31.10.28.03

.03 Limitations and Exclusions.

A. Crime.

(1) Except as provided in §A(3) of this regulation, an individual health insurance contract may not include a limitation or exclusion for loss to which a contributing cause was the insured's commission of or attempt to commit a crime.

(2) An individual health insurance contract may not include a limitation or exclusion for loss for which a contributing cause was the commission of or the attempt to commit a crime by an individual other than the insured.

(3) A disability benefit or an accidental death and dismemberment benefit in an individual health insurance contract:

(a) May be subject to exclusion or limitation for loss to which a contributing cause was the insured's commission of or attempt to commit a felony; and

(b) May not be subject to an exclusion or limitation regarding the commission of or attempt to commit a crime that is more restrictive to the insured than the exclusion or limitation set forth in §A(3)(a) of this regulation.

B. Illegal Occupation.

(1) Except as provided in §B(2) of this regulation, an individual health insurance contract may not include a limitation or exclusion for loss to which a contributing cause was the insured's being engaged in an illegal occupation.

(2) A disability benefit or an accidental death and dismemberment benefit in an individual health insurance contract:

(a) May be subject to an exclusion or limitation for loss to which a contributing cause was the insured's being engaged in an illegal occupation; and

(b) May not be subject to an exclusion or limitation regarding an illegal occupation that is more restrictive to the insured than the exclusion or limitation set forth in §B(2)(a) of this regulation.

C. Intoxicants and Narcotics.

(1) Except as provided in §C(2) of this regulation, an individual health insurance contract may not include a limitation or exclusion for loss:

(a) Sustained or contracted in consequence of the insured's being intoxicated or under the influence of any drug;

(b) Due to the use of alcohol;

(c) Due to the use of drugs or narcotics; or

(d) Due to alcoholism or drug addiction.

(2) A disability benefit or an accidental death and dismemberment benefit in an individual health insurance contract:

(a) May be subject to an exclusion or limitation for loss sustained or contracted in consequence of the insured's being intoxicated or under the influence of any narcotic unless administered on the advice of a physician; and

(b) May not be subject to an exclusion or limitation regarding the use of alcohol or drugs that is more restrictive to the insured than the exclusion or limitation set forth in §C(2)(a) of this regulation.

D. Preexisting Condition Limitation. If an individual health insurance contract contains a preexisting condition limitation or exclusion, the limitation or exclusion may not apply to a condition that the applicant revealed in the application for the contract, unless the condition is excluded by means of a signed waiver rider attached to the contract.