(1)
General rules.
a. Each individual policy of accident and
sickness insurance or hospital, medical, or dental service corporation
subscriber contract shall include a renewal, continuation, or nonrenewal
provision. The language or specifications of the provision must be consistent
with the type of contract to be issued. This 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.
b. Except for riders or
endorsements by which the insurer effectuates a request made in writing by the
policyholder or exercises a specifically reserved right under the policy, all
riders or endorsements added to a policy after date of issue or at
reinstatement or renewal which reduce or eliminate benefits or coverage in the
policy shall require signed acceptance by the policyholder. After date of
policy issue, any rider or endorsement which increases benefits or coverage
with a concomitant increase in premium during the policy term must be agreed to
in writing signed by the insured, except if the increased benefits or coverage
is required by law.
c. 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.
d. A policy which provides
for the payment of benefits based on standards described as "usual and
customary," "reasonable and customary," or words of similar import shall
include a definition and explanation of the terms "usual and customary" or
"reasonable and customary" in its accompanying outline of coverage.
e. If a policy contains any limitations with
respect to preexisting conditions the limitations must appear as a separate
paragraph of the policy and be labeled as "Preexisting Condition
Limitations."
f. All
accident only
policies shall contain a prominent statement on the first page of the policy or
attached to it, in either contrasting color or in boldface type at least equal
to the size of type used for policy captions, as follows:
"This is an accident only policy and it does not pay benefits
for loss from sickness."
g.
All policies, except single premium nonrenewable policies and as otherwise
provided in this paragraph, shall have a notice prominently printed on the
first page of the policy or attached to it stating in substance that the
policyholder shall have the right to return the policy within ten days of its
delivery and to have the premium refunded if, after examination of the policy,
the policyholder is not satisfied for any reason.
h. If age is to be used as a determining
factor for reducing the maximum aggregate benefits made available in the policy
as originally issued, such fact must be prominently set forth in the outline of
coverage.
i. If a policy 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.
j. Insurers issuing policies which provide
hospital or medical expense coverage on an expense-incurred or indemnity basis
other than incidentally, to a person(s) eligible for Medicare by reason of age,
shall provide to the policyholder a Medicare supplement buyer's guide in the
form of the booklet "Choosing a Medigap Policy: A Guide to Health Insurance for
People with Medicare" developed jointly by the National Association of
Insurance Commissioners and the Centers for Medicare and Medicaid Services of
the U.S. Department of Health and Human Services. Delivery of the buyer's guide
shall be made whether or not the policy qualifies as a "Medicare supplement
coverage" in accordance with 191-Chapter 37. Except in the case of direct
response insurers, delivery of the buyer's guide shall be made at the time of
application and acknowledgment of receipt of certification of delivery of the
buyer's guide shall be provided to the insurer. Direct response insurers shall
deliver the buyer's guide upon request but not later than at the time the
policy is delivered.
k. Outlines of
coverage delivered in connection with policies defined in this chapter as
Hospital Confinement Indemnity, Specified Disease or Limited Benefit Health
Insurance Coverages to persons eligible for
Medicare by reason of age shall
contain, in addition to the requirements of 36.7(6), 36.7(10) and 36.7(12), the
following language which shall be printed on or attached to the first page of
the outline of coverage:
This policy IS NOT A MEDICARE SUPPLEMENT policy. If you are
eligible for Medicare review the Choosing a Medigap Policy: Guide to Health
Insurance for People with Medicare, issued by the Centers for Medicare and
Medicaid Services, available from the company.
l. If payment will not be made for services
performed by a chiropractor acting within the scope of the chiropractor's
license when those services would be compensable if performed by a medical
doctor, then a statement that services performed by a chiropractor are not
compensable shall be included in all outlines of coverage delivered in
accordance with this chapter.
m.
Disclosure requirements. All insurers shall include in contracts and evidence
of coverage forms a statement disclosing the existence of any prescription drug
formularies. Upon request, all insurers offering policies under this chapter
that include a prescription drug formulary shall inform policyholders, and
prospective policyholders at time of issuance, whether a prescription drug
specified in the request is included in such formulary.
