Utah Admin. Code R590-126-6 - Required Provisions
(1)
(a) An enrollment form question regarding a
health condition may not be vague and shall reference a reasonable time frame
in relation to the health condition.
(b)
(i) A
completed application shall be made part of the policy.
(ii) A copy of the completed enrollment form
shall be provided to the applicant or insured before or at delivery of the
contract.
(c) Except
under Subsection (1)(f), an enrollment form shall include the following
prominent disclosure statement, in either contrasting color or boldface type at
least equal to the font size used for the headings or captions of sections of
the enrollment form and in close conjunction with the signature block on the
enrollment form, stating, "This (policy)(certificate) provides limited
benefits. Review your (policy)(certificate) carefully."
(d) An enrollment form shall provide a
statement regarding a preexisting waiting period and the requirement to receive
any applicable credit for previous coverage.
(e)
(i) An
enrollment form shall include a question regarding whether the insurance to be
issued is intended to replace any other accident and health insurance currently
in force.
(ii) A supplementary
enrollment form or other form signed by the applicant containing the question
may be used.
(f) An
enrollment form for dental or vision insurance shall include the following
prominent disclosure statement, in either contrasting color or boldface type at
least equal to the font size used for the headings or captions of sections of
the enrollment form and in close conjunction with the signature block on the
enrollment form, stating, "This (policy)(certificate) provides (dental)(vision)
benefits only. Review your (policy)(certificate) carefully."
(2)
(a) A contract shall include a renewal,
continuation, and nonrenewal provision.
(b) Each provision shall:
(i) appear on the first page of the
contract;
(ii) be appropriately
captioned; and
(iii) clearly state
the duration, if limited, and the renewability of the coverage.
(3)
(a) Except for an endorsement by which the
insurer effectuates a written request by the policyholder or exercises a
specifically reserved right under the contract, signed acceptance by the
policyholder is required for an endorsement that reduces or eliminates a
benefit or coverage and is added to a contract after the date of issue, at
reinstatement, or at renewal.
(b)
After the contract issue date, an endorsement that increases a benefit or
coverage with a concurrent increase in premium during the contract term shall
be agreed to in writing and signed by the policyholder, except if the increased
benefit or coverage is required by law.
(4) If a separate additional premium is
charged for a benefit provided in connection with an endorsement, the premium
charge shall be set forth in the contract.
(5) A contract that provides for the payment
of a benefit based on a standard described as usual and customary, reasonable
and customary, or similar words, shall include a definition and explanation of
the term in the accompanying outline of coverage or benefit summary.
(6)
(a) If
a contract includes a limitation regarding a preexisting condition, the
limitation shall appear as a separate paragraph in the contract and be labeled
as "Preexisting Condition Limitation."
(b) The limitation shall include a
description of the existence and term of the preexisting condition exclusion,
including the maximum preexisting exclusion period.
(7)
(a) An
accident only insurance contract shall include the following prominent
disclosure statement on the first page of the contract, in either contrasting
color or boldface type at least equal to the font size used for headings or
captions of sections in the contract, stating, "Notice to Buyer: This is an
accident only (policy)(certificate) and it does not pay benefits for loss from
sickness. Review your (policy)(certificate) carefully."
(b) An accident only insurance contract that
provides coverage for hospital or medical care shall include the following
statement in addition to the notice in Subsection (7)(a), "This
(policy)(certificate) provides limited benefits. Benefits provided are
supplemental and are not intended to cover all medical expenses."
(c) An accident only insurance contract
providing benefits that vary according to the type of accidental cause shall
prominently state in the outline of coverage the circumstances when benefits
are payable that are less than the maximum amount payable under the
policy.
(8) If age is
used as a determining factor for reducing the maximum aggregate benefit
available in the contract as originally issued, that fact shall be prominently
set forth in the contract and outline of coverage.
(9) If a contract includes a disappearance
benefit, payment shall be made within the time limits under Sections
31A-26-301 and
R590-192-9 when proper proof of
loss, satisfactory to the insurer, is filed and it is reasonable to assume
death occurred, but a body cannot be found.
(10)
(a) If
a contract includes a conversion privilege, it shall caption the provision as
"Conversion Privilege" or similar language.
(b) The provision shall indicate each
individual eligible for conversion, the circumstance applicable to the
conversion privilege, including any limitation on the conversion, and how an
individual may exercise a conversion privilege.
