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11 CRR-NY 52.17NY-CRR

STATE COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK

TITLE 11. INSURANCE

CHAPTER III. POLICY AND CERTIFICATE PROVISIONS

SUBCHAPTER A. LIFE, ACCIDENT AND HEALTH INSURANCE

PART 52. MINIMUM STANDARDS FOR FORM, CONTENT AND SALE OF HEALTH INSURANCE, INCLUDING STANDARDS OF FULL AND FAIR DISCLOSURE

11 CRR-NY 52.17

52.17 Rules relating to content of forms for individual insurance.

The following provisions shall apply to individual insurance:

(a) General rules.

(1) The first page of the policy shall indicate whether the policy is renewable or nonrenewable.

(2) Provisions respecting renewability by the insurer shall appear on the first page of the policy or reference shall be made thereto in a brief description on the first page.

(3) Any reduction in benefits because of the attainment of an age limit shall have a reference to such reduction set forth on the first page or specification page of the policy. For purposes of this requirement, a reduction in a benefit period is a reduction in benefits requiring such reference.

(4) Except with respect to the actual provisions, any description required to be contained on the first page of the policy shall also be contained on the filing back of the policy, if any.

(5) The term noncancellable or noncancellable 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 age 65 or, as an alternative with respect to policies defined in section 52.8 of this Part, until receipt of retirement benefits under the Social Security Act of the United States. During such period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force.

(6) Except as provided in paragraph (5) of this subdivision, 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 age 65 or, as an alternative with respect to policies defined in section 52.8 of this Part, until receipt of retirement benefits under the Social Security Act of the United States. During such 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.

(7) The words guaranteed renewable shall not be used in a policy unless the insurer's right to change rates is also stated in such a way that it is not minimized or made obscure.

(8) Accident benefits shall not be predicated upon loss occurring through accidental means or violent and external means.

(9) In any policy which provides for a suspension of coverage while the covered person is in military service, the policy shall provide that, upon written request, the insurer will refund any unearned premiums for the period of such suspension. Upon termination of military service of no longer than five years, the person must have the right to renew his coverage on the same basis as before suspension of coverage took effect, without restriction as to preexisting conditions except those applicable on the date coverage was suspended. Such renewal shall take effect on the date military service terminates, subject to written application and payment of the required premium within 60 days after such date.

(10) Family policies may provide for a new contestable period for each new member added, but shall not provide for a new contestable period for the policy.

(11) Special nurse benefits may be provided either with a maximum amount or on a copayment basis, or both.

(12) Rider or endorsement forms used to reduce or eliminate coverage after policy issuance shall provide for signed acceptance by the insured.

(13) Riders or endorsements relinquishing any right of an insurer on a class or classes of similar policies may be used when transferring coverage on such policies within a company or between companies.

(14) Riders or endorsements providing a benefit for which a specific premium is charged shall show the premium on the application, rider, or elsewhere in the policy.

(15) Termination of a policy of hospital, surgical or medical expense insurance shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period while the policy was in force may be predicated upon the continuous total disability of the insured, or limited to the extent of the benefit period, if any, or payment of the maximum benefit. If no specific benefit period is provided, an extended benefit period of at least 12 months must be included in the contract. A loss shall commence when a medical service, whether or not covered by the policy, is rendered for the condition causing total disability.

(16) Different maximum daily hospital benefits or durations of coverage contained in the same policy shall not be based on the type of room accommodation, but may be based on the level of care unit (such as intensive care or extended care) to which a covered person is assigned.

(17) Surgical fee schedules shall provide benefits for various surgical procedures which bear a rational relationship and reasonable relativity to each other, based on the nature of the procedure. Schedules conforming to the relativities of the State of New York Certified Surgical Fee Schedule shall be deemed to meet the requirements of this paragraph.

(18) Surgical schedules contained in the policy shall include a provision providing coverage for procedures not specifically listed in the schedules and not otherwise excluded by the policy, and benefits therefor shall be consistent with the benefits for comparable procedures.

(19) Multiple surgical procedures performed during the same operative session and through the same incision shall be reimbursed in an amount not less than that stated in the schedule for the most expensive procedure then being performed. Multiple surgical procedures performed during the same operative session but through different incisions shall be reimbursed in an amount not less than that stated in the schedule for the most expensive procedure then being performed, and with regard to the less expensive procedures in an amount at least equal to 50 percent of the scheduled amount for these procedures, unless a different amount is specifically set forth in the State of New York Certified Surgical Fee Schedule.

(20) In major medical insurance policies and policies providing major medical type benefits, the benefit period and the maximum amount payable during the benefit period shall be such that the maximum can reasonably be expected to be incurred during the benefit period, unless the policy maximum is designed to protect against catastrophic loss.

(21) In major medical insurance policies and policies providing major medical type benefits, if a benefit period commences with the first expense used to satisfy a deductible, and under the policy terms no further benefits become payable for the same cause after the termination of such period, no benefit period shall end before the expiration of nine months after the deductible is satisfied, except when the benefit period is determined by a calendar date unrelated to the incidence of the first expense.