All insurers shall also disclose the existence of any
contractual arrangements providing rebates received by them for prescription
drugs or durable medical equipment. Durable medical equipment means equipment
that can stand repeated use and is primarily and customarily used to serve a
medical purpose and is generally not useful to a person who is not sick or
injured or used by other family members and is appropriate for home use for the
purpose of improving bodily functions or preventing further deterioration of
the medical condition caused by sickness or injury.
(2)
Outline of coverage requirements
for individual coverages. No individual
accident and
sickness
insurance policy or nonprofit
hospital, medical or dental service corporation
subscriber contract subject to this chapter shall be delivered or issued for
delivery in this state unless an appropriate outline of coverage, as prescribed
in 36.7(3) to 36.7(12), is completed as to the policy or contract and
a. Delivered with the policy; or
b. Delivered to the applicant at the time
application is made and acknowledgment of receipt or certification of delivery
of the outline of coverage is provided to the insurer.
If an outline of coverage was delivered at the time of
application and the policy or contract is issued on a basis which would require
revision of the outline, a substitute outline of coverage properly describing
the policy or contract must accompany the policy or contract when it is
delivered and contain the following statement, in no less than 12-point type,
immediately above the company name: "NOTICE: Read this outline of coverage
carefully. It is not identical to the outline of coverage provided upon
application and the coverage originally applied for has not been
issued."
The appropriate outline of coverage for policies or contracts
providing hospital coverage which only meets the standards of 36.6(2) shall be
that statement contained in 36.7(3). The appropriate outline of coverage for
policies providing coverage which meets the standards of both 36.6(2) and
36.6(3) shall be the statement contained in 36.7(5). The appropriate outline of
coverage for policies providing coverage which meets the standards of both
36.6(2) and 36.6(5) or 36.6(3) and 36.6(5) or 36.6(2), 36.6(3), and 36.6(5)
shall be the statement contained in 36.7(7).
Appropriate changes in terminology may be made in the outline
of coverage in the case of contracts of hospital, medical, or dental service
corporations. In any other case where the prescribed outline of coverage is
inappropriate for the coverage provided by the policy or contract, an alternate
outline of coverage shall be submitted to the commissioner for prior
approval.
(3)
Basic hospital expense coverage (outline of coverage). An
outline of coverage, in the form prescribed below, shall be issued in
connection with policies meeting the standards of 36.6(2). The items included
in the outline of coverage must appear in the sequence prescribed.
(COMPANY NAME)
BASIC HOSPITAL EXPENSE COVERAGE
OUTLINE OF COVERAGE
a. 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.
b. Basic hospital expense coverage. Policies
of this category are designed to provide to persons insured coverage for
hospital expenses incurred as a result of a covered accident or sickness.
Coverage is provided for daily hospital room and board, miscellaneous hospital
services, and hospital outpatient services, subject to any limitations,
deductibles and copayment requirements set forth in the policy. Coverage is not
provided for physicians' or surgeons' fees or unlimited hospital
expenses.
c. (A brief specific
description of the benefits, including dollar amounts and number of days
duration where applicable, contained in this policy in the following order:
(1) Daily hospital room and board;
(2) Miscellaneous hospital
services;
(3) Hospital outpatient
services; and
(4) Other benefits,
if any.)
(Note: The above 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.)
d. (A description of any policy
provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any
other manner operate to qualify payment of the benefits described
in"c" above.)
e.
(A description of policy provisions respecting renewability or continuation of
coverage, including age restrictions or any reservation of right to change
premiums.)
(4)
Basic medical-surgical expense coverage (outline of coverage).
An outline of coverage, in the form prescribed below, shall be issued in
connection with policies meeting the standards of subrule 36.6(3). The items
included in the outline of coverage must appear in the sequence prescribed:
(COMPANY NAME)
BASIC MEDICAL-SURGICAL EXPENSE COVERAGE
OUTLINE OF COVERAGE
a. 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 your policy. 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.
b. Basic medical-surgical expense coverage.
