California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.5 - Standards for Determining Conformity of Individual Disability Policies with the Provisions of Paragraph (7) of Subdivision (b) of Section 10291.5 of the Insurance Code › Subarticle 2 - Standards › Section 2220.8 - Exceptions, Limitations and Reductions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A benefit shall be deemed not sufficient
					 to be of real economic value to the insured if it is subject to exceptions,
					 limitations or reductions concerning any subject matter other than the
					 following:
(b) War; service in
					 armed forces; workers' compensation; participation in a riot or insurrection;
					 suicide or attempted suicide; intentionally self-inflicted injury; voluntary or
					 involuntary inhalation of gas; mental or emotional disorders or functional
					 nervous disorders; pregnancy or childbirth; treatment on or to the teeth or
					 gums except when necessitated by accident; hallucinatory drugs; while a
					 passenger other than a fare-paying passenger in any aircraft or while passenger
					 in a military aircraft or acting as pilot or crew in any aircraft; facilities
					 for treatment of armed forces members or ex-members except when an actual
					 charge is made; services for which no charge is made in the absence of
					 insurance; services covered under any governmental plan except those
					 governmental plans which by law either define or specify disability insurance
					 coverage as primary; rest cure or routine medical examinations; eye refractions
					 or eye glasses; hearing aids; surgery for cosmetic purposes; motorcycle use;
					 racing contests; professional athletics; hazardous avocations (when the
					 hazardous avocation is specified specifically); reasonable territorial
					 limits.
(c) A limitation which
					 constitutes a reasonable definition of the losses covered and the benefits
					 provided shall not be construed as materially lessening the value of the
					 benefit if the definition is not otherwise inconsistent with any provision of
					 this Article.
(d) The words
					 "exceptions, limitations, or reductions" as used in this section shall not
					 prohibit any provision which the Insurance Code specifies permissible or which
					 is approved by the Insurance Commissioner, and shall not include any provision
					 contained in any insuring paragraph or paragraphs that modifies solely the
					 subject thereof, where such insuring paragraph or paragraphs, including such
					 provision, constitutes, over all, an affirmative definition of one of the
					 hazards, a class of hazards or all of the hazards which the policy insures
					 against and which the Insurance Commissioner deems to be a reasonable
					 definition or statement of one or more of the hazards which the policy insures
					 against.
(e) This section shall not
					 apply to any matter contained in any rider the original or copy of which is
					 signed by the insured and issued for attachment to the policy when the policy
					 is issued or reinstated when the rider is used solely to waiver coverage for
					 existing specified medical or physical conditions which actually exist. Such a
					 rider may also be used to waive coverage for specified hazardous avocations.
The words and phrases designated in this section as
						"subject matters" of exceptions, limitations and reductions are to be given a
						broad generic interpretation and do not control the actual words or phrases
						used are not less favorable to the insured person than the words or phrases
						used in this section.
1.
						Amendment of subsection (b) filed 12-2-75; designated effective 1-1-76
						(Register 75, No.49).