Section
5 Policy Definitions
Except as provided hereinafter, no accident or sickness
insurance policy or hospital, medical, or dental service corporation subscriber
contract delivered or issued for delivery to any person in this state shall
contain definitions respecting the matters set forth below unless such
definitions comply with the requirements of this section. All policies shall be
written in simple language, and in a form easily understood by
purchasers.
A. "One period of
confinement" means consecutive days of in hospital service received as an
inpatient, or successive confinements when discharge from and readmission to
the hospital for the treatment of the same or related condition occurs within a
period of time not more than 90 days or three times the maximum number of days
of in-hospital coverage provided by the policy to a maximum of 180
days.
B. "Hospital" may be defined
in relation to is status, facilities and available services or to reflect its
accreditation by the Vermont Department of Health.
(1) The definition of the term "hospital"
shall not be more restrictive than one requiring that the hospital:
(a) be an institution operated pursuant to
law: and
(b) be primarily and
continuously engaged in providing or operating, either on its premises or in
facilities available to the hospital on a pre-arranged basis and under the
supervision of a staff of duly licensed physicians, medical, diagnostic and
major surgical facilities for the medical care and treatment of sick or injured
persons on an inpatient basis for which a charge is made; and
(c) provide 24 hour nursing service by or
under the supervision of registered graduate professional nurses
(R.N.'s).
(2) The
definition of the term "hospital" may state that such term shall not be
inclusive of:
(a) convalescent homes,
convalescent, rest or nursing facilities; or
(b) facilities primarily affording custodial,
educational or rehabilitory care; or
(c) facilities for the aged, drug addicts or
alcoholics; or
(d) any military or
veterans hospital or soldiers home or any hospital contracted for or operated
by any national government or agency thereof for the treatment of members or
ex-members of the armed forces, except for services rendered on an emergency
basis where a legal liability exists for charges made to the individual for
such services.
C. "Convalescent Nursing Home," "Extended
Care Facility" or "Skilled Nursing Facility" shall be defined in relation to
its status, facilities, and available services.
(1) A definition of such home or facility
shall not be more restrictive than one requiring that it:
(a) be operated pursuant to law;
(b) be approved for payment of Medicare
benefits or be qualified to receive such approvals, if so requested;
(c) be primarily engaged in providing, in
addition to room and board accommodations, skilled nursing care under the
supervision of a duly licensed physicians;
(d) provide continuous 24 hours a day nursing
service by or under the supervision of a registered graduate professional nurse
(R.N.); and
(e) maintains a daily
medical record of each patient.
(2) The definition of such home or facility
may provide that such term not be inclusive of:
(a) any home, facility or part thereof used
primarily for rest;
(b) a home or
facility for the aged or for the care of drug addicts or alcoholics;
or
(c) a home or facility primarily
used for the care and treatment of mental diseases, or disorders, or custodial
or educational care.
D. "Accident," "Accidental Injury,"
"Accidental Means" shall be defined to employ "result" language and shall not
include words which establish an accidental means test or use words such as
"external, violent, visible wounds" or similar words of description or
characterization.
The definition shall not be more restrictive than the
following: Injury or injuries, for which benefits are provided, means
accidental bodily injury sustained by the insured person and directly caused by
an accident which is not the result of disease or bodily infirmity.
Such definition may provide that injuries shall not include
injuries for which benefits are provided under any workmen's compensation,
employer's liability or similar law, motor vehicle no-fault plan, unless
prohibited by law, or injuries occurring while the insured person is engaged in
any activity pertaining to any trade, business, employment or occupation for
wage or profit.
E.
"Sickness" shall not be defined to be more restrictive than the following:
Sickness means sickness or disease of an insured person which first manifests
itself after the effective day of issuance while the insurance is in force. A
definition of sickness may provide for a probationary period which will not
exceed thirty (30) days from the effective date of the coverage of the insured
person. The definition may be further modified to exclude sickness or disease
for which benefits are provided under any workmen's compensation, occupational
disease, employers liability or similar law.
F. "Pre-existing Condition" shall not be
defined to be more restrictive than the following: Pre-existing condition means
the existence of symptoms which would cause an ordinarily prudent person to
seek diagnosis, care or treatment with a two (2) year period preceding the
effective date of the coverage of the insured person or a condition for which
medical advice or treatment was recommended by a physician or received from a
physician with a two (2) year period preceding the effective date of the
coverage of the insured person.
G.
"Physician" may be defined by including words such as "duly qualified
physician" or "duly licensed physician". The use of such terms requires an
insurer to recognize and to accept, to the extent of its obligation under the
contract, all providers of medical care and treatment when such services are
within the scope of the provider's licensed authority and are provided pursuant
to applicable law.
H. "Nurses" may
be defined so that the description of nurse is restricted to a type of nurse,
such as registered graduate professional nurse (R.N.), a licensed practical
nurse (L.P.N.), or a licensed vocational nurse (L.V.N.). If the words "nurse,"
"trained nurse" or "registered nurse" are used without specific instruction,
then the use of such terms requires the insurer to recognize the services of
any individual who qualifies under such terminology in accordance with 26
V.S.A., Chapter 27.
I. "Total
Disability"
(1) A general definition of total
disability cannot be more restrictive than one requiring the individual to be
totally disabled from engaging in any employment or occupation for which he is
or becomes qualified by reason of education, training or experience and not, in
fact, engaged in any employment or occupation for wage or profit.
(2) Total disability may be defined in
relation to the inability of the person to perform duties but may not be based
solely upon an individual's inability to:
(a)
Perform "any occupation whatsoever," "any occupational duty," or "any and every
duty of his occupation," or
(b)
Engage in any training or rehabilitation program.
(3) An insurer may specify the requirement of
the complete inability of the person to perform all of the substantial and
material duties of his regular occupation or words of similar import. An
insurer may require care by a physicians (other than the insurer or a member of
the insured's immediate family).
J. "Partial Disability" shall be defined in
relation to the individual's inability to perform one or more but not all of
the "major," "important," or "essential" duties of employment or occupation or
may be related to a "percentage" of time worked or to a "specified number of
hours" or to "compensation." Where a policy provides total disability benefits
and partial disability benefits, only one elimination period may be
required.