Policies of this category are designed to provide to persons insured coverage
for medical-surgical expenses incurred as a result of a covered accident or
sickness. Coverage is provided for surgical services, anesthesia services, and
in-hospital medical services, subject to any limitations, deductibles and
copayment requirements set forth in the policy. Coverage is not provided for
hospital expenses or unlimited medical-surgical expenses.
c. (A brief specific description of the
benefits, including dollar amounts and number of days duration where
applicable, contained in this policy, in the following order:
(1) Surgical services;
(2) Anesthesia services;
(3) In-hospital medical services;
and
(4) Other benefits, if any.)
(Note: The above 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.)
d. (A description of any policy
provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any
other manner operate to qualify payment of the benefits described
in"c" above.)
e.
(A description of policy provisions respecting renewability or continuation of
coverage, including age restrictions or any reservation of right to change
premiums.)
(5)
Basic hospital and medical-surgical expense coverage (outline of
coverage). An outline of coverage, in the form prescribed below, shall
be issued in connection with policies meeting the standards of 36.6(2) and
36.6(3) of this chapter. The items included in the outline of coverage must
appear in the sequence prescribed:
(COMPANY NAME)
BASIC HOSPITAL AND MEDICAL-SURGICAL EXPENSE COVERAGE
OUTLINE OF COVERAGE
a. 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.
b. Basic hospital and medical-surgical
expense coverage. Policies of this category are designed to provide, to persons
insured, coverage for hospital and medical-surgical expenses incurred as a
result of a covered accident or sickness. Coverage is provided for daily
hospital room and board, miscellaneous hospital services, hospital outpatient
services, surgical services, anesthesia services, and in-hospital medical
services, subject to any limitations, deductibles and copayment requirements
set forth in the policy. Coverage is not provided for unlimited hospital or
medical-surgical expenses.
c. (A
brief specific description of the benefits, including dollar amounts and number
of days duration where applicable, contained in this policy, in the following
order:
(1) Daily hospital room and
board;
(2) Miscellaneous hospital
services;
(3) Hospital outpatient
services;
(4) Surgical
services;
(5) Anesthesia
services;
(6) In-hospital medical
services; and
(7) Other benefits,
if any.)
(Note: The above 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.)
d. (A description of any policy
provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any
other manner operate to qualify payment of the benefits described
in"c" above.)
e.
(A description of policy provisions respecting renewability or continuation of
coverage, including age restrictions or any reservation of right to change
premiums.)
(6)
Hospital confinement indemnity coverage (outline of coverage).
An outline of coverage, in the form prescribed below, shall be issued in
connection with policies meeting the standards of 36.6(4). The items included
in the outline of coverage must appear in the sequence prescribed:
(COMPANY NAME)
HOSPITAL CONFINEMENT INDEMNITY COVERAGE
OUTLINE OF COVERAGE
a. 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.
b. Hospital confinement indemnity coverage.
Policies of this category are designed to provide, to persons insured, coverage
in the form of a fixed daily benefit during periods of hospitalization
resulting from a covered accident or sickness, subject to any limitations set
forth in the policy. These policies do not provide any benefits other than the
fixed daily indemnity for hospital confinement and any additional benefit
described below.
c. (A brief
specific description of the benefits contained in this policy, in the following
order:
(1) Daily benefit payable during
hospital confinement; and
(2)
Duration of benefit described in
"c" (1).)
(Note: The above description of benefits shall be stated
clearly and concisely.)
d. (A description of any policy provisions
which exclude, eliminate, restrict, reduce, limit, delay, or in any other
manner operate to qualify payment of the benefits described
in"c" above.)
e.
(A description of policy provisions respecting renewability or continuation of
coverage, including age restrictions or any reservation of right to change
premiums.)
f.
(Any
benefits provided in addition to the daily hospital benefit.)
