N.H. Code Admin. R. Ins 401.04 - Rules Applicable to All Forms

Current through Register Vol. 41, No. 52, December 30, 2021

(a) Each form shall be designated by a form number composed of either figures or letters or both.
(1) The form number shall be:
a. Sufficient to distinguish the form from all other forms used by the company; and
b. Placed in the lower left-hand corner on the front of each form;
(2) The form number for a policy form may contain the prefix "Form No.";
(3) Policy forms utilizing less than a full sheet as the face page or cover page shall place the form number in the lower left-hand corner of the specifications page; and
(4) Any time any change is made, the form shall be resubmitted as a new form with a new form number.
(b) Each policy and certificate shall recite on the back page or specifications page the:
(1) Full corporate or legal title of the company, association, exchange, or society;
(2) Official home address, including city and state or province;
(3) Administrative office address, if different from address in (2) above; and
(4) Toll-free telephone number of the company and, if available, a facsimile number and website address.
(c) Each policy and certificate shall provide a brief description of the nature of the policy, as follows:
(1) The brief description shall be printed on:
a. The face page, specifications page, or the back page, if the policy form has a full size cover page; or
b. On the specifications page so that the description is visible, if the policy form has less than a full size cover page; and
(2) In the instance of individual life or individual annuity contracts, the brief description shall contain a statement indicating whether the policy is "participating" or "nonparticipating".
(d) The words, "preferred," "special," "unlimited," "union," "labor," "New Hampshire," or any other words or combination of words shall not be used in any way that might reasonably cause anyone to believe that they are receiving or shall receive preferential treatment unless that person is, in fact, receiving preferential treatment or will receive preferential treatment.
(e) No policy or group certificate providing accident and health insurance benefits shall use the terms "major," "comprehensive," "catastrophic" or words of similar import in its title or brief description unless such policy or certificate satisfies the minimum benefit standards for major medical expense coverage.
(f) The word "compensation" shall not be used in any way that might reasonably cause the policyholder to be confused with workers' compensation coverage.
(g) The word "medicare" shall not be used in any way that might reasonably cause anyone to believe that the policyholder is participating in a government program.
(h) If the policy contains an exception for injury arising out of riots, the exception shall be confined to those instances in which the insured is injured while participating in such riot.
(i) Any policy or certificate that contains exclusions, limitations, reductions, or conditions of such a restrictive nature that the payment of benefits under such policies is limited in frequency or in amounts shall carry the legend "This is a Limited Policy - Read it Carefully" imprinted across the face and filing back, if any, of the policy in not less than 18-point outline type of contrasting color, not less than 24-point outline type of non-contrasting color diagonally, or not less than 24-point bold within a black border.
(j) Any provision, requirement, or other document standard contained in this part shall not act to prevent the use of any other language that is at least as favorable to any insured or group policyholder.
(k) Except as otherwise specifically provided by New Hampshire statutes or this part, any contract or policy of insurance or annuity contract issued, delivered, used, or sold in this state that violates any of the provisions of New Hampshire statutes or this part shall be:
(1) Valid and binding upon the insurer making or issuing the policy; and
(2) Enforceable as if it conformed to such requirements or prohibitions.
(l) Discretionary clauses relating to life, accident, or health policies shall be approved by the department only when such clauses:
(1) Are contained in a separate endorsement containing no other language, terms or provisions;
(2) Are offered on an optional basis to the plan sponsor;
(3) Implement a policy governed by the Employment Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq. and those policies contain the following language:

"The following applies only when the administration of the policy is governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq.:

Under ERISA, [the Company] is hereby designated by the plan sponsor as a claim fiduciary with discretionary authority to determine eligibility for benefits and to interpret and construe the terms and provisions of the policy. As claim fiduciary, [the Company] has a duty to administer claims solely in the interest of the [participants and beneficiaries] of the employee benefit plan and in accordance with the documents and instruments governing the plan. This assignment of discretionary authority does not prohibit a participant or beneficiary from seeking judicial review of [the Company's] benefit eligibility determination after exhausting administrative remedies. The assignment of discretionary authority made under this provision may affect the standard of review that a court will use in reviewing the appropriateness of [the Company's] determination. In order to prevail, a plan participant or beneficiary may be required to prove that [the Company's] determination was arbitrary and capricious or an abuse of discretion"; and

(4) Pursuant to (l)(3) above, if a health carrier, as this term is defined in RSA 420-J:3, is a claim fiduciary, the following sentence shall be included at the end of the second paragraph in (l)(3) above,:

"This designation as a claim fiduciary under ERISA does not apply to determinations that health carriers make as to whether a health care service, supply, or drug meets requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness."

(m) Policies providing disability income protection shall not in any way condition benefit payments for "total disability" on "continuous confinement within doors" or language of similar import.
(n) Short term major medical shall comply with RSA 415:5, III.
(o) All policy forms and certificates issued on or after January 1, 2010, that provide coverage as defined in RSA 420-G:2, IX or prescription drug and dental benefits offered separately as described in RSA 420-G:2, IX(j), issued on or after January 1, 2010, shall clearly state that the benefit plan or coverage represented by the policy is under the jurisdiction of the New Hampshire insurance commissioner pursuant to RSA 400-A:15-c.
(p) All policy forms filed with the commissioner shall be written in the English language.
(q) An insurer may also provide applicants and insureds with a policy, application, or other forms in a language other than English if the non-English version of the policy, application, or other form, that has not been reviewed by the commissioner:
(1) Is a certified translation of a policy, application, or other form that has been filed with and approved by the commissioner;
(2) Is accompanied by a certification written in English that the non-English version is a complete and accurate translation of the English form filed;
(3) Is in the same format as the English version;
(4) Contains a disclosure, both in the non-English language and in English, that is attached to the front of the policy, application, or other forms, including a statement that:
a. The policy, application, or other form is a translation that has not been approved by the commissioner; and
b. The English version of the policy, application, or other forms shall control in any disputes, complaints, or litigation; and
(5) Identifies the English form number that corresponds to the non-English version.
(r) If an insurer offers a non-English policy, application, or other form in accordance with (q), the insurer shall file the translator certification and disclosure required by (q)(2) and (q)(4) with the commissioner as an information filing.
(s) This paragraph shall not prohibit an insurer from advertising or providing information related to the policy or claims with translations to consumers in a language other than English.
(t) If there is a dispute between the English version and the non-English version, the English version shall control and the non-English version shall carry a disclaimer in the non-English language to this effect. The insurance policy is controlling and any advertisements or informational materials used by an insurer shall not be construed to modify or change the insurance policy.

Notes

N.H. Code Admin. R. Ins 401.04

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5653, eff 7-1-93; ss by #7016, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8726, eff 9-18-06; amd by #10195, eff 10-1-12

Amended by Volume XXXVII Number 15, Filed April 13, 2017, Proposed by #12126, Effective 3/8/2017, Expires 3/8/2027.

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