K. "Residual Disability"
shall be defined in relation to the individual's reduction in earnings and may
be related either to the inability to perform some part of the "major,"
"important," or "essential" duties of employment or occupation, or to the
inability to perform all usual business duties for as long as is usually
required. A policy which provides residual disability benefits may require a
qualification period, during which the insured must be continuously, totally
disabled before residual disability benefits are payable. The qualification
period for residual benefits may be longer than the elimination period for
total disability. In lieu of the term "residual disability", the insurer may
use "proportionate disability" or other term of similar import which in the
opinion of the commissioner adequately and fairly describes the
benefit.
L. "Medicare" shall be
defined in any hospital, surgical or medical expense policy which relates its
coverage to eligibility for Medicare or Medicare benefits. Medicare may be
substantially defined as "The Health Insurance for the Aged Act, Title XVIII of
the Social Security Amendments of 1965 as Then Constituted or Later Amended,"
or "Title I, Part I of Public Laws 89-97, as Enacted by the Eighty-Ninth
Congress of the United States of America and popularly known as the Health
Insurance for the Aged Act," "as then constituted and any later amendments or
substitutes thereof," or words of similar import.
M. "Complications of Pregnancy" shall be
defined to include:
(1) conditions, requiring
hospital confinement (when the pregnancy is not terminated), whose diagnosis
are distinct from pregnancy but are adversely affected by pregnancy or are
caused by pregnancy, such as acute nephritis, nephroses, cardiac
decompensation, missed abortion and similar medical and surgical conditions of
comparable severity, but shall not include false labor, occasional spotting,
physician prescribed rest during the period of pregnancy, morning sickness,
hyperemesis gravidarum, pre-eclampsia and similar conditions associated with
the management of a difficult pregnancy not constituting a nosologically
distinct complication of pregnancy; and
(2) non-elective caesarean section, ectopic
pregnancy which is terminated and spontaneous termination of pregnancy, which
occurs during a period of gestation in which a viable birth is not
possible.
N. "Mental or
Nervous Disorders" shall not be defined more restrictively than a definition
including neurosis, psychoneurosis, psychopathy, psychosis, or mental or
emotional disease or disorder of any kind.
Section 6 Prohibited Policy Provisions
A. Except as provided in Section
5(E),
no policy shall contain provisions establishing a probationary or waiting
period during which no coverage is provided under the policy subject to the
further exception that a policy may specify a probationary or waiting period
not to exceed six (6) months for specified diseases or conditions and losses
resulting therefrom for hernia, disorder or reproduction organs, varicose
veins, adenoids, appendix and tonsils. However, the permissible six (6) months
exception shall not be applicable where such specified diseases or conditions
are treated on an emergency basis. Accident policies shall not contain
probationary or waiting periods.
B.
No policy or rider for additional coverage may be issued as a dividend unless
an equivalent cash payment is offered to the policyholder as an alternative to
such dividend policy or rider. No such dividend policy or rider shall be issued
for an initial term of less than six (6) months.
The initial renewal subsequent to the issuance of any policy
or rider as a dividend shall clearly disclose that the policyholder is renewing
the coverage that was provided as a dividend for the previous term and that
such renewal is optional with the policyholder.
C. No policy shall exclude coverage for loss
due to a pre-existing condition for a period greater than 12 months following
policy issue where the application for such insurance does not seek disclosure
of prior illness, disease or physical conditions or prior medical care and
treatment and such pre-existing condition is not specifically excluded by the
terms of the policy.
D. Policies
providing hospital confinement indemnity coverage shall not contain provisions
excluding coverage because of confinement in a hospital operated by the federal
government.
E. No policy shall
limit or exclude coverage by type of illness, accident, treatment or medical
condition, except as follows:
(1)
pre-existing conditions or diseases except for congenital anomalies of a
covered dependent child;
(2) mental
or emotional disorders, alcoholism and drug addiction;
(3) pregnancy, except for complications of
pregnancy, other than for policies defined in Section 7 F. of this
Regulation;
(4) illness, treatment
or medical condition arising out of:
(a) war
or act of war (whether declared or undeclared); participation in a felony, riot
or insurrections; service in the armed forces or units auxiliary
thereto,
(b) suicide (sane or
insane), attempted suicide or intentionally self-inflicted injury,
(c) aviation,
(d) with respect to short-term non-renewable
policies, interscholastic sports;
(5) cosmetic surgery, except that "cosmetic
surgery" shall not include reconstructive surgery when such service is
incidental to or follows surgery resulting from trauma, infection or other
diseases of the involved part, and reconstructive surgery because of congenital
disease or anomaly of the covered dependent child which has resulted in a
functional defect;
(6) foot care in
connection with corns, calluses, flat feet, fallen arches, weak feet, chronic
foot strain, or symptomatic complaints of the feet;
(7) care in connection with the detection and
correction by manual or mechanical means of structural imbalance, distortion,
or subluxation in the human body for purposes of removing nerve interference
and the effects thereof, where such interference is the result of or related to
distortion, misalignment or subluxation of, or in the vertebral
column;
(8) treatment provided in a
government hospital; benefits provided under Medicare or other governmental
program (except Medicaid), any state or federal workmen's compensation,
employer's liability or occupational disease law, or any motor vehicle no-fault
law; services rendered by employees of hospitals, laboratories or other
institutions; services performs by a member of the covered person's immediate
family and services for which no charge is normally made in the absence of
insurance;
(9) dental care or
treatment;
(10) eye glasses,
hearing aids and examination for the prescription or fitting thereof;
(11) rest cures, custodial care,
transportation and routine physical examinations;
(12) territorial limitations.
F. Other provisions of this
Regulation shall not impair or limit the use of waivers to exclude, limit or
reduce coverage or benefits for specifically named or described pre-existing
diseases, physical condition or extra hazardous activity. Where waivers are
required as a condition of issuance, renewal or reinstatement, signed
acceptance by the insured is required unless on initial issuance the full text
of the waiver is contained either on the first page or specification page of
the policy or unless notice of the waiver appears on the first page or
specification page.
G. Policy
provisions precluded in this section shall not be construed as a limitation on
the authority of the commissioner to disapprove other policy provisions which,
in the opinion of the commissioner, are unjust, unfair, or unfairly
discriminatory to the policyholder, beneficiary or any person insured under the
policy.
H. A policy covering a
specified disease shall not require diagnosis by biopsy if such biopsy is
medically unadvisable. The condition may be verified conclusively by biopsy,
x-ray examinations, laboratory determinations or if an external defect, by
unequivocal observation.