(22) No policy shall be designated “basic” or “major medical” unless it provides at least the minimum benefits in section 52.5, 52.6 or 52.7 of this Part, respectively. Policies meeting the definition of section 52.8, 52.9 or 52.10 of this Part shall not be designated in any manner inconsistent with the applicable definition, or which would encourage misrepresentation of the actual coverages provided.

(23) Where a policy is written that provides at least the coverages required for both basic hospital insurance under section 52.5 of this Part and basic medical insurance under section 52.6, the allowable deductible may be applied to the combined coverage.

(24) Where a policy is written that provides at least the coverages required for both basic hospital insurance under section 52.5 of this Part and basic medical insurance under section 52.6, the required anesthetic coverage may be provided as part of the miscellaneous hospital benefit instead of a separate anesthetic benefit, provided that the limit of the miscellaneous hospital benefit is sufficient to meet the combined minimum requirements of both the miscellaneous hospital benefit of basic hospital insurance and the anesthesia benefit of basic medical insurance.

(25)

(i) Unilateral modifications by an insurer to existing accident and health coverage shall be made in accordance with applicable laws upon at least 30 days’ prior written notice to the policyholder.

(ii) An insurer may unilaterally modify the coverage for a policy of hospital, surgical or medical expense insurance only at the time of coverage renewal.

(iii) Where a policyholder is contractually required to provide prior written notice to terminate coverage, the notice referred to in subparagraph (i) of this paragraph must be provided to such policyholder no less than 14 days prior to the date by which the policy holder is required to provide notice to terminate coverage.

(26) Except as specifically permitted by statute or regulation, no policy shall require the loss from accidental injury to commence within less than 30 days after the date of an accident, nor shall any such policy which the insurer may cancel or refuse to renew require that it be in force at the time loss commences if the accident occurred while the policy was in force.

(27) No policy shall exclude, limit or reduce coverage for a loss due to a preexisting condition for a period greater than 12 months following the effective date, 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 preexisting condition is not specifically excluded, limited or reduced in accordance with section 52.16(e) of this Part.

(28) Policies issued to persons aged 65 or older, other than those defined in sections 52.11, 52.12 and 52.13 of this Part, shall not contain any provision which excludes, limits or reduces coverage for a loss due to a preexisting condition for a period greater than six months following the effective date, unless the preexisting condition is specifically excluded, limited or reduced in accordance with section 52.16(e) of this Part.

(29) When rates are based on attained age, other than for policies which provide hospital, medical or surgical expense benefits, the policy shall include the applicable schedule of rates.

(30) A family policy shall provide that adopted children and stepchildren dependent upon the insured be eligible for coverage on the same basis as natural children.

(31) A family policy covering a proposed adoptive parent, on whom the child is dependent, shall provide that such child be eligible for coverage on the same basis as a natural child during any waiting period prior to the finalization of the child's adoption.

(32)

(i) Insurers issuing accident and health policies which provide hospital or medical coverage on an expense incurred or indemnity basis to a person(s) eligible for Medicare shall provide to those applicants a Guide to Health Insurance for People with Medicare in the form developed jointly by the National Association of Insurance Commissioners and the Health Care Financing Administration and in a type size no smaller than 12-point type. Delivery of the guide shall be made whether or not such policies are advertised, solicited or issued as Medicare supplement insurance as defined in this regulation. Except in the case of direct response insurers, delivery of the guide shall be made to the applicant at the time of application and written acknowledgment of receipt of the guide shall be obtained by the insurer. Direct response insurers shall deliver the guide to the applicant upon request but in no event later than at the time the policy is delivered. If the guide has not been made available from the Health Care Financing Administration at the time that the insurer is required to deliver such guide, then the insurer shall provide the applicant with a notice that the guide is presently unavailable and that it will be delivered to the applicant at such time that it is available to the insurer.

(ii) For the purposes of this paragraph, form means the language, format, type size, type proportional spacing, bold character, and line spacing.

(33)

(i) Any accident and health insurance policy, other than a Medicare supplement policy, a policy issued pursuant to a contract under section 1876 of the Federal Social Security Act (42 U.S.C. section 1395 et seq.), or disability income policy, delivered or issued for delivery in this State to persons eligible for Medicare shall notify insureds under the policy that the policy is not a Medicare supplement policy. The notice shall either be printed on or attached to the first page of the disclosure statement delivered to insureds to comply with section 52.54 of this Part or to the first page of the policy delivered to insureds. The notice shall be in no less than 12-point type and shall contain the following language:

“THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company.”

(ii) Where applicable, applications provided to persons eligible for Medicare for the accident and health insurance policies described in subparagraph (i) of this paragraph shall disclose, using the applicable statement prescribed in 42 U.S.C. section 1395ss(d)(3)(D), the extent to which the policy duplicates Medicare. The disclosure statement shall be provided as a part of, or together with, the application for the policy.