(7)
Major
medical expense coverage (outline of coverage). An outline of
coverage, in the form prescribed below, shall be issued in connection with
policies meeting the standards of 36.6(5) of this chapter. The items included
in the outline of coverage must appear in the sequence prescribed:
(COMPANY NAME)
MAJOR MEDICAL EXPENSE COVERAGE
OUTLINE OF COVERAGE
a. 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.
b. Major medical expense coverage. Policies
of this category are designed to provide, to persons insured, coverage for
major hospital, medical and surgical expenses incurred as a result of a covered
accident or sickness. Coverage is provided for daily hospital room and board,
miscellaneous hospital services, surgical services, anesthesia services,
in-hospital medical services, and out-of-hospital care, subject to any
deductibles, copayment provisions, or other limitations which may be set forth
in the policy. Basic hospital or basic medical insurance coverage is not
provided.
c. (A brief specific
description of the benefits, including dollar amounts, contained in this
policy, in the following order:
(1) Daily
hospital room and board;
(2)
Miscellaneous hospital services;
(3) Surgical services;
(4) Anesthesia services;
(5) In-hospital medical services;
(6) Out-of-hospital care;
(7) Maximum dollar amount for covered
charges; and
(8) Other benefits, if
any.)
(Note: The above 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.)
d. (A description of any policy
provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any
other manner operate to qualify payment of the benefits described
in"c" above.)
e.
(A description of policy provisions respecting renewability or continuation of
coverage, including age restrictions or any reservation of right to change
premiums.)
(8)
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 36.6(7) of this chapter. The
items included in the outline of coverage must appear in the sequence
prescribed:
(COMPANY NAME)
DISABILITY INCOME PROTECTION COVERAGE
OUTLINE OF COVERAGE
a. 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.
b. Disability income protection coverage.
Policies of this category are designed to provide, to persons insured, coverage
for disabilities resulting from a covered accident or sickness, subject to any
limitations set forth in the policy. Coverage is not provided for basic
hospital, basic medical-surgical, or major medical expenses.
c. (A brief specific description of the
benefits contained in this policy:)
(Note: The above description of benefits shall be stated
clearly and concisely.)
d.
(A description of any policy provisions which exclude, eliminate, restrict,
reduce, limit, delay, or in any other manner operate to qualify payment of the
benefits described in"c" above.)
e. (A description of policy provisions
respecting renewability or continuation of coverage, including age restrictions
or any reservation of right to change premiums.)
(9)
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 36.6(8).
The items included in the outline of coverage must appear in the sequence
prescribed:
(COMPANY NAME)
ACCIDENT ONLY COVERAGE
OUTLINE OF COVERAGE
a. 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.
b. Accident only coverage. Policies of this
category are designed to provide, to persons insured, coverage for certain
losses resulting from a covered accident ONLY, subject to any limitations
contained in the policy. Coverage is not provided for basic hospital, basic
medical-surgical, or major medical expenses.
c. (A brief specific description of the
benefits contained in this policy:)
(Note: The above 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. Proper disclosure of
benefits which vary according to accidental cause shall be made in accordance
with 36.6(1)"m.")
d. (A description of any policy provisions
which exclude, eliminate, restrict, reduce, limit, delay, or in any other
manner operate to qualify payment of the benefits described
in"c" above.)
e.
(A description of policy provisions respecting renewability or continuation of
coverage, including age restrictions or any reservation of right to change
premiums.)
(10)
Specified disease or specified accident coverage (outline of
coverage). An outline of coverage, in the form prescribed below, shall
be issued in connection with policies meeting the standards of 36.6(8). The
coverage shall be identified by the appropriate bracketed title. The items
included in the outline of coverage must appear in the sequence prescribed:
(COMPANY NAME)
(SPECIFIED DISEASE) (SPECIFIED ACCIDENT) COVERAGE
OUTLINE OF COVERAGE
a. 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.
b. (Specified disease) (Specified accident)
coverage. Policies of this category are designed to provide, to persons
insured, restricted coverage paying benefits ONLY when certain losses occur as
a result of (specified diseases) or (specified accidents). Coverage is not
provided for basic hospital, basic medical-surgical or major medical
expenses.
