211 CMR 90.06 - Benefit Contracts

Current through Register 1466, April 1, 2022

Each insurer and membership plan sponsor must submit a copy of its group and individual contract forms along with the plan of operation. Each group contract form must be accompanied by the certificate that summarizes the provisions of the contract for the group subscribers. Each certificate and individual contract form must be accompanied by its Flesch scale readability score, computed by the procedure specified in M.G.L. c. 175, § 2B.

The Commissioner will disapprove any certificate or group or individual contract form that contains any provisions which are unfair, inequitable, misleading or deceptive. The Commissioner will disapprove a certificate or contract form under this standard if it permits the insurer or membership plan sponsor to reduce the level of benefits or assess subscribers during the coverage period.

The Commissioner will disapprove any certificate or individual contract form that does not meet the standards set out in M.G.L. c. 175, § 2B or that does not state clearly and in understandable style and language :

(1) The benefits available to the subscriber and his or her covered dependents.
(2) The limitations and exclusions on the benefits, including an explanation of any deductible, coinsurance, or copayment features and any waiting periods.
(3) The manner of obtaining benefits, including the type of attorneys that may be used, the procedures, including those of appeal, that must be followed before nonparticipating attorneys may be used and the claims procedure.
(4) The organization's procedure for the use of the subscriber satisfaction form and its procedure for resolving complaints concerning the operations of the legal services plan and the quality of participating attorneys, including a telephone number for registering grievances.
(5) The role of the Board of Bar Overseers in regulating attorney conduct and the procedure for submitting complaints to the Board.
(6) The statutory procedure for obtaining a Division of Insurance hearing on any dispute or controversy arising between the insurer or sponsor and any subscriber or between any attorney and subscriber.
(7) The conditions upon which the certificate maybe extended, renewed, amended, canceled or otherwise terminated.
(8) The premium which must be paid by or on behalf of the subscriber and the coverage period.
(9) The number of days of grace (minimum of 30) which will be allowed for making any payment due under the certificate or individual contract.
(10) A general information telephone number.

Notes

211 CMR 90.06

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