28 Tex. Admin. Code § 3.3052 - Standards for Termination of Insurance Provision
(a) A policy subject to this subchapter must
include termination provisions that specify as to each eligible family member,
as set out in §
3.3051 of this title (relating to
Initial and Subsequent Conditions of Eligibility Provision), the age, or event,
if any, upon which coverage under the policy will terminate.
(b) In regard to individual hospital, medical
or surgical coverage, a policy may only contain the following bases for
termination of coverage:
(1) the bases for
nonrenewal contained in §
3.3038 of this title (relating to
Mandatory Guaranteed Renewability Provisions for Individual Hospital, Medical
or Surgical Coverage; Exceptions);
(2) in regard to policies covering a spouse
of the primary insured or dependents:
(A)
Coverage of the spouse may terminate upon the dissolution of the marriage
through divorce or other lawful means, subject to this section, §
21.407 of this title (relating to
Continuance of Coverage) and other applicable law; and
(B) Coverage of a dependent may terminate
upon the dependent's attainment of a limiting age, subject to Insurance Code §
1201.059, this
section, and other applicable law.
(c) A policy containing noncancellable,
guaranteed renewable or limited guarantee of renewability provisions 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 provision must stipulate that in the
event of the insured's death the spouse of the insured, if covered under the
policy, will become the insured.
(d) The provision must stipulate that if the
insurer accepts 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 will continue during the period for which an identifiable premium
was accepted, except where such acceptance was predicated on a misstatement of
age outlined in Insurance Code §
1201.011.
(e) In the event of cancellation by the
insurer or refusal to renew by the insurer of a policy providing pregnancy
benefits, the provision must 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.
(f) The provision must stipulate that
termination of the policy by the insurer will 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 total disability of the insured person limited
to the duration of the policy benefit period, payment of the maximum benefits
or to a time period of not less than three months.
(g) The provision may provide for the
termination or suspension of family members who become eligible for coverage
provided by the federal government.
(h) A policy may not provide for termination
of coverage of a dependent child on attainment of the limiting age for
dependent children specified in the policy while the child is:
(1) incapable of self-sustaining employment
due to mental retardation or physical handicap; and
(2) chiefly dependent upon the insured for
support and maintenance. Proof of the incapacity and dependency must be
furnished to the insurer by the insured within 31 days of the child's
attainment of the limiting age and subsequently as may be required but not more
frequently than annually after the two-year period following the child's
attainment of the limiting age. Upon the attainment of the limiting age, the
applicable adult premium may be charged.
Notes
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