c. (A brief specific
description of the benefits, including dollar amounts, contained in this
policy:)
(Note: The above description of benefits shall be stated
clearly and concisely, and shall include a description of any deductible or
copayment provisions applicable to the benefits described. Proper disclosure of
benefits which vary according to accidental cause shall be made in accordance
with 36.6(1)"m.")
d. (A description of any policy provisions
which exclude, eliminate, restrict, reduce, limit, delay, or in any other
manner operate to qualify payment of the benefits described
in"c" above.)
e.
(A description of policy provisions respecting renewability or continuation of
coverage, including age restrictions or any reservation or right to change
premiums.)
(11)
Reserved.
(12)
Limited
benefit health coverage (outline of coverage). An outline of coverage,
in the form prescribed below, shall be issued in connection with policies which
do not meet the minimum standards of subrules 36.6(2) to 36.6(8). The items
included in the outline of coverage must appear in the sequence prescribed:
(COMPANY NAME)
LIMITED BENEFIT HEALTH COVERAGE
OUTLINE OF COVERAGE
a. 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.
b. Limited benefit health coverage. Policies
of this category are designed to provide, to persons insured, limited or
supplemental coverage.
c. (A brief
specific description of the benefits, including dollar amounts, contained in
this policy:)
(Note: The above description of benefits shall be stated
clearly and concisely, and shall include a description of any deductible or
copayment provisions applicable to the benefits described. Proper disclosure of
benefits which vary according to accidental cause shall be made in accordance
with subrule 36.6(1)"n.")
d. (A description of any policy provisions
which exclude, eliminate, restrict, reduce, limit, delay, or in any other
manner operate to qualify payment of the benefits described in
36.7(12)"c.")
e.
(A description of policy provisions respecting renewability or continuation of
coverage, including age restrictions or any reservation of right to change
premiums.)
(13)
Short-term limited-duration insurance coverage.
a.
Outline of coverage. An
outline of coverage, in the form prescribed below, shall be issued in
connection with any
short-term limited-duration insurance, as set forth in
subrule 36.6(11). This outline of coverage must be provided in addition to the
notices required by paragraph 36.6(11)
"g." The items included
in the outline of coverage must appear in the sequence prescribed below, and
Section A must be in at least 14-point type or, if electronic, of equivalent
prominence:
[COMPANY NAME]
SHORT-TERM LIMITED-DURATION INSURANCE COVERAGE OUTLINE OF
COVERAGE
[If coverage begins before January 1, 2019, the following
notice shall appear in at least 14-point type or, if electronic, of equivalent
prominence:]
A. THIS COVERAGE IS NOT
REQUIRED TO COMPLY WITH CERTAIN FEDERAL MARKET REQUIREMENTS FOR HEALTH
INSURANCE, PRINCIPALLY THOSE CONTAINED IN THE AFFORDABLE CARE
ACT. BE SURE TO
CHECK YOUR POLICY CAREFULLY TO MAKE SURE YOU ARE AWARE OF ANY EXCLUSIONS OR
LIMITATIONS REGARDING COVERAGE OF PREEXISTING CONDITIONS OR HEALTH BENEFITS
(SUCH AS HOSPITALIZATION, EMERGENCY SERVICES, MATERNITY CARE, PREVENTIVE CARE,
PRESCRIPTION DRUGS, AND
MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES).
YOUR POLICY MIGHT ALSO HAVE LIFETIME AND/OR ANNUAL DOLLAR LIMITS ON HEALTH
BENEFITS. IF THIS COVERAGE EXPIRES OR YOU LOSE ELIGIBILITY FOR THIS COVERAGE,
YOU MIGHT HAVE TO WAIT UNTIL AN OPEN ENROLLMENT PERIOD TO GET OTHER HEALTH
INSURANCE COVERAGE. ALSO, THIS COVERAGE IS NOT "MINIMUM ESSENTIAL COVERAGE" FOR
ANY MONTH IN 2018. YOU MAY HAVE TO MAKE A PAYMENT WHEN YOU FILE YOUR TAX RETURN
UNLESS YOU QUALIFY FOR AN EXEMPTION FROM THE REQUIREMENT THAT YOU HAVE HEALTH
COVERAGE FOR THAT MONTH.
