A. An application form for individual health
insurance shall include a question designed to elicit information as to whether
the insurance to be issued is intended to replace any other health insurance
presently in force. A supplementary application or other form to be signed by
the applicant containing the question may be used.
B. Upon determining that a sale will involve
replacement, an insurer, other than a direct response insurer, or its agent
shall furnish the applicant, prior to issuance or delivery of the policy, the
notice described in Subsection C below. The insurer shall retain a copy of the
notice. A direct response insurer shall deliver to the applicant upon issuance
of the policy, the notice described in Subsection D below. In no event,
however, will the notices be required in the solicitation of the following
types of policies: accident-only and single-premium nonrenewable
policies.
C. The notice required by
Subsection B above for an insurer, other than a direct response insurer, shall
provide, in substantially the following form:
NOTICE TO APPLICANT REGARDING REPLACEMENT
OF HEALTH INSURANCE
According to [your application] [information you have
furnished], you intend to lapse or otherwise terminate existing health
insurance and replace it with a policy to be issued by [insert company name]
Insurance Company. For your own information and protection, you should be aware
of and seriously consider certain factors that may affect the insurance
protection available to you under the new policy.
(1) Health conditions that you may presently
have, (preexisting conditions) may not be immediately or fully covered under
the new policy. This could result in denial or delay of a claim for benefits
present under the new policy, whereas a similar claim might have been payable
under your present policy. [This subsection may be modified or omitted if
preexisting conditions are covered under the new policy.]
(2) 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 interests to
make sure you understand all the relevant factors involved in replacing your
present coverage.
(3) Do not cancel
your present policy until you have actually received your new policy and are
sure you want to keep it.
(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.
The above "Notice to Applicant" was delivered to me
on:
____________________________
(Date)
____________________________
(Applicant's Signature)
D. The notice required by Subsection B of
this section for a direct response insurer shall be as follows:
NOTICE TO APPLICANT REGARDING REPLACEMENT
OF HEALTH INSURANCE
According to [your application] [information you have
furnished] you intend to lapse or otherwise terminate existing health insurance
and replace it with the policy delivered herewith issued by [insert company
name] Insurance Company. Your new policy provides ten [insert higher number if
the policy provides a longer period] 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 that
may affect the insurance protection available to you under the new
policy.
(1) Health conditions that you
may presently have, (preexisting 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 or omitted
if preexisting conditions are covered under the new policy.]
(2) 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 interests to
make sure you understand all the relevant factors involved in replacing your
present coverage.
(3) Do not cancel
your present policy until you have actually received your new policy and are
sure you want to keep it.
(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 [insert company name and
address] within ten days if any information is not correct and complete, or if
any past medical history has been left out of the application.
[COMPANY NAME]