(34) At the time of an event described in 42 U.S.C. section 1395ss(s)(3)(B) or (F)^* because of which an individual loses coverage or benefits due to the termination of the policy or the individual ceases enrollment under the policy, the insurer of the policy from which termination or disenrollment occurs shall provide the individual with written notification of his or her rights and of the obligations of issuers of Medicare supplement insurance policies under Part 58 of this Title. If an individual loses coverage or benefits due to termination of the policy, such notification must be provided contemporaneously with the notification of termination. If an individual ceases enrollment under the policy, such notification must be provided within 10 working days of the insurer receiving notification of disenrollment.

(35) Insurers issuing policies and contracts subject to the provisions of section 4303(s) of the Insurance Law shall use standards and guidelines no less favorable than those established and adopted by the American Society for Reproductive Medicine in relation to the following:

(i) the determination of infertility for purposes of compliance with section 4303(s)(3) of the Insurance Law;

(ii) the identification of experimental procedures and treatments not covered for the diagnosis and treatment of infertility;

(iii) the identification of the required training, experience and other standards for health care providers for the provision of procedures and treatments for the diagnosis and treatment of infertility; and

(iv) the determination of appropriate medical candidates by the treating physician.

Said standards and guidelines are taken from The American Society for Reproductive Medicine's Practice Committee Opinions on The Definition of Experimental, The Definition of Infertility, The Guidelines for the Provision of Infertility Services and The Revised Minimum Standards for Invitro Fertilization, Gamete Intrafallopian Transfer and Related Procedures. These Practice Committee Opinions were approved by the Practice Committee of the American Society for Reproductive Medicine (formerly The American Fertility Society) on March 27, 1993 and approved by the Board of Directors of the American Society for Reproductive Medicine (formerly The American Fertility Society) on May 17, 1993. The Practice Committee Opinions can be obtained from The American Society for Reproductive Medicine formerly The American Fertility Society, 1209 Montgomery Highway, Birmingham, AL 35216-2809 and are available for public inspection and copying from the New York State Department of Financial Services at either One State Street, New York, NY 10004 or One Commerce Plaza, Albany, NY 12257.

(36) An insurer issuing a policy subject to the provisions of Insurance Law sections 1120, 3216(i)(17), 3217-g, 4303(j) or 4306-f or Public Health Law section 4406-f that provides coverage for direct access to screening and referral for maternal depression performed by a provider of obstetrical, gynecologic, or pediatric services of the mother’s choice, shall provide coverage for the screening and referral for maternal depression under the mother’s policy. However, if the infant is covered under a different policy than the mother and the screening and referral are performed by a provider of pediatric services, coverage for the screening and referral shall also be provided under the policy in which the infant is covered.

(b) Accident policies.

(1) Accidental death and dismemberment benefits shall be payable if the loss occurs within 90 days from the date of the accident, irrespective of total disability.

(2) Filing of policies to be sold by vending machine shall be accompanied by information describing the operation of the machine. Copy of any information and direction used in connection with the machine shall be included in the filing.

(3) Specific dismemberment benefits shall not be in lieu of other benefits unless the specific benefit exceeds the other benefit.

(1) Benefits for specific injury due to accident shall not be in lieu of disability benefits, unless the specific benefit exceeds the disability benefit.

(2) Policies which limit benefits for disability to specified items (such as business overhead policies) must provide for a premium refund, pro rata or in accordance with a short rate table, in the event that none of the items to be indemnified exist (e.g., where a professional person discontinues his office), but only if the insured gives timely notice. Any premium refund may be limited to a one-year premium.

(3) No policy shall provide for reduction of benefits prior to age 65 by reason of a change in employment status or the income of the insured, except in accordance with the optional standard provision entitled “change of occupation” or “relation of earnings to insurance” of section 164 of the Insurance Law, whichever is applicable, and no reduction of benefits shall be made applicable solely on the basis of the sex or marital status of the insured.

(4) Disability benefits conditioned upon hospital confinement shall be considered as hospital, medical or surgical expense benefits for purposes of subdivisions (2)(B)(3) and (6) of section 164 of the Insurance Law and any relevant regulations.

(5) Policies providing disability benefits for dependents shall adequately define the conditions establishing disability.

(d) Telehealth.

(1) Telehealth has the meaning set forth in Insurance Law sections 3217-h and 4306-g and includes audio-only visits.

(2) For the purposes of Insurance Law sections 3217-h and 4306-g, an insurer may engage in reasonable fraud, waste and abuse detection efforts, including to prevent payments for services that do not warrant a separate billable encounter.

Footnotes

42 United States Code 1395ss (2007) published by Office of Law Revision Counsel, United States House of Representatives. It is available from the New York State Department of Financial Services, Office of General Counsel, One State Street, New York, NY 10004.

11 CRR-NY 52.17

Current through July 31, 2021

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