Section
7 Accident and Sickness Minimum Standards for Benefits
The following minimum standards for benefits are prescribed
for the categories of coverage noted in the following subsections. No policy of
accident and sickness insurance or non-profit hospital, medical or dental
service corporation contract shall be delivered or issued for delivery in this
state which does not meet the required minimum standards for the specified
categories unless the commissioner finds that such policies or contracts are
approvable as Limited Benefit Health Insurance and the Outline of Coverage
complies with the appropriate outline in Section 8.L. of this
Regulation.
Nothing in this section shall preclude the issuance of any
policy or contract combining two or more categories of coverage set forth in
this Regulation.
A. General Rules.
(1) A "non-cancelable," "guaranteed
renewable" or "non-cancelable and guaranteed renewable" policy shall 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 policy 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.
(2) The
terms "non-cancelable," "guaranteed renewable," or non-cancelable and
guaranteed renewable" shall not be used without further explanatory language in
accordance with the disclosure requirements of Section 8.A.(1).
The terms "non-cancelable" or "non-cancelable and 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 set forth in the policy
until the age of sixty-five (65) or to eligibility for Medicare, during which
period the insurer has no right to make unilaterally any change in any
provision of the policy while the policy is in force. Provided, however, any
accident and health or accident only policy which provides for periodic
payments, weekly or monthly, for a specified period during the continuance of
disability resulting from accident or sickness may provide that the insured has
the right to continue the policy only to age sixty (60) if, at age sixty (60),
the insured has the right to continue the policy in force at least to age
sixty-five (65) while actively or regularly employed. Except as provided above,
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 until the
age of sixty-five (65) or to eligibility for Medicare, during which period the
insurer has no right to make unilaterally any change in any provision of the
policy while the policy is in force, except that the insurer may make changes
in premium rates by classes: Provided, however, any accident and health or
accident only policy which provides for periodic payments, weekly or monthly,
for a specified period during the continuance of disability resulting from
accident or sickness may provide that the insured has the right to continue the
policy only to age sixty (60) if, at age sixty (60), the insured has the right
to continue the policy in force at least to age sixty-five (65) while actively
and regularly employed.
(3)
In a family policy covering both husband and wife, the age of the younger
spouse must be used as the basis for meeting the age and durational
requirements of the definitions of "non-cancelable" or "guaranteed renewable."
However, this requirement shall not prevent termination of coverage of the
older spouse upon attainment of the stated age limit (e.g. age 65) so long as
the policy may be continued in force as to the younger spouse, to the age or
for the durational period as specified in said definition.
(4) When accidental death and dismemberment
coverage is part of the insurance coverage offered under the contract, the
insured shall have the option to include all insureds under such coverage and
not just the principal insured.
(5)
If a policy contains a status type military service exclusion or a provision
which suspends coverage during military service, the policy shall provide, upon
receipt of written request, for refund of premiums as applicable to such person
on a pro rata basis.
(6) In the
event the insurer cancels or refuses to renew, policies providing pregnancy
benefits 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 remained in force.
(7)
Policies providing convalescent or extended care benefits following
hospitalization shall not condition such benefits upon admission to the
convalescent or extended care facility within a period of less than
twenty-eight (28) days after discharge from the hospital.
(8) Family coverage shall continue for any
dependent child who is incapable of self-sustaining employment due to mental
retardation or physical handicap on the date that such child's coverage would
otherwise terminate under the policy due to the attainment of a specified age
limit for children and is chiefly dependent on the insured for support and
maintenance. The policy may require that within 31 days of such date, the
company receive due proof of such incapacity in order for the insured to elect
to continue the policy in force with respect to such child, or that a separate
converted policy be issued at the option of the insured or
policyholder.
(9) Any 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, after
benefits for the recipient's own expenses have been paid.
(10) A policy may contain a provision
relating to recurrent disabilities; provided, however, that no such provision
shall specify that a recurrent disability be separated by a period greater than
six (6) months.
(11) Accidental
death and dismemberment benefits shall be payable if the loss occurs within
ninety (90) days from the date of the accident, irrespective of total
disability. Disability income benefits, if provided, shall not require the loss
to commence less than thirty (30) days after the date of accident, nor shall
any policy which the insurer cancels or refuses to renew require that it be in
force at the time disability commences if the accident occurred while the
policy was in force.
(12) Specific
dismemberment benefits shall not be in lieu of other benefits unless the
specific benefit equals or exceeds the other benefits.
(13) Any accident only policy providing
benefits which vary according to the type of accidental cause shall prominently
set forth in the outline of coverage the circumstances under which benefits are
payable which are lesser than the maximum amount payable under the
policy.
(14) Termination of the
policy shall be without prejudice to any continuous loss which commenced while
the policy was in force but the extension of disability benefits beyond the
period the policy was in force maybe predicated upon the continuous total
disability of the insured, limited to the duration of the policy benefit
period, if any, or payment of the maximum benefits.
(15) With respect to individual accident and
sickness contracts, any rates filed, whether initial or revised, will be
disapproved unless the aggregate anticipated loss ratio for the entire period
for which rate are computed to provide coverage meets the following standards:
(a) 60% for optionally renewable
policies;
(b) 55% for conditionally
renewable and guaranteed renewable policies; and
(c) 50% for guaranteed rate
policies;
(d) 60% for all policies
sold to persons eligible for Medicare by reason of age;
(e) 45% for all specified accident or
short-term non-renewable coverage and for policies covering accident only;
and
(f) For the purposes of this
subsection ( Section 7.A. (15)), optionally renewable means renewal at the
option of the insurance company; conditionally renewable means renewal can be
declined by the insurance company only for stated reasons other than
deterioration of health; guaranteed renewable means renewal cannot be declined
by the insurance company for any reason, but the insurance company can revise
rates on a class basis; and guaranteed rate means renewal cannot be declined
nor can rates be revised by the insurance
company.
B.
Basic Hospital Expense Coverage.
