02-031 C.M.R. ch. 755, § 5 - Prohibited Policy Provisions

The restrictions set forth in this section are in addition to any other applicable restrictions as specified in Section 3(D).

A. A policy shall not contain provisions establishing a probationary or waiting period during which no coverage is provided under the policy, except:

(1) A policy may specify a probationary or waiting period for sickness not to exceed 30 days from the effective date of the coverage of the insured person; and

(2) A policy may specify a probationary or waiting period not to exceed six months for specified diseases or conditions and losses resulting from disease or condition related to hernia, disorder of reproduction organs, varicose veins, adenoids, appendix, and tonsils. However, the permissible six-month exception shall not be applicable where the specified diseases or conditions are treated on an emergency basis.

Accident policies shall not contain probationary or waiting periods. Nothing in this subsection is intended to restrict the use of elimination periods for disability income benefits.

B. A policy shall not exclude coverage for a loss, due to a preexisting condition, that occurs beyond the 12 months following the issuance of the policy or certificate where the application or enrollment form for the insurance does not seek disclosure of prior illness, disease, physical conditions, medical care, or treatment and where the preexisting condition is not specifically excluded by the terms of the policy or certificate.

C. Unless the Superintendent specifically finds that it is in the best interest of the insureds, no policy subject to this rule shall provide a return of premium or cash value benefit, except: return of unearned premium upon termination or suspension of coverage; retroactive waiver of premium paid during disability; payment of dividends on participating policies; or experience rating refunds.

D. Policies providing hospital confinement indemnity coverage shall not contain provisions excluding coverage because of confinement in a hospital operated by the state or federal government or because the insured is not liable for hospital charges.

E. A policy shall not limit or exclude coverage by type of illness, accident, treatment, or medical condition, except as provided in this subsection. Exclusions and limitations may be further limited by other applicable restrictions as specified in Section 3(D). A policy may contain coverage limitations or exclusions deemed reasonable by the Superintendent including but not limited to the following:

(1) Preexisting conditions, except for congenital anomalies of a dependent child covered at birth;

(2) Mental or emotional disorders, alcoholism, or drug addiction;

(3) Pregnancy, except for complications of pregnancy;

(4) Illness, treatment, or medical condition arising out of war or act of war (whether declared or undeclared), participation in a felony, riot, or insurrection, or service in the armed forces or units auxiliary to it;

(5) Illness or medical condition arising out of Suicide (sane or insane), attempted suicide or intentionally self-inflicted injury, except that this exclusion must not apply to benefits for medical expenses;

(6) Illness, treatment, or medical condition arising out of Aviation, other than as a ticketed passenger on a commercial airline;

(7) With respect to short-term nonrenewable policies, Illness, treatment, or medical condition arising out of interscholastic sports; or

(8) With respect to disability income protection policies, Illness, treatment, or medical condition arising out of incarceration.

(9) Cosmetic surgery, except that "cosmetic surgery" shall not include reconstructive surgery when the service is incidental to or follows surgery resulting from trauma, infection, or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child that has resulted in a functional defect;

(10) Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, or symptomatic complaints of the feet;

(11) Care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion, or subluxation in the human body for purposes of removing nerve interference and the effects of it, where the interference is the result of or related to distortion, misalignment, or subluxation of, or in the vertebral column;

(12) Treatment provided in a government hospital, benefits provided under Medicare or other governmental program (except Medicaid or MaineCare), a state or federal workers' compensation, or employers liability or occupational disease law, services performed by a member of the covered person's immediate family, and services for which no charge is normally made in the absence of insurance;

(13) Dental care or treatment;

(14) Eye glasses, hearing aids, and examinations for the prescription or fitting of them;

(15) Rest cures, custodial care, transportation, and routine physical examinations;

(16) Territorial limitations;

(17) Injuries from accidents occurring while the insured person is engaged in any activity pertaining to a trade, business, employment, or occupation for wage or profit.

F. This rule shall not impair or limit the use of waivers to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases, physical conditions, or hazardous activities. Where waivers are required as a condition of issuance, renewal, or reinstatement, signed acceptance by the insured is required unless on initial issuance the full text of the waiver is contained either on the first page or specification page.

G. Policy provisions precluded in this section shall not be construed as a limitation on the authority of the Superintendent to disapprove other policy provisions that in the opinion of the Superintendent are unjust, unfair, or unfairly discriminatory to the policyholder, beneficiary, or a person insured under the policy.

Notes

02-031 C.M.R. ch. 755, § 5