(A) Application
forms shall include the following questions designed to elicit information as
to whether the applicant has another Medicare supplement insurance policy or
certificate in force, as of the date of the application, or whether a Medicare
supplement policy or certificate is intended to replace any other accident and
sickness policy or certificate. This requirement may be satisfied through use
of a supplementary application or other form to be signed by the applicant and,
except where the coverage is sold without an agent, by the agent:
(1) Do you have another Medicare supplement
insurance policy or certificate in force (including health care service
contract or health maintenance organization contract)"
(2) Did you have another Medicare supplement
policy or certificate in force during the last twelve (12) months"
(a) If so, with which company:
(b) If that policy lapsed, when did it
lapse"
(3) Are you
covered by Medicaid"
(4) Do you
intend to replace any of your medical or health insurance coverage with this
policy (certificate)"
(B) Agents shall list any other health
insurance policies they have sold to the applicant.
(1) List policies sold which are still in
force.
(2) List policies sold in
the past five (5) years which are no longer in force.
(C) Upon determining that a sale will involve
replacement, an issuer or agent shall deliver to the applicant, prior to
issuance or delivery of the Medicare supplement policy or certificate, a notice
regarding replacement of accident and sickness coverage, except that a direct
response insurer shall deliver such notice at the time the policy is issued.
One copy of the notice signed by the applicant, and by the agent except where
the coverage is sold without an agent, shall be provided to the applicant, and
an additional signed copy shall be retained by the issuer. The required notice,
if the issuer is not a direct response insurer, shall be provided in
substantially the following form:
NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE
SUPPLEMENT INSURANCE
[Insurance Company's Name and Address]
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE
FUTURE.
According to [your application] [information you have
furnished], you intend to lapse or otherwise terminate existing Medicare
Supplement insurance and replace it with a policy to be issued by [Company
Name] Insurance Company. Your new policy provides thirty (30) days within which
you may decide without cost whether you desire to keep the policy. For your own
information and protection, you should be aware of and seriously consider
certain factors which may affect the insurance protection available to you
under the new policy.
You should review this new coverage carefully, comparing it
with all accident and sickness coverage you now have, and terminate your
present policy only if, after due consideration, you find that purchase of this
Medicare supplement coverage is a wise decision.
STATEMENT TO APPLICANT BY AGENT [BROKER OR OTHER
REPRESENTATIVE]:
(Use additional sheets, as necessary.)
I have reviewed your current medical or health insurance
coverage. I believe the replacement of insurance involved in this transaction
materially improves your position. My conclusion has taken into account the
following considerations, which I call to your attention:
(1) Health conditions which you may presently
have, which may be referred to in the policy as pre-existing conditions, may
not be immediately or fully covered under the new policy. This could result in
denial or delay of a claim for benefits under the new policy, whereas a similar
claim might have been payable under your present policy.
[This subsection may be modified if pre-existing conditions
are covered under the new policy.]
(2) State law provides that your replacement
policy or certificate may not contain new pre-existing conditions, waiting
periods, elimination periods, or probationary periods. The insurer will waive
any time periods applicable to pre-existing conditions, waiting periods,
elimination periods, or probationary periods in the new policy (or coverage)
for similar benefits to the extent such time was spent (depleted) under the
original policy.
(3) If you are
replacing existing Medicare supplement insurance coverage, you may wish to
secure the advice of your present insurer or its agent regarding the proposed
replacement of your present policy. This is not only your right, but it is also
in your best interest to make sure you understand all the relevant factors
involved in replacing your present coverage.
(4) If, after due consideration, you still
wish to terminate your present policy and replace it with new coverage, 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.
[Signature of Agent, Broker or Other Representative]
[Typed Name and Address of Agent or Broker]
The above "Notice to Applicant" was delivered to me
on:
_____________
(Date)
_____________
(Applicant's Signature)
(D) The notice required by subsection (C)
above for a direct response insurer shall be in substantially the following
form:
NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE
SUPPLEMENT INSURANCE
[Insurance Company's Name and Address]
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE
FUTURE.
According to [your application] [information you have
furnished] you intend to lapse or otherwise terminate existing Medicare
supplement insurance and replace it with the policy delivered herewith issued
by [Company Name] Insurance Company. Your new policy provides thirty (30) days
within which you may decide without cost whether you desire to keep the policy.
For your own information and protection, you should be aware of and seriously
consider certain factors which may affect the insurance protection available to
you under the new policy.
You should review this new coverage carefully, comparing it
with all accident and sickness coverage you now have, and terminate your
present policy only if, after due consideration, you find that purchase of this
Medicare supplement coverage is a wise decision.
(1) Health conditions which you may presently
have, which may be referred to in the policy as pre-existing conditions, may
not be immediately or fully covered under the new policy. This could result in
denial or delay of a claim for benefits under the new policy, whereas a similar
claim might have been payable under your present policy. [This subsection may
be modified if pre-existing conditions are covered under the new
policy.]
(2) State law provides
that your replacement policy or certificate may not contain pre-existing
conditions, waiting periods, elimination periods, or probationary periods. Your
insurer will waive any time periods applicable to pre-existing conditions,
waiting periods, elimination periods, or probationary periods in the new policy
(or coverage) for similar benefits to the extent such time was spent (depleted)
under the original policy.
(3) If
you are replacing existing Medicare supplement insurance coverage, you may wish
to secure the advice of your present insurer or its agent regarding the
proposed replacement of your present policy. This is not only your right, but
it is also in your best interest to make sure you understand all the relevant
factors involved in replacing your present coverage.
(4) [To be included only if the application
is attached to the policy.] If, after due consideration, you still wish to
terminate your present policy and replace it with new coverage, read the copy
of the application attached to your new policy and be sure that all questions
are answered fully and correctly. Omissions or misstatements in the application
could cause an otherwise valid claim to be denied. Carefully check the
application and write to [Company Name and Address] within thirty (30) days if
any information is not correct and complete, or if any past medical history has
been left out of the application.
_____________
[Company Name]
