Utah Admin. Code R590-126-5 - General Requirements
(1) A contract may
not include a definition regarding a matter defined in Section
R590-126-3 unless the definition
complies with that section.
(2)
(a) A contract that provides coverage to a
spouse of the contract holder:
(i) 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 contract
holder, other than for nonpayment of premium;
(ii) shall provide that in the event of the
contract holder's death, the spouse shall become the contract holder;
and
(iii) shall use the age of the
younger spouse as the basis for meeting the age and durational requirements of
a noncancellation or renewal provision of a contract.
(b) The requirement in Subsection (2)(a)(iii)
may not prevent termination of coverage of the older spouse upon attainment of
the stated age limit in the contract, so long as the contract may be continued
for the younger spouse to the age or durational period as specified in the
renewal provision.
(3)
(a) The term "conditionally renewable,"
"guaranteed renewable," "noncancellable," or "optionally renewable" may not be
used without further explanatory language under the disclosure requirements of
Subsection R590-126-6(2).
(b) The term "conditionally renewable" may be
used only in a contract for which the insured has the right to continue
coverage by the timely payment of premiums at least to age 65, during which
period the insurer:
(i) may not make a
unilateral change to a provision of the contract to the detriment of the
insured; and
(ii) may, by timely
notice:
(A) decline renewal by class,
geographic area, or for a reason stated in the contract; and
(B) make changes in premium rates by
class.
(c) The
term "guaranteed renewable" may be used only in a contract for which the
insured has the right to continue coverage by the timely payment of premiums at
least to age 65, and during which period the insurer:
(i) may not:
(A) decline renewal; or
(B) make a unilateral change to a provision
of the contract to the detriment of the insured while the contract is in force;
and
(ii) may, by timely
notice, make changes in premium rates by class.
(d) The term "noncancellable" may be used
only in a contract for which the insured has the right to continue coverage by
the timely payment of premiums at least to age 65, and during which period the
insurer may not:
(i) decline
renewal;
(ii) make a unilateral
change to a provision of the contract to the detriment of the insured;
or
(iii) make changes in premium
rates by class.
(e) The
term "optionally renewable" may be used only in a contract for which the
insured has the right to continue coverage by the timely payment of premiums at
least to age 65, and during which period the insurer:
(i) may not make a unilateral change to a
provision of the contract to the detriment of the insured while the contract is
in force; and
(ii) may, by timely
notice:
(A) decline renewal; or
(B) make changes in premium rates by
class.
(f)
Notice of nonrenewal shall be given no less than 90 days before
nonrenewal.
(g) A contract may not
be canceled or nonrenewed solely on the grounds of deterioration of
health.
(h) Termination of a
contract shall be without prejudice to any continuous loss that commenced while
the contract was in force.
(i) The
continuous total disability of the insured may be a condition for an extension
of benefits beyond the period the contract was in force, limited to the
duration of the benefit period, if any, or payment of the maximum
benefits.
(4) When
accidental death and dismemberment coverage is offered under a contract, the
contract holder shall have the option to include each insured under the
coverage.
(5) If a contract
includes a status-type military service exclusion or a provision that suspends
coverage during military service, the contract shall, upon receipt of a written
request, provide for a refund of premiums, as applicable, to the insured on a
pro-rata basis.
(6)
(a) If an insurer cancels or refuses to renew
a contract providing pregnancy benefits, the contract shall provide an
extension of benefits for the pregnancy benefits, if:
(i) the pregnancy commenced while the
contract was in force; and
(ii) a
benefit would have been payable had the contract remained in force.
(b) Subsection (6)(a) does not
apply to a contract that is canceled due to the insured:
(i) failing to pay the required premium in
accordance with the contract terms;
(ii) performing an act or practice that
constitutes fraud in connection with the coverage; or
(iii) making an intentional misrepresentation
of material fact under the terms of the contract.
(7) A contract providing
convalescent care or extended care benefits following hospitalization may not
condition the benefits upon admission to a convalescent nursing home or
extended care facility within a period of less than 14 days after discharge
from the hospital.
(8) A contract
providing coverage for the recipient in a transplant operation shall also
provide reimbursement of medically necessary transplant expenses of a live
donor, to the extent benefits remain and are available under the recipient's
contract and after benefits for the recipient's expenses have been
paid.
(9)
(a) A contract including a provision for
total disability may not exclude or reduce benefits based on the insured's:
(i) ability to engage in any employment or
occupation for wage or profit;
(ii)
inability to perform any occupation, any occupational duty, or any and every
duty of the insured's occupation; or
(iii) inability to engage in any training or
rehabilitation program.
(b) A contract including a provision for
total disability may require care by a physician other than the insured or a
member of the insured's immediate family.
(10) A contract may include a provision
relating to a recurrent disability, but the provision may not specify that a
recurrent disability be separated by a period greater than six
months.
(11) An accidental death
and dismemberment benefit shall be payable if the loss occurs within 180 days
from the date of the accident, regardless of total disability.
(12) A contract with an income replacement
benefit may not require:
(a) the loss to begin
less than 30 days after the date of accident; or
(b) the contract be in force at the time a
disability commences if the accident occurred while the coverage was in
force.
(13) A contract
with a specific dismemberment benefit may not be in lieu of another benefit
unless the specific benefit is equal to or exceeds the other benefit.
(14) A contract providing a fracture or
dislocation benefit may not limit benefits based on a full or complete fracture
or dislocation.
