Connecticut Administrative Code › Title 38a - Insurance Department › 505 - Individual Accident and Sickness Insurance Minimum Standards › Section 38a-505-9 - Accident and sickness minimum standards for benefits

Current through July 10, 2024
The following minimum standards for benefits are prescribed for
				the categories of coverage noted in the following subsections. No individual
				policy of accident and sickness insurance or fraternal benefit society
				certificate 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
				38a-505-10(K).
				Nothing in this section shall preclude the issuance of any policy or contract
				combining two or more categories of coverage such as hospital expense coverage
				and medical-surgical expense coverage.
(A)
General Rules.
(1) A "non-cancellable," "guaranteed
			 renewable," or "non-cancellable 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 non-payment 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-cancellable," "guaranteed renewable," or "non-cancellable and
			 guaranteed renewable" shall not be used without further explanatory language in
			 accordance with the disclosure requirements of Section
			 38a-505-10(A)
			 (1). The terms "non-cancellable" or "non-cancellable 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 as mandated by statute and 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-cancellable" 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 benefit following
			 hospitalization shall not condition such benefits upon admission to the
			 convalescent or extended care facility within a period of less than fourteen
			 (14) 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) All Medicare
			 supplement policies providing in-hospital benefits only shall include in their
			 provided benefits the initial Part A Medicare deductible as established from
			 time to time by the Social Security Administration.
(15) Termination of the policy shall be
			 without prejudice to any continuous loss which commenced while the policy was
			 in force, but the extension of benefits beyond the period the policy was in
			 force may be 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.