"Basic Hospital Expense Coverage" is a policy of accident and
sickness insurance which provides coverage for a period of not less than
thirty-one (31) days during any continuous hospital confinement for each person
insured under the policy, for expense incurred for necessary treatment and
services rendered as a result of accident or sickness for at least the
following:
(1) daily hospital room and
board in an amount not less than the lesser of (a) 80% of the charges for
semi-private room accommodations for (b) $ 50.00 per day;
(2) miscellaneous hospital services for
expenses incurred for the charges made by the hospital for services and
supplies which are customarily rendered by the hospital and provided for use
only during any one period of confinement in an amount not less than either 80%
of the charges incurred up to at least $ 1,000.00 or ten times the daily
hospital room and board benefits;
(3) hospital outpatient services consisting
of (a) hospital services on the day surgery is performed, and (b) hospital
services rendered within 72 hours after accidental injury, in an amount not
less than $ 50.00, and (c) x-ray and laboratory tests to the extent that
benefits for such services would have been provided to an extent not less than
$ 100.00 if rendered to an inpatient of the hospital; and
(4) benefits provided under (1) and (2) of B.
above, may be provided subject to a combined deductible amount not in excess of
$ 100.00.
C. Basic
Medical-Surgical Expense Coverage.
"Basic Medical-Surgical Expense Coverage" is a policy of
accident and sickness insurance which provides coverage for each person insured
under the policy for the expenses incurred for the necessary services rendered
by a physician for treatment of an injury or sickness for at least the
following:
(1) Surgical service:
(a) in amounts not less than those provided
on an acceptable fee schedule of surgical procedures, up to a maximum of at
least $ 500.00 for any one procedure; or
(b) not less than 80% of the reasonable
charges.
(2) Anesthesia
services, consisting of administration of necessary general anesthesia and
related procedures in connection with covered surgical service rendered by a
physician other than the physician (or his assistant) performing the surgical
services:
(a) in an amount not less than 80%
of the reasonable charges; or
(b)
15% of the surgical service benefit.
(3) In-hospital medical services, consisting
of physician services rendered to a person who is a bed patient in a hospital
for treatment of sickness or injury other than that for which surgical care is
required, in an amount not less than 80% of the reasonable charges; or $ 5.00
per day for not less than twenty-one (21) days during one period of
confinement.
D. Hospital
Confinement Indemnity Coverage.
"Hospital Confinement Indemnity Coverage" is a policy of
accident and sickness insurance which provides daily benefits for hospital
confinement on an indemnity basis in an amount not less than $ 30.00 per day
and not less than thirty-one (31) days during any one period of confinement for
each person insured under the policy.
E. Major Medical Expense Coverage.
"Major Medical Expense Coverage" is an accident and sickness
insurance policy which provides hospital, medical and surgical expense coverage
to an aggregate maximum of not less than $ 10,000.00; co-payment by the covered
person not to exceed 25% of covered charges; a deductible stated on a per
person, per family, per illness, per benefit period, or per year basis, or a
combination of such bases not to exceed 5% of the aggregate maximum limit under
the policy, unless the policy is written to complement underlying hospital and
medical insurance in which case such deductible may be increased by the amount
of the benefits provided by such underlying insurance, for each covered person
for at least:
(1) daily hospital room
and board expenses, prior to application of the co-payment percentage, for not
less than $ 50.00 daily (or in lieu thereof the average daily cost of
semi-private room rate in the area where the insured resides) for a period of
not less than 31 days during continuous hospital confinement;
(2) miscellaneous hospital services, prior to
application of the co-payment percentage, for an aggregate maximum of not less
than $ 1,500.00 or 15 times the daily room and board rate if specified in
dollar amounts;
(3) surgical
services, prior to application of co-payment percentage to a maximum of not
less than $ 600.00 for the most severe operation with the amount provided for
other operations reasonably related to such maximum amount;
(4) anesthesia services, prior to application
of the co-payment percentage, for a maximum of not less than 15 percent of the
covered surgical fees or, alternatively, if the surgical schedule is based on
relative values, not less than the amount provided therein for anesthesia
services at the same unit value as used for the surgical schedule;
(5) in-hospital medical services, prior to
application of the co-payment percentage, as defined in subdivision C. (3) of
Section 7;
(6) out-of-hospital
care, prior to application of the co-payment percentage, consisting of
physicians' services rendered on an ambulatory basis where coverage is not
provided elsewhere in the policy for diagnosis and treatment of sickness or
injury, and diagnostic x-ray, laboratory services, radiation therapy and
hemodialysis ordered by a physician; and
(7) not fewer than three of the following
additional benefits, prior to application of the co-payment percentage, for an
aggregate maximum of such covered charges of not less than $ 1,000:
(a) In-hospital private duty graduate
registered nurse services.
(b)
Convalescent nursing home care.
(c)
Diagnosis and treatment by a radiologist or physiotherapist.
(d) Rental of special medical equipment, as
defined by the insurer in the policy.
(e) Artificial limbs or eyes, casts, splints,
trusses or braces.
(f) Treatment
for functional nervous disorders and mental and emotional disorders.
(g) Out-of-hospital prescription drugs and
medications.
F.
Disability Income Protection Coverage.
"Disability Income Protection Coverage" is a policy which
provides for periodic payments, weekly or monthly, for a specified period
during the continuance of disability resulting from either sickness or injury
or a combination thereof which:
(1)
Provides that periodic payments which are payable at ages after 62 and reduced
solely on the basis of age are at least 50% of amounts payable immediately
prior to 62.
(2) Contains an
elimination period no greater than:
(a)
Ninety (90) days in the case of a coverage providing a benefit of one (1) year
or less;
(b) One-hundred eighty
(180) days in the case of coverage providing a benefit of more than one year
but not greater than two (2) years; or
(c) Three-hundred sixty-five (365) days in
all other cases during the continuance of disability resulting from sickness or
injury.
(3) Has a maximum
period of time for which it is payable during disability of at least six (6)
months except in the case of a policy covering disability arising out of
pregnancy, childbirth, or miscarriage in which case the period for such
disability may be one (1) month. This exception shall not apply to
complications of pregnancy as defined in section
5.M. No
reduction in benefits shall be put into effect because of any increase in
Social Security or similar benefits during a benefit period. Section 7.F. does
not apply to those policies providing business buy-out coverage.
G. Accident Only Coverage.
"Accident Only Coverage" is a policy of accident insurance
which provides coverage, singly or in combination, for death, dismemberment,
disability, or hospital and medical care caused by accident. Accidental death
and double dismemberment amounts under such a policy shall be at least $
5,000.00 and a single dismemberment amount shall be at least $ 2,500.00
H. Specified Disease and Specified
Accident Coverage.
