31.11.10.06

.06 Limitations and Exclusions.

A. Crime.

(1) Except as described in A(3) of this regulation, a group health insurance contract or blanket 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) A group health insurance contract or blanket 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 group disability benefit or a group accidental death and dismemberment benefit:

(a) May include an 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 contain an exclusion or limitation which 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 described in B(2) of this regulation, a group health insurance contract or blanket 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 group disability benefit or a group accidental death and dismemberment benefit:

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

(b) May not contain an exclusion or limitation which 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 described in C(2) of this regulation, a group health insurance contract or blanket health insurance contract may not include a limitation or exclusion for loss:

(a) Sustained or contracted in consequence of the insured 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 group disability benefit or a group accidental death and dismemberment benefit:

(a) May include an exclusion or limitation for loss sustained or contracted in consequence of the insured's being intoxicated or under the influence of any narcotic; and

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

D. Preexisting Conditions.

(1) Each group health insurance contract or blanket health insurance contract shall contain a provision specifying the additional exclusions or limitations, if any, applicable under the contract with respect to a disease or physical condition of an individual, not otherwise excluded from the individual's coverage by name or specific description effective on the date of the individual's loss, that existed before the effective date of the individual's coverage under the contract.

(2) The exclusion described in D(1) of this regulation may apply only to a disease or physical condition for which medical advice or treatment was received by the individual during the 12 months before the effective date of the individual's coverage.

(3) The exclusion described in §D(1) of this regulation does not apply to loss incurred or disability beginning after the earlier of:

(a) The end of a continuous period of 12 months beginning on or after the effective date of the individual's coverage during all of which the individual has received no medical advice or treatment in connection with the disease or physical condition;

(b) The end of the 1-year period beginning on the effective date of the individual's coverage, if the individual's application or enrollment form does not include health questions; and

(c) The end of the 2-year period beginning on the effective date of the individual's coverage, if the individual's application or enrollment form includes health questions.

(4) If a group health insurance contract or blanket 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.