A provision may not contain the words "reimburse" or "reimbursement" or the phrase "amount actually expended". A benefit may not be conditioned on the payment by the claimant of expenses for which the policy provides a benefit.

Q. A form may not contain the phrase "strict compliance" or words of similar import.

R. Except in the case of a health benefit plan, in any policy form in which the carrier has the right to change premium rates, the policy shall provide that notice of any increase in rates shall be given to the policyholder by mail at least 40 days before the expiration of the grace period applicable to the first increased premium.

S. In any individual health benefit plan in which the carrier has the right to change premium rates, the health benefit plan shall provide that notice of any increase in premium rates shall be given to the policyholder by mail:

(1) For grandfathered health plan coverage, at least 60 days before the change in premium rates is proposed to become effective; and

(2) For nongrandfathered health plan coverage, before the first day of the annual open enrollment period.

T. A noncancellable or guaranteed renewable family health insurance policy which covers the spouse of the insured shall provide that, in the event of the death of the insured applicant, the spouse will become the successor insured.