(1) "Specified Disease
Coverage" is a policy which meets one of the following definitions:
(a) A policy which provides coverage for each
person insured under the policy for a specifically named disease (or diseases)
with a deductible amount not in excess of $ 250.00 and an overall aggregate
benefit limit of no less than $ 10,000.00 and a benefit period of not less than
two (2) years for at least the following incurred expenses:
(i) Hospital room and board and any other
hospital furnished medical services or supplies;
(ii) Treatment by a legally qualified
physician or surgeon;
(iii) Private
duty services of a registered nurse (R.N.);
(iv) X-ray, radium and other therapy
procedures used in diagnosis and treatment;
(v) Professional ambulance for local service
to or from a local hospital;
(vi)
Blood transfusions, including expense incurred for blood donors;
(vii) Drugs and medicines prescribed by a
physician;
(viii) The rental of an
iron lung or similar mechanical apparatus;
(ix) Braces, crutches and wheelchairs as are
deemed necessary by the attending physician for the treatment of the
disease;
(x) Emergency
transportation if in the opinion of the attending physician it is necessary to
transport the insured to another locality for treatment of the disease; and
(xi) May include coverage of any
other expenses necessarily incurred in the treatment of the disease.
(b) A policy which provides
coverage for each person insured under the policy for a specifically named
disease (or diseases) with no deductible amount, and an overall aggregate
benefit limit of not less than $ 25,000 payable at the rate of not less than $
50 a day while confined in a hospital and a benefit period of not less than 500
days.
(2) "Specified
Accident Coverage" is an accident insurance policy which provides coverage for
a specifically identified kind of accident (or accidents) for each person
insured under the policy for accidental death or accidental death and
dismemberment, combined with a benefit amount not less than $ 5,000.00 for
accidental death $ 5,000.00 for double dismemberment, $ 2,500.00 for single
dismemberment.
I. Limited
Benefit Health Insurance Coverage.
"Limited Benefit Health Insurance Coverage" is any policy or
contract which provides benefits that are less than the minimum standards for
benefits required under Section 7. Such policies or contracts may be delivered
or issued for delivery in this state only if the outline of coverage required
by Section 8.L. of this Regulation is completed and delivered as required by
Section 8.B. of this Regulation.
Section 8 Required Disclosure Provisions
A. General Rules.
(1) Each policy of accident and sickness
insurance or hospital, medical or dental service corporation subscriber
contract shall include a renewal, continuation or non-renewal provision. The
language or specifications of such provision must be consistent with the type
of contract to be issued. Such 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.
(2) Except for riders or
endorsements by which the insurer effectuates a request made in writing by the
policy holder or exercises a specifically reserved right under the policy, all
riders or endorsements added to a policy after date of issue or at
reinstatement or renewal which reduce or eliminate benefits or coverage in the
policy shall require signed acceptance by the policyholder. After date of
policy issue, any rider or endorsement which increases benefits or coverage
with a concomitant increase in premium during the policy term must be agreed to
in writing signed by the insured, except if the increased benefits or coverage
is required by law.
(3) Where a
separate additional premium is charged for benefits provided in connection with
riders or endorsements, such a premium charge shall be set forth in the
policy.
(4) A policy which provides
for the payment of benefits based on standards described as "usual and
customary," "reasonable and customary," or word of similar import shall include
a definition of such terms and an explanation of such terms in its accompanying
outline of coverage.
(5) If a
policy contains any limitations with respect to pre-existing conditions, such
limitations must appear as a separate paragraph of the policy and be labeled as
"Pre-existing Conditions Limitations."
(6) All accident only policies shall contain
a prominent statement on the first page of the policy or attached thereto in
either contrasting color or in bold-faced type at least equal to the size of
type used for policy captions, a prominent statement as follows:
"This is an accident only policy and it does not pay benefits
for loss from sickness."
(7)
If age is to be used as a determining factor for reducing the maximum aggregate
benefits made available in the policy as originally issued, such fact must be
prominently set forth in the outline of coverage.
(8) If a policy contains a conversion
privilege, it shall comply, in substance, with the following: the caption of
the provision shall be "Conversion Privilege," or words of similar import. The
provision shall indicate the persons eligible for conversion, the circumstances
applicabgle [applicable] to 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 the
purpose.
(9) All policies shall
comply with the requirements of
8 V.S.A. Section
4063 including the provision with respect to
cancellation of a policy without cost to the insured.
(10) A policy which provides for the payment
of benefits for cancer as a named disease shall include the disclosure
statement set out at Exhibit II.
B. Outline of Coverage Requirements
No accident and sickness insurance policy, or certificate or
non-profit hospital, medical or dental service corporation subscriber contract
subject to this Regulation shall be delivered or issued for delivery in this
state unless an appropriate outline of coverage, as prescribed in Section 8.C.
through L. is completed as to such policy, certificate or contract. Direct
response insurers shall deliver the outline of coverage upon request but not
later than at the time the policy or certificate is delivered and:
(1) for all other policies, or certificates,
the outline is either:
(a) delivered with the
policy, or certificate; or
(b)
delivered to the applicant at the time application is made and acknowledgement
of receipt or certification of delivery of such outline of coverage is provided
to the insurer.
(2) In
every case, one copy of the outline of coverage shall be retained by the
company for a period of three years; and
(3) A copy of the outline of coverage
completed in John Doe fashion will be filed for each policy form with the
commissioner for approval.
If an outline of coverage was delivered at the time of
application and the policy, certificate or contract is issued on a basis which
would require revision of the outline, a substitute outline of coverage
properly describing the policy, certificate or contract must accompany the
policy, certificate or contract when it is delivered and contain the following
statement, in no less than twelve (12) point type, immediately above the
company name: "NOTICE: Read this outline of coverage carefully. It is not
identical to the outline of coverage provided upon application and the coverage
originally applied for has not been issued."
The appropriate outline of coverage for policies or contracts
providing hospital coverage which only meets the standards of Section 7.B.
shall be that statement contained in Section 8.C. The appropriate outline of
coverage for policies providing coverage which meets the standards of both
Sections 7.B. and C. shall be the statement contained in Section 8.E. The
appropriate outline of coverage for policies providing coverage which meets the
standards of both Section 7.B. and E. or Section 7.C. and E. or Section 7.B.,
C. and E. shall be the statement contained in Section 8.G.
Appropriate changes in terminology may be made in the outline
of coverage in the case of contracts of hospital, medical or dental service
corporations. In any other case where the prescribed outline of coverage is
inappropriate for the coverage provided by the policy or contract, an alternate
outline of coverage shall be submitted to the commissioner for prior
approval.