[If coverage begins on or after January 1, 2019, the
following notice shall appear in at least 14-point type or, if electronic, of
equivalent prominence:]
A.
THIS COVERAGE IS NOT REQUIRED TO COMPLY WITH CERTAIN FEDERAL MARKET
REQUIREMENTS FOR HEALTH INSURANCE, PRINCIPALLY THOSE CONTAINED IN THE
AFFORDABLE CARE
ACT. BE SURE TO CHECK YOUR POLICY CAREFULLY TO MAKE SURE YOU
ARE AWARE OF ANY EXCLUSIONS OR LIMITATIONS REGARDING COVERAGE OF PREEXISTING
CONDITIONS OR HEALTH BENEFITS (SUCH AS HOSPITALIZATION, EMERGENCY SERVICES,
MATERNITY CARE, PREVENTIVE CARE, PRESCRIPTION DRUGS, AND
MENTAL HEALTH AND
SUBSTANCE USE DISORDER SERVICES). YOUR POLICY
MIGHT ALSO HAVE LIFETIME AND/OR ANNUAL DOLLAR LIMITS ON
HEALTH BENEFITS. IF THIS COVERAGE EXPIRES OR YOU LOSE ELIGIBILITY FOR THIS
COVERAGE, YOU MIGHT HAVE TO WAIT UNTIL AN OPEN ENROLLMENT PERIOD TO GET OTHER
HEALTH INSURANCE COVERAGE.
B. 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.
C. [A brief specific
description of the benefits, including dollar amounts, contained in this
policy. The description of benefits shall be stated clearly and concisely, and
shall include a description of any deductible or copayment or other
out-of-pocket cost provisions applicable to the benefits described. The
description of benefits shall also clearly state any applicable provider
network requirements including but not limited to distinctions in cost
provisions for in-network and out-of-network providers.]
D. [A description of any other policy
provisions which exclude, eliminate, restrict, reduce, limit, delay, or in any
other manner operate to qualify payment of the benefits described in Section C,
above, including but not limited to any preexisting condition exclusions for
policies.]
E. [A description of
policy provisions regarding renewability or continuation of coverage, including
any reservation of right to change premiums.]
b.
Application for coverage for
short-term limited-duration insurance. All applications for short-term
limited-duration policies shall contain the notice prescribed below, which
shall be in at least 14-point type or, if electronic, of equivalent prominence.
One signed copy of such notice shall be retained by the applicant and an
additional copy signed by the applicant shall be retained by the insurer.
STATEMENT TO APPLICANT BY ISSUER [PRODUCER, BROKER OR OTHER
REPRESENTATIVE]:
Health conditions which you may presently have
(preexisting conditions) may not be immediately or fully covered under this
policy. This could result in a denial or delay of payment of benefits.
If you wish to purchase a short-term limited-duration policy, be certain to
truthfully and completely answer all questions on the application concerning
your medical health history. Failure to include all material medical
information on an application may provide a basis for the company to deny any
future claims and to refund your premium as though your policy had never been
in force. After the application has been completed and before you sign it,
reread it carefully to be certain that all information has been properly
recorded.
ALSO NOTE THAT, IF THIS COVERAGE EXPIRES OR YOU LOSE
ELIGIBILITY FOR THIS COVERAGE, YOU MIGHT HAVE TO WAIT UNTIL AN OPEN ENROLLMENT
PERIOD TO GET OTHER HEALTH INSURANCE COVERAGE.
________________________________
(Signature of Producer, Broker or Other Representative of the
Company)
[Typed Name and Address of Producer, Broker or Other
Representative]
The above "Statement to Applicant" was delivered to me
on:
(Date)
(Applicant's Signature)
