Fla. Admin. Code Ann. R. 69O-157.012 - Exclusions, Limitations, Reductions

(1) Exclusions, limitations, reductions, generally -

(a) Any exclusions, limitations, or reductions on the risk undertaken whether applicable to amounts, duration of benefits, age, or other matters, must be specified with clarity and certainty in appropriately entitled provision or provisions of the contract;

(b) Such principal exclusions, limitations, or reductions shall be included in the applicable "Outline of Coverage" delivered to an applicant for an individual policy or included in the "Certificate" issued pursuant to a group policy delivered or issued for delivery in this state; and

(c) Any exclusion, limitation, or reduction must be clearly expressed as part of the benefit provision to which it applies or, if applicable, to more than one benefit provision, shall be set forth as a separate provision and appropriately captioned.

(2) Exclusion - An exclusion is any provision in a policy or contract whereby coverage for a specified hazard is entirely eliminated. It is a statement of risk not assumed under the terms and provisions of the contract.

(3) Limitation - A limitation is any provision in a policy or contract whereby coverage amounts or duration of benefits or conditions under which benefits are delivered are specified.

(4) Reduction - A reduction is any provision in a policy or contract which takes away some portion, but not all of the coverage of such policy or contract under certain specific conditions. Such provision may limit the coverage amounts or duration of benefits to some coverage amount or duration of benefit which is less than would be otherwise applicable had such reduction clause not been used.

(5) No long-term care insurance policy or certificate may exclude or use waivers or riders of any kind to exclude, limit, or reduce coverage or benefits for specifically named or described pre-existing diseases or physical conditions beyond any general pre-existing condition waiting period otherwise permitted by statute or rule.

(6) Exclusions and limitations prohibited - No policy or contract may exclude or limit coverage by type of illness, treatment, medical condition or accident, except as follows:

(a) Pre-existing conditions or diseases as further specified in Rule 69O-157.009, F.A.C.;

(b) Mental or nervous disorders which shall not exclude or limit coverage for any condition other than a neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind. However, this shall not permit exclusion or limitation of benefits on the basis of Alzheimers Disease or similar organic brain syndrome;

(c) Alcoholism and drug addiction;

(d) Illness, treatment or medical condition arising out of:

1. War or act of war (whether declared or undeclared);

2. Participation in a felony, riot or insurrection; or

3. Service in the armed forces or units auxiliary thereto;

4. Attempted suicide, or intentionally self-inflicted injury.

(7) The exclusions and limitations provisions of this rule are not intended to prohibit those allowable exclusions and limitations by type of provider or territorial limitations, provided that any such territorial limitations may not exclude coverage in any state of the United States.

Notes

Fla. Admin. Code Ann. R. 69O-157.012

Rulemaking Authority 624.308(1), 627.9407(1) FS. Law Implemented 624.307(1), 627.9407(1) FS.

New 5-17-89, Formerly 4-81.012, 4-157.012.

New 5-17-89, Formerly 4-81.012, 4-157.012.