C. Basic
Hospital Expense Coverage (Outline of Coverage).
An outline of coverage, in form prescribed below, shall be
issued in connection with policies meeting the standards of Section 7.B. of
this Regulation. The items included in the outline of coverage must appear in
the sequence prescribed.
(COMPANY NAME)
BASIC HOSPITAL EXPENSE COVERAGE
OUTLINE OF COVERAGE
(1) Read Your Policy Carefully -- This
outline of coverage provides a very brief description of the important features
of your policy. This is not the insurance contract and only the actual policy
provisions will control. The policy itself sets forth in detail the rights and
obligations of both you and your insurance company. It is, therefore, important
that you READ YOUR POLICY CAREFULLY!
(2) Basic Hospital Expense Coverage --
Policies of this category are designed to provide to persons insured coverage
for hospital expenses incurred as a result of a covered accident or sickness.
Coverage is provided for daily hospital room and board, miscellaneous hospital
services, and hospital outpatient services, subject to any limitations,
deductibles and co-payment requirements set forth in the policy. Coverage is
not provided for physicians or surgeons fees or unlimited hospital
expenses.
(3) A brief specific
description of the benefits, including dollar amounts and number of days
duration where applicable, contained in this policy in the following order:
(a) daily hospital room and board;
(b) miscellaneous hospital
services;
(c) hospital outpatient
services; and
(d) other benefits,
if any.
(4) A description
of any policy provisions which exclude, eliminate, restrict, reduce, limit,
delay or in any other manner operate to qualify payment of the benefits
described in (3) above.
(5) A
description of policy provisions respecting renewability or continuation of
coverage, including age restrictions or any reservation of right to change
premiums.
D. Basic
Medical-Surgical Expense Coverage (Outline of Coverage).
An outline of coverage, in the form prescribed below, shall
be issued in connection with policies meeting the standards of Section 7.C. of
this Regulation. The items included in the outline of coverage must appear in
the sequence prescribed.
(COMPANY NAME)
BASIC MEDICAL-SURGICAL EXPENSE COVERAGE
OUTLINE OF COVERAGE
(1) Read Your Policy Carefully -- This
outline of coverage provides a very brief description of the important features
of your policy. This is not the insurance contract and only the actual policy
provisions will control your policy. The policy itself sets forth in detail the
rights and obligations of both you and your insurance company. It is,
therefore, important that you READ YOUR POLICY CAREFULLY!
(2) Basic Medical-Surgical Expense Coverage
-- Policies of this category are designed to provide to persons insured
coverage for medical-surgical expenses incurred as a result of a covered
accident or sickness. Coverage is provide for surgical services, anesthesia
services and in-hospital medical services, subject to any limitations,
deductibles and co-payment requirements set forth in this policy. Coverage is
not provided for hospital expenses or unlimited medical-surgical
expenses.
(3) A brief specific
description of the benefits, including dollar amounts and number of days
duration where applicable, contained in this policy, in the following order:
(a) surgical services;
(b) anesthesia services;
(c) in-hospital medical services;
and
(d) other benefits, if any.
(Note: The above description of benefits shall be stated
clearly and concisely, and shall include a description of any deductible or
co-payment provision applicable to the benefits described.)
(4) A description of any policy
provisions which exclude, eliminate, restrict, reduce, limit, delay or in any
other manner operate to qualify payment of the benefits described in (3)
above.
(5) A description of policy
provisions respecting renewability or continuation of coverage, including age
restrictions or any reservation of right to change premiums
E. Basic Hospital and
Medical-Surgical Expense Coverage (Outline of Coverage).
An outline of coverage, in the form prescribed below, shall
be issued in connection with policies meeting the standards of Section 7.B. and
C. of this Regulation. The items include in the outline of coverage must appear
in the sequence prescribed.
(COMPANY NAME)
BASIC HOSPITAL AND MEDICAL-SURGICAL EXPENSE COVERAGE
OUTLINE OF COVERAGE
(1) Read Your Policy Carefully -- This
outline of coverage provides a very brief description of the important features
of your policy. This is not the insurance contract and only the actual policy
provisions will control. The policy itself sets forth in detail the rights and
obligations of both you and your insurance company. It is, therefore, important
that your READ YOUR POLICY CAREFULLY!
(2) Basic Hospital and Medical-Surgical
Expense Coverage -- Policies of this category are designed to provide, to
persons insured, coverage for hospital and medical-surgical expenses incurred
as a result of a covered accident and sickness. Coverage is provided for daily
hospital room and board, miscellaneous hospital services, hospital out-patient
services, surgical services, anesthesia services, and in-hospital medical
services, subject to any limitations, deductibles and co-payment requirements
set forth in the policy. Coverage is not provided for unlimited hospital or
medical-surgical expenses.
(3) A
brief specific description of the benefits, including dollar amounts and number
of days duration where applicable, contained in this policy, in the following
order:
(a) daily hospital room and
board;
(b) miscellaneous hospital
services;
(c) hospital out-patient
services;
(d) surgical
services;
(e) anesthesia
services;
(f) in-hospital medical
services; and
(g) other benefits,
if any.
(Note: The above description of benefits shall be stated
clearly and concisely, and shall include a description of any deductible or
co-payment provision applicable to the benefits described.)
(4) A description of any policy
provisions which exclude, eliminate, restrict, reduce, limit, delay or in any
other manner operate to qualify payment of the benefits described in (3)
above.
(5) A description of policy
provision respecting renewability or continuation of coverage, including age
restrictions or any reservation of right to change premiums.
F. Hospital Confinement Indemnity
Coverage (Outline of Coverage).
An outline of coverage, in the form prescribed below, shall
be issued in connection with policies meeting the standards of Section 7.D. of
this Regulation. The items included in the outline of coverage must appear in
the sequence prescribed.
(COMPANY NAME)
HOSPITAL CONFINEMENT INDEMNITY COVERAGE
OUTLINE OF COVERAGE
(1) Read Your Policy Carefully -- This
outline of coverage provides a very brief description of the important features
of your policy. This is not the insurance contract and only the actual policy
provisions will control. The policy itself sets forth in detail the rights and
obligations of both you and your insurance company. It is, therefore, important
that you READ YOUR POLICY CAREFULLY!
