Connecticut Administrative Code › Title 38a - Insurance Department › 513 - Group Specified Disease Health Insurance Minimum Standards › Section 38a-513-3 - Minimum standards for group health insurance benefits

Current through July 10, 2024
The following minimum standards for benefits are prescribed for
				the categories of coverage noted in subsections (a) to (g), inclusive, of this
				section. No such group policy or certificate shall be delivered or issued for
				delivery in this state that 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. Nothing in this
				section shall preclude the issuance of any policy or contract combining two or
				more categories of 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 explanation. The terms "non-cancellable" or "non-cancellable
			 and guaranteed renewable" may be used only in a policy that 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 unilaterally make any change in any
			 provision of the policy while the policy is in force. Any accident and health
			 or accident only policy that 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 that 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 unilaterally make 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. Any accident and health or
			 accident only policy that 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) If a
			 policy contains a status type military service exclusion or a provision that
			 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.
(4) In the
			 event an insurer cancels or refuses to renew, policies providing pregnancy
			 benefits shall provide for an extension of benefits as to a pregnancy that
			 commences while the policy is in force and for which benefits would have been
			 payable had the policy remained in force.
(5) 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.
(6) Family coverage shall
			 continue for any dependent child who is incapable of self sustaining employment
			 due to mental 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 thirty-one (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.
(7) 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.
(8) A policy may contain a provision relating
			 to recurrent disabilities, except that no such provision shall specify that a
			 recurrent disability be separated by a period of greater than six (6)
			 months.
(9) Accidental death and
			 dismemberment benefits shall be payable if the loss occurs within ninety (90)
			 days after 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
			 that 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.
(10) Specific dismemberment
			 benefits shall not be in lieu of other benefits unless the specific benefit
			 equals or exceeds the other benefits.
(11) Any accident only policy providing
			 benefits that vary according to the type of accidental cause shall prominently
			 describe the circumstances under which benefits are payable that are lesser
			 than the maximum amount payable under the policy
(12) Termination of the policy shall be
			 without prejudice to any continuous loss that 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.