31 Pa. Code § 88.41 - Family policy provisions

A family policy providing hospital, surgical, medical expense, hospital confinement indemnity or accident only insurance shall include provisions which shall specify the following:

(1) As to the insured, the age or event, if any, upon which coverage under the policy will terminate such as age 65, eligibility for Medicare.

(2) As to the spouse, the age or event, if any, upon which coverage under the policy will terminate such as age 65, eligibility for Medicare, legal separation, divorce, or annulment.

(3) As to child, the age or event upon which coverage under the policy will terminate such as age 19, marriage of the child, cessation of dependency. The policy shall provide that coverage of an unmarried dependent child shall not terminate if that child is incapable of self-sustaining employment by reason of mental retardation or physical handicap, under section 617(A)(9) of the Insurance Company Law of 1921 (40 P. S. § 752(A)(9)).

(4) For other family members, the age or event, if any, or such other reasons as are appropriate for termination of coverage as to persons not coming within paragraph (1), (2) or (3).

(5) A noncancellable and guaranteed renewable or guaranteed renewable policy may not provide for termination of coverage of the spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than nonpayment of premium. The provisions shall provide that in the event of the insured's death the spouse of the insured, if covered under the policy, shall become the insured.

(6) The provisions shall provide that if the insurer accepts the premium for coverage extending beyond the date, age, or event specified for termination as to an insured family member, then coverage as to such person shall continue during the period for which an identifiable premium was accepted, except where such acceptance was predicated on a misstatement of age.

(7) The provisions shall provide that, in the event of cancellation or refusal to renew by the insurer, where permitted by law, except for nonpayment of premium, of a policy providing pregnancy benefits, such policy shall provide for an extension of benefits as to pregnancy commencing while the policy is in force and for which benefits would have been payable had the policy continued in force.

(8) The provisions shall provide that termination of the policy by the insurer shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period the policy was in force may be predicated upon the continuous disability of the insured person, limited to the duration of the policy benefit period or to the payment of the maximum benefits.

(9) The termination provision may provide for the termination or suspension of coverage if the insured individual becomes eligible for Medicare under the Social Security Act (42 U.S.C.A. § 1395 et seq).

Notes

31 Pa. Code § 88.41

This section cited in 31 Pa. Code § 88.35 (relating to accidental injuries).