(2) Hospital Confinement Indemnity Coverage
-- Policies of this category are designed to provide, to person insured,
coverage in the form of a fixed daily benefit during periods of hospitalization
resulting from a covered accident or sickness, subject to any limitations set
forth in the policy. Such policies do not provide any benefits other than the
fixed daily indemnity for hospital confinement and any additional benefit
described below.
(3) (A brief
specific description of the benefits contained in this policy, in the following
order:
(a) daily benefit payable during
hospital confinement; and
(b)
duration of benefit described in (a).)
(Note: The above description of benefits shall be stated
clearly and concisely.)
(4) A description of any policy provisions
which exclude, eliminate, restrict, reduce, limit, delay or in any other manner
operate to qualify payment of the benefits described in (3) above.
(5) A description of policy provisions
respecting renewability or continuation of coverage, including age restrictions
or any reservation of right to change premiums.
(6) Any benefits provided in addition to the
daily hospital benefit.
G. Major Medical Expense Coverage (Outline of
Coverage).
An outline of coverage, in the form prescribed below, shall
be issued in connection with policies meeting the standards of Section 7.E. of
this Regulation. The items included in the outline of coverage must appear in
the sequence prescribed.
(COMPANY NAME)
MAJOR MEDICAL EXPENSE COVERAGE
OUTLINE OF COVERAGE
(1) Read Your Policy Carefully -- This
outline of coverage provides a very brief description of the important features
of your policy. This is not the insurance contract and only the actual policy
provisions will control. The policy itself sets forth in detail the rights and
obligations of both you and your insurance company. It is, therefore, important
that you READ YOUR POLICY CAREFULLY!
(2) Major Medical Expense Coverage --
Policies of this category are designed to provide, to persons insured, coverage
for major hospital, medical, and surgical expenses incurred as a result of a
covered accident or sickness. Coverage is provided for daily hospital room and
board, miscellaneous hospital services, surgical services, anesthesia services,
in-hospital medical services and out-of-hospital care, subject to any
deductibles, co-payment provisions or other limitations which maybe set forth
in the policy. Basic hospital or basic medical insurance coverage is not
provided.
(3) A brief specific
description of the benefits, including dollar amounts, contained in this
policy, in the following order:
(a) daily
hospital room and board;
(b)
miscellaneous hospital services;
(c) surgical services;
(d) anesthesia services;
(e) in-hospital medical services;
(f) out-of-hospital care;
(g) maximum dollar amount for covered
charges; and
(h) other benefits, if
any.
(Note: The above description of benefits shall be stated
clearly and concisely, and shall include a description of any deductible or
co-payment provision applicable to the benefits described.)
(4) A description of any policy
provisions which exclude, eliminate, restrict, reduce, limit, delay or in any
other manner operate to qualify payment of the benefits described in (3)
above.
(5) A description of policy
provisions respecting renewability or continuation of coverage, including age
restrictions or any reservation of right to change premiums.
H. Disability Income Protection
Coverage (Outline of Coverage).
An outline of coverage, in the form prescribed below, shall
be issued in connection with policies meeting the standards of Section 7.F. of
this Regulation. The items included in the outline of coverage must appear in
the sequence prescribed.
(COMPANY NAME)
DISABILITY INCOME PROTECTION COVERAGE
OUTLINE OF COVERAGE
(1) Read Your Policy Carefully -- This
outline of coverage provides a very brief description of the important features
of your policy. This is not the insurance contract and only the actual policy
provisions will control. The policy itself sets forth in detail the rights and
obligations of both you and your insurance company. It is, therefore, important
that you READ YOUR POLICY CAREFULLY!
(2) Disability Income Protection Coverage --
Policies of this category are designed to provide, to persons insured, coverage
for disabilities resulting from a covered accident or sickness, subject to any
limitations set forth in the policy. Coverage is not provided for basic
hospital, basic medical-surgical or major medical expenses.
(3) A brief specific description of the
benefits contained in this policy.
(Note: The above description of benefits shall be stated
clearly and concisely.)
(4)
A description of any policy provision which exclude, eliminate, restrict,
reduce, limit, delay or in any other manner operate to qualify payment of the
benefits described in (3) above.
(5) A description of policy provisions
respecting renewability or continuation of coverage, including age restrictions
or any reservation of right to change premiums.
I. Accident Only Coverage (Outline of
Coverage).
An outline of coverage in the form prescribed below, shall be
issued in connection with policies meeting the standards of Section 7.G. of
this Regulation. The items included in the outline of coverage must appear in
the sequence prescribed.
(COMPANY NAME)
ACCIDENT ONLY COVERAGE
OUTLINE OF COVERAGE
(1) Read Your Policy Carefully -- This
outline of coverage provides a very brief description of the important features
of your policy. This is not the insurance contract and only the actual policy
provisions will control. The policy itself sets forth in detail the rights and
obligations of both you and your insurance company. It is, therefore, important
that you READ YOUR POLICY CAREFULLY!
(2) Accident Only Coverage -- Policies of
this category are designed to provide, to persons insured, coverage for certain
losses resulting from a covered accident ONLY, subject to any limitations
contained in the policy. Coverage is not provided for basic hospital, basic
medical-surgical or major medical expenses.
(3) A brief specific description of the
benefits contained in this policy:
(Note: The above description of benefits shall be stated
clearly an concisely and shall include a description of any deductible or
co-payment provision applicable to the benefits described. Proper disclosure of
benefits which vary according to accidental cause shall be made in accordance
with subsection A. (13) of Section 7. of this Regulation.)
(4) A description of any policy provisions
which exclude, eliminate, restrict, reduce, limit, delay or in any other manner
operate to qualify payment of the benefits described in (3) above.
(5) A description of policy provisions
respecting renewability or continuation of coverage, including age restrictions
or any reservation of right to change premiums.
J. Specified Disease or Specified Accident
Coverage (Outline of Coverage).
An outline of coverage, in the form prescribed below, shall
be issued in connection with policies meeting the standards of Section 7.H. of
this Regulation. The coverage shall be identified by the appropriate bracketed
title. The items included in the outline of coverage must appear in the
sequence prescribed.