(c) The provision shall specify the benefits
to be provided on conversion or may state that the converted coverage will be
provided through a contract offered by the insurer for that purpose.
(11)
(a) An insurer, except for a direct response
insurer, shall give an applicant for a specified disease insurance contract a
buyer's guide at the time of application and shall obtain the recipient's
written acknowledgment of the guide's delivery.
(b) A direct response insurer shall provide a
specified disease insurance buyer's guide upon request, but before or at the
delivery of the contract.
(c) A
specified disease insurance contract shall include the following prominent
disclosure statement on the first page or attached to it, in either contrasting
color or boldface type at least equal to the font size used for headings or
captions of sections in the contract, stating, "Notice to Buyer: This is a
specified disease (policy)(certificate). This (policy)(certificate) provides
limited benefits. Benefits provided are supplemental and are not intended to
cover all medical expenses. Read your (policy)(certificate) carefully with the
outline of coverage and the buyer's guide."
(12) A fixed indemnity insurance or limited
benefit health insurance contract shall include the following prominent
disclosure statement on the first page of the contract, or attached to it, in
either contrasting color or boldface type at least equal to the font size used
for headings or captions of sections in the contract, "Notice to Buyer: This is
a (fixed indemnity)(limited benefit health) (policy)(certificate). This
(policy)(certificate) provides limited benefits. Benefits provided are
supplemental and are not intended to cover all medical expenses."
(13) A basic hospital expense, a basic
medical-surgical expense, or a basic hospital medical-surgical expense
insurance contract shall include the following prominent disclosure statement
on the first page of the contract, or attached to it, in either contrasting
color or boldface type at least equal to the font size used for headings or
captions of sections in the contract, "Notice to Buyer: This is a (basic
hospital)(basic medical-surgical)(basic hospital/medical-surgical) expense
(policy)(certificate). This (policy)(certificate) provides limited benefits and
should not be considered a substitute for comprehensive health insurance
coverage."
(14) A dental or vision
contract shall include the following prominent disclosure statement on the
first page of the contract, or attached to it, in either contrasting color or
boldface type at least equal to the font size used for headings or captions of
sections in the contract, "Notice to Buyer: This (policy)(certificate) provides
(dental)(vision) coverage only."
(15)
(a) A
contract providing an accident benefit shall define accident, accidental
injury, or accidental means to employ result language.
(b) A contract may not define accident,
accidental injury, or accidental means to include words that establish an
accidental means test or use words such as external, violent, visible wounds,
or similar words.
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) Applications.
(a) Questions used to elicit health condition information may not be vague and must reference a reasonable time frame in relation to the health condition.
(b) Completed applications shall be made part of the policy. A copy of the completed application shall be provided to the applicant prior to or upon delivery of the policy.
(c) All applications shall contain a prominent statement by type, stamp or other appropriate means in either contrasting color or in boldface type at least equal to the size type used for the headings or captions of sections of the application and in close conjunction with the applicant's signature block on the application as follows:
"The (policy) (certificate) provides limited benefits. Review your (policy)(certificate) carefully."
(d) Application forms shall provide a statement regarding the pre-existing waiting period and the requirements to receive any applicable credit for previous coverage.
(e) An application form shall include a question designed to elicit information as to whether the insurance to be issued is intended to replace any other accident and health insurance presently in force. A supplementary application or other form to be signed by the applicant containing the question may be used.
(f) All applications for dental and vision plans shall contain a prominent statement by type, stamp or other appropriate means in either contrasting color or in boldface type at least equal to the size type used for the headings or captions of sections of the application and in close conjunction with the applicant's signature block on the application as follows:
"The (policy) (certificate) provides (dental) (vision) benefits only. Review your (policy) (certificate) carefully."
(2) Renewal and nonrenewal provisions. Accident and health insurance shall include a renewal, continuation or nonrenewal provision. The language or specification of the provision shall be consistent with the type of contract to be issued. The provision shall be appropriately captioned, shall appear on the first page of the policy, and shall clearly state the duration, where limited, of renewability and the duration of the term of coverage for which the policy is issued and for which it may be renewed.
(3) Endorsement acceptance.
