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11 CRR-NY 52.22NY-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 52.22

52.22 Volunteer firefighter enhanced cancer insurance.

(a) General Municipal Law section 205-cc requires every legally organized fire district, department or company in this State to provide and maintain for each eligible volunteer firefighter an enhanced cancer disability benefit insurance program. The law requires the Division of Homeland Security and Emergency Services’ Office of Fire Prevention and Control to promulgate regulations, in consultation with the Department of Financial Services and the Workers’ Compensation Board, to implement General Municipal Law section 205-cc. Those regulations are contained in Part 210 of Title 9 NYCRR. This section establishes the minimum requirements for policies issued in satisfaction of those requirements.

(b) Definitions.

As used in this section:

(1) Active volunteer firefighter shall have the meaning set forth in Part 210 of Title 9 NYCRR.

(2) Cancer means a disease caused by an uncontrolled division of abnormal cells in a part of the body or a malignant growth or tumor resulting from the division of abnormal cells affecting the prostate or breast, lymphatic, hematological, digestive, urinary, neurological, or reproductive systems, or melanoma.

(3) Insured firefighter means a volunteer firefighter covered under the policy and who meets the eligibility requirements for coverage set forth in Part 210 of Title 9 NYCRR.

(4) Total disability shall have the meaning set forth in Part 210 of Title 9 NYCRR.

(5) Volunteer firefighter enhanced cancer insurance means a blanket insurance policy or certificate that provides cancer benefits to volunteer firefighters in accordance with General Municipal Law section 205-cc.

(1) A volunteer firefighter enhanced cancer insurance policy or certificate issued in satisfaction of the requirements of General Municipal Law section 205-cc shall be clearly labeled as “volunteer firefighter enhanced cancer insurance.” An insurer shall issue a policy of volunteer firefighter enhanced cancer insurance only as a stand-alone policy and shall not issue the coverage combined or offered in conjunction with any other insurance.

(2) Every volunteer firefighter enhanced cancer insurance policy or certificate shall conspicuously set forth the following statement on the first page of the policy or certificate in boldface type: “This is a limited policy (or certificate). It pays benefits only for specific losses from cancer. Read it carefully.”

(3) An insurer may not impose any preexisting condition limitation or exclusion on coverage for an insured firefighter.

(4) Benefits shall be payable under the policy without regard to other coverage except:

(i) benefits shall not be payable if the insured is already provided paid firefighter benefits under General Municipal Law article 10; and

(ii) the monthly disability benefit provided pursuant to subparagraph (d)(1)(iii) of this section shall be secondary to disability benefits from any other source (other than individual disability income insurance purchased by the insured firefighter) such as group or blanket disability, Social Security disability or workers’ compensation benefits. Where the policy is secondary, benefits shall be limited to the difference between the amount paid from the other source and the benefit specified in the policy.

(5) The policy shall comport with the claims process requirements provided in Part 210 of Title 9 NYCRR.

(6) The exclusions in section 52.16(c) of this Part shall not be applicable to this coverage. A claim for benefits may be denied only for the reasons set forth in Part 210 of Title 9 NYCRR.

(7) Conditions for nonrenewal or termination by the insurer shall be fully set forth in the policy. Notices of nonrenewal or termination shall provide for at least 60 days’ prior written notice to the policyholder.

(8) Any change in premium rates shall be subject to the prior approval of the superintendent. The insurer shall provide each policyholder with at least 60 days’ prior written notice before implementing an approved rate adjustment.

(d) Benefits.

(1) In accordance with General Municipal Law section 205-cc, every volunteer firefighter enhanced cancer insurance policy shall include each of the following benefits:

(i) A lump sum benefit of $25,000 for each diagnosis payable to the insured firefighter upon acceptable proof to the insurer of a diagnosis by a board-certified physician in the medical specialty appropriate for the type of cancer diagnosed that there are one or more malignant tumors characterized by the uncontrollable and abnormal growth and spread of malignant cells with invasion of normal tissue and that either:

(a) there is metastasis; and

(1) surgery, radiotherapy, or chemotherapy is medically necessary; or

(2) there is a tumor of the prostate, provided that it is treated with radical prostatectomy or external beam therapy; or

(b) the insured firefighter has terminal cancer, the firefighter’s life expectancy is 24 months or less from the date of diagnosis, and will not benefit from, or has exhausted, curative therapy.

(ii) A lump sum benefit of $6,250 for each diagnosis payable to the insured firefighter upon acceptable proof to the insurer of a diagnosis by a board-certified physician in the medical specialty appropriate for the type of cancer involved that either:

(a) there is carcinoma in situ such that surgery, radiotherapy, or chemotherapy has been determined to be medically necessary;

(b) there are malignant tumors that are treated by endoscopic procedures alone; or

(iii) A monthly benefit of $1,500, of which the first payment shall be made six months after total disability and submission of acceptable proof of such disability to the insurer that the disability is caused by cancer and that such cancer precludes the insured firefighter from serving as a firefighter. Such benefit shall continue for up to 36 consecutive monthly payments.

(a) Any insured firefighter receiving such monthly benefits may be required to have his or her condition reevaluated. In the event any such reevaluation reveals that the insured firefighter has regained the ability to perform duties as a firefighter, then his or her monthly benefits shall cease the last day of the month of reevaluation.

(b) In the event that there is a subsequent reoccurrence of a disability caused by cancer that precludes the insured firefighter from serving as a firefighter, he or she shall be entitled to receive any remaining monthly payments.

(iv) A death benefit in the amount of $50,000 that is payable to the insured firefighter or his or her beneficiary upon acceptable proof by a board-certified physician that the insured firefighter's death resulted from complications associated with cancer.

(2) The combined total of all lump sum benefits received during an insured firefighter’s lifetime pursuant to subparagraphs (1)(i) and (ii) of this subdivision shall not exceed $50,000.

(3) An insured firefighter shall remain eligible for the benefits in subparagraphs (1)(i), (ii) and (iv) of this subdivision for 60 months after the formal cessation of the insured firefighter’s status as an active volunteer firefighter.

(4) Any policy that conditions payment upon pathological diagnosis of a covered cancer shall also provide that if such a pathological diagnosis is medically inappropriate, a clinical diagnosis will be accepted in lieu thereof. Any type of medically appropriate diagnosis shall be accepted.

11 CRR-NY 52.22

Current through July 31, 2021

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