(COMPANY NAME)
(SPECIFIED DISEASE) (SPECIFIED ACCIDENT) COVERAGE
OUTLINE OF COVERAGE
(1) Read Your Policy Carefully -- This
outline of coverage provides a very brief description of the important features
of your policy. This is not the insurance contract and only the actual policy
provisions will control. The policy itself sets forth in detail the rights and
obligations of both you and your insurance company. It is, therefore, important
that your READ YOUR POLICY.
(2)
(Specified Disease) (Specified Accident) Coverage -- Policies of this category
are designed to provide, to persons insured, restricted coverage paying
benefits ONLY when certain losses occur as a result of (specified diseases) or
(specified accidents). Coverage is not provided for basic hospital, basic
medical-surgical or major medical expenses.
(3) A brief specific description of the
benefits, including dollar amounts, contained in this policy:
(Note: The above description of benefits shall be stated
clearly and concisely, and shall include a description of any deductible or
co-payment provisions applicable to the benefits described. Proper disclosure
of benefits which vary according to accidental cause shall be made in
accordance with subsection A. (13) of Section 7 of this Regulation.)
(4) A description of any policy
provisions which exclude, eliminate, restrict, reduce, limit, delay or in any
other manner operate to qualify payment of the benefits described in (3)
above.
(5) A description of policy
provisions respecting renewability or continuation of coverage, including age
restrictions or any reservation of right to change premiums.
K. Limited Benefit Health Coverage
(Outline of Coverage).
An outline of coverage, in the form prescribed below, shall
be issued in connection with policies which do not meet the minimum standards
of section 7.B., C., D., E., F., G. and H. of this Regulation. The items
included in the outline of coverage must appear in the sequence
prescribed.
(COMPANY NAME)
LIMITED BENEFIT HEALTH COVERAGE
OUTLINE OF COVERAGE
(1) Read Your Policy Carefully -- This
outline of coverage provides a very brief description of the important features
of your policy. This is not the insurance contract and only the actual policy
provisions will control. The policy itself sets forth in detail the rights and
obligations of both you and your insurance company. It is, therefore, important
that you READ YOUR POLICY CAREFULLY!
(2) Limited Benefit Health Coverage --
Policies of this category are designed to provide, to persons insured, limited
or supplemental coverage.
(3) A
brief specific description of the benefits, including dollar amounts, contained
in this policy:
(Note: the above description of benefits shall be stated
clearly and concisely, and shall include a description of any deductible or
co-payment provisions applicable to the benefits described. Proper disclosure
of benefits which vary according to accidental cause shall be made in
accordance with subsection A. (13) of Section 7 of this Regulation.)
(4) A description of any policy
provision which exclude, eliminate, restrict, reduce, limit, delay, or in any
other manner operate to qualify payment of the benefits described in (3)
above.
(5) A description of policy
provisions respecting renewability or continuation of coverage, including age
restrictions or any reservation of right to change premiums.
Section 9 Requirements
for Replacement
A. Application forms shall
include a question designed to elicit information as to whether the insurance
to be issued is intended to replace any other accident and sickness insurance
presently in force. A supplementary application or other form to be signed by
the applicant containing such a question may be used.
B. Upon determining that a sale will involve
replacement, an insurer, other than a direct response insurer, or its agent
shall furnish the applicant prior to issuance or delivery of the policy, the
notice described in C. below, One (1) copy of such notice shall be retained by
the applicant and an additional copy signed by the applicant shall be retained
by the insurer. A direct response insurer shall deliver to the applicant upon
issuance of the policy, the notice described in D. below. In no event, however,
will such a notice be required in the solicitation of the following type of
policies: accident only and single premium non-renewable policies.
C. The notice required by B. above for an
insurer, other than a direct response insurer, shall provide, in substantially
the following form:
NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND
SICKNESS INSURANCE
According to (your application) (information you have
furnished), you intend to lapse or otherwise terminate existing accident and
sickness insurance and replace it with a policy to be issued by (company name)
Insurance Company. For your own information and protection, you should be aware
of and seriously consider certain factors which may affect the insurance
protection available to you under the new policy.
(1) Health conditions which you may presently
have, (pre-existing conditions) may not be immediately or fully covered under
the new policy. This could result in denial or delay of a claim or benefits
under the new policy, whereas a similar claim might have been payable under
your present policy.
(2) You may
wish to secure the advice of your present insurer or its agent regarding the
proposed replacement of your present policy. This is not only your right, but
it is also in your best interest to make sure you understand all the relevant
factors involved in replacing your present coverage.
(3) If, after due consideration, you still
wish to terminate your present policy and replace it with new coverage, be
certain to truthfully and completely answer all questions on the application
concerning your medical/health history. Failure to include all material medical
information an an application may provide a basis for the company to deny any
future claims and to refund your premium as though your policy had never been
in force. After the application has been completed and before you sign it,
reread it carefully to be certain that all information has been properly
recorded.
The above "Notice to Applicant" was delivered to me
on:
....
(Date)
....
(Applicant's Signature)
D. The notice required by B. above for a
direct response insurer shall be as follows:
NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND
SICKNESS INSURANCE
According to (your application) (information you have
furnished), you intend to lapse or otherwise terminate existing accident and
sickness insurance and replace it with the policy delivered herewith issued by
(company name) Insurance Company. Your new policy provides 10 days within which
you may decide without costs whether you desire to keep the policy. For your
own information and protection, you should be aware of and seriously consider
certain factors which may affect the insurance protection available to you
under the new policy.
(1) Health
conditions which you may presently have, (pre-existing conditions) may not be
immediately or fully covered under the new policy. This could result in denial
or delay of a claim for benefits under the new policy, whereas a similar claim
might have been payable under your present policy.
(2) You may wish to secure the advice of your
present insurer or its agent regarding the proposed replacement of your present
policy. This is not only your right, but it is also in your best interest to
make sure you understand all the relevant factors involved in replacing your
present coverage.
(3) (To be
included only if the application is attached to the policy). If after due
consideration, you still wish to terminate your present policy and replace it
with new coverage, read the copy of the application attached to your new policy
and be sure that all questions are answered fully and correctly. Omissions or
misstatements in the application could cause an otherwise valid claim to be
denied. Carefully check the application and write to (company name and address)
within 10 days if any information is not correct and complete, or if any past
medical history has been left out of the application.
....
(Company Name)