(a) Except for endorsements by which the insurer effectuates a request made in writing by the policyholder or exercises a specifically reserved right under the policy, all endorsements added to a policy after date of issue or at reinstatement or renewal that reduce or eliminate benefits or coverage in the policy shall require signed acceptance by the policyholder.
(b) After the date of policy issue, any endorsement that increases benefits or coverage with a concurrent increase in premium during the policy term, must be agreed to in writing signed by the policyholder, except if the increased benefits or coverage is required by law.
(4) Additional premium. Where a separate additional premium is charged for benefits provided in connection with endorsements, the premium charge shall be set forth in the policy or certificate.
(5) Benefit payment standard. A policy or certificate that provides for the payment of benefits based on standards described as usual and customary , reasonable and customary, or words of similar import shall include a definition of the terms and an explanation of the terms in its accompanying outline of coverage.
(6) Preexisting conditions. If a policy or certificate contains any limitations with respect to preexisting conditions, the limitations shall appear as a separate paragraph of the policy or certificate and be labeled as "Preexisting Condition Limitations."
(7) Accident Only Policies.
(a) An accident only policy or certificate shall contain a prominent statement on the first page of the policy or certificate, in either contrasting color or in boldface type at least equal to the size of type used for headings or captions of sections in the policy or certificate, as follows:
Notice to Buyer: This is an
(b) Accident only policies or certificates that provide coverage for hospital or medical care shall contain the following statement in addition to the notice above:
This (policy)(certificate) provides limited benefits. Benefits provided are supplemental and are not intended to cover all medical expenses.
(c) An accident -only policy providing benefits that vary according to the type of accidental cause shall prominently set forth in the outline of coverage the circumstances under which benefits are payable that are lesser than the maximum amount payable under the policy.
(8) Age limitation. If age is to be used as a determining factor for reducing the maximum aggregate benefits made available in the policy or certificate as originally issued, that fact shall be prominently set forth in the outline of coverage and schedule page.
(9) Disappearance. If a policy or certificate includes a disappearance benefit, payment must be made within the time limits provided by R590-192-9 when proof of loss, satisfactory to the company, is filed and it is reasonable to assume death occurred, but a body cannot be found.
(10) Conversion privilege. If a policy or certificate contains a conversion privilege, it shall comply, in substance, with the following: The caption of the provision shall read "Conversion Privilege" or words of similar import. The provision shall indicate the persons eligible for conversion, the circumstances applicable to the conversion privilege, including any limitations on the conversion, and the person by whom the conversion privilege may be exercised. The provision shall specify the benefits to be provided on conversion or may state that the converted coverage will be as provided on a policy form then being used by the insurer for that purpose.
(11) Specified Disease Insurance Buyers Guide. An insurer, except a direct response insurer, shall give a person applying for specified disease insurance, a buyer's guide filed with the commissioner at the time of enrollment and shall obtain recipient's written acknowledgement of the guide's delivery. A direct response insurer shall provide the buyer's guide upon request, but not later than the time that the policy or certificate is delivered.
(12) Specified disease policies or certificates shall contain on the first page or attached to it in either contrasting color or in boldface type, at least equal to the size type used for headings or captions of sections in the policy or certificate, a prominent statement as follows:
Notice to Buyer: This is a specified disease (policy) (certificate). This (policy) (certificate) provides limited benefits. Benefits provided are supplemental and are not intended to cover all medical expenses. Read your (policy) (certificate) carefully with the outline of coverage and the buyer's guide.
(13) Hospital confinement indemnity and limited benefit health policies or certificates shall display prominently by type, stamp or other appropriate means on the first page of the policy or certificate, or attached to it, in either contrasting color or in boldface type at least equal to the size type used for headings or captions of sections in the policy or certificate the following:
Notice to Buyer: This is a (
(14) Basic hospital , basic medical-surgical, and basic hospital -medical surgical expense policies and certificates shall display prominently by type, stamp or other appropriate means on the first page of the policy or certificate, or attached to it, in either contrasting color or in boldface type at least equal to the size type used for headings or captions of sections in the policy or certificate the following:
Notice to Buyer: This is a (basic
(15) Dental and vision coverage policies and certificates shall display prominently by type or stamp on the first page of the policy or certificate, or attached to it, in either contrasting color or in boldface type at least equal to the size type used for headings or captions of sections in the policy or certificate the following:
Notice to Buyer: This (policy) (certificate) provides (dental) (vision) coverage only.