(15)
(a) Specified disease insurance, also known
as critical illness, dread disease, or similar language, sold in conjunction
with other insurance, including a life insurance policy or an annuity contract,
shall be in the form of a separate endorsement complying with each applicable
provision of this rule.
(b)
Specified disease insurance may not be incorporated into a life insurance or
annuity contract.
(16) A
premium change notice shall be given no less than 45 days before the renewal
date.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(1) Policy definitions. No policy subject to this rule may contain definitions respecting the matters defined in Section R590-126-3 unless such definitions comply with the requirements of that section.
(2) Rights of spouse. The following provisions apply to policies that provide coverage to a spouse of the insured:
(a) A 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 for nonpayment of premium.
(b) A policy shall provide that in the event of the insured's death the spouse of the insured shall become the insured.
(c) The age of the younger spouse shall be used as the basis for meeting the age and durational requirements of the noncancellation or renewal provisions of the policy. However, this requirement may not prevent termination of coverage of the older spouse upon attainment of stated age limit in the policy, so long as the policy may be continued in force as to the younger spouse to the age or for durational period as specified in said definition.
(3) Cancellation, Renewability, and Termination.
The terms "
(a) Conditionally renewable . The term "conditionally renewable " may be used only in a policy which the insured may have the right to continue in force by the timely payment of premiums at least to age 65, during which period the insurer has no right to make any unilateral change to the detriment of the insured while the policy is in force. However, the insurer, at its option, and by timely notice, may decline renewal for reasons stated in the policy, or may make changes in premium rates by classes.
(b) Guaranteed renewable . The term "guaranteed renewable " may be used only in a policy which the insured has the right to continue in force by the timely payment of premiums at least to age 65, during which period the insurer has no right to make any unilateral change to the detriment of the insured while the policy is in force, except that the insurer may make changes in premium rates by classes.
(c) Noncancellable. The term "noncancellable" may be used only in a policy that the insured has the right to continue in force by the timely payment of premiums until the age of 65, during which period the insurer has no right to make unilaterally any change in any provision of the policy to the detriment of the insured.
(d) Optionally renewable . The term "optionally renewable " may be used only in a policy which the insured may have the right to continue in force by the timely payment of premiums at least to age 65, during which period the insurer has no right to make any unilateral change in any provision of the policy while the policy is in force. However, the insurer, at its option, and by timely notice, may decline renewal of the policy or may make changes in premium rates by classes.
(e) Notice of nonrenewal shall be given 90 days prior to nonrenewal.
(f) A policy may not be cancelled or nonrenewed solely on the grounds of deterioration of health.
(g) Termination of the policy shall be without prejudice to a continuous loss that commenced while the policy or certificate was in force. The continuous total disability of the insured may be a condition for the extension of benefits beyond the period the policy was in force, limited to the duration of the benefit period, if any, or payment of the maximum benefits.
(4) Optional insureds. When accidental death and dismemberment coverage is part of the accident and health insurance coverage offered under the contract, the insured shall have the option to include all insureds under the coverage and not just the principal insured.
(5) Military service. If a policy contains a status-type military service exclusion or a provision that suspends coverage during military service, the policy shall provide, upon receipt of written request, for refund of premiums as applicable to the person on a pro rata basis.
(6) Pregnancy benefit extension. In the event the insurer cancels or refuses to renew a policy providing pregnancy benefits, the policy shall provide an extension of benefits for a pregnancy commencing while the policy is in force and for which benefits would have been payable had the policy remained in force. This requirement does not apply to a policy that is canceled for the following reasons:
(a) the insured fails to pay the required premiums in accordance with the terms of the plan; or
(b) the insured person performs an act or practice that constitutes fraud in connection with the coverage or makes an intentional misrepresentation of material fact under the terms of the coverage.
(7) Post hospital admission requirement. A policy providing convalescent or extended care benefits following hospitalization shall not condition the benefits upon admission to the convalescent or extended care facility within a period of less than 14 days after discharge from the hospital .
(8) Transplant donor coverage. A policy providing coverage for the recipient in a transplant operation shall also provide reimbursement of any medical expenses of a live donor to the extent that benefits remain and are available under the recipient's policy or certificate, after benefits for the recipient's own expenses have been paid.
(9) Recurrent disability. A policy may contain a provision relating to recurrent disabilities, but a provision relating to recurrent disabilities shall not specify that a recurrent disability be separated by a period greater than 6 months.
(10) Time limit for occurrence of loss.
(a) Accidental death and dismemberment benefits shall be payable if the loss occurs within 180 days from the date of the accident , irrespective of total disability .
(b) Disability income benefits, if provided, shall not require the loss to commence less than 30 days after the date of accident , nor shall any policy that the insurer cancels or refuses to renew require that it be in force at the time disability commences if the accident occurred while the coverage was in force.
(11) Specific dismemberment benefits shall not be in lieu of other benefits unless the specific benefit equals or exceeds the other benefits.
(12) A policy providing coverage for fractures or dislocations may not provide benefits only for "full or complete" fractures or dislocations.
(13) Specified disease, also known as critical illness, dread disease, etc., insurance sold in conjunction with another insurance product, including but not limited to life insurance or annuities, shall be in the form of a separate endorsement complying with all provisions of this rule. Specified Disease insurance shall not be incorporated into a life insurance policy or annuity contract.
(14) Notice of premium change. A notice of change in premium shall be given no fewer than 45 days before the renewal date.