Illinois Administrative Code › Title 50 - INSURANCE › Part 2007 - MINIMUM STANDARDS OF INDIVIDUAL ACCIDENT AND HEALTH INSURANCE › Section 2007.70 - Accident and Health Minimum Standards for Benefits

Current through Register Vol. 48, No. 28, July 12, 2024
a) The following minimum standards for
			 benefits are prescribed for the categories of coverage noted in subsection (b).
			 No individual policy of accident and health insurance shall be delivered or
			 issued for delivery in this State that does not meet the required minimum
			 standards for the specified categories, except that, if the Director finds that
			 the policies are Limited Benefit Health Insurance, the Outline of Coverage
			 shall comply with Section
			 2007.80(c).
b) Nothing in this Section shall preclude the
			 issuance of any policy combining two or more categories of coverage as set
			 forth in Section 355a(4) of the Illinois Insurance Code [215 ILCS
			 5/355a(4) ].
1) General Rules
A) With respect to excepted benefit policies
			 and grandfathered health plans, a "noncancellable", "guaranteed renewable", or
			 "noncancellable 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
			 nonpayment 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.
B) With respect
			 to excepted benefit policies and grandfathered health plans, the terms
			 "noncancellable", "guaranteed renewable", or "noncancellable and guaranteed
			 renewable" shall not be used without further explanatory language in accordance
			 with the disclosure requirements of Section
			 2007.80(a)(1).
			 The terms "noncancellable" or "noncancellable and guaranteed renewable" shall
			 be defined as in 50 Ill. Adm. Code 2003.
C) With respect to excepted benefit policies
			 and grandfathered health plans, in a family policy covering both husband and
			 wife, the age of the younger spouse shall be used as the basis for meeting the
			 age and durational requirements of the definitions of "noncancellable" 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 by the younger spouse
			 to the age or for the durational period as specified in the
			 definition.
D) With respect to
			 excepted benefit policies and grandfathered health plans, if a policy contains
			 a status-type military service exclusion of a provision that suspends coverage
			 during military service, the policy shall provide, upon receipt of written
			 request, for refund of premiums as applicable to that person on a pro rata
			 basis.
E) Policies providing normal
			 pregnancy benefits shall provide that, in the event the insurer cancels or
			 refuses to renew the policy, there shall be an extension of benefits for
			 pregnancy commencing while the policy is in force and at the same level for
			 which benefits would have been payable had the policy remained in
			 force.
F) Policies providing
			 convalescent or extended care benefits following hospitalization shall not
			 condition those benefits upon admission to the convalescent or extended care
			 facility within a period of less than 14 days after discharge from the
			 hospital.
G) With respect to
			 excepted benefit policies and grandfathered health plans, any medical, surgical
			 or other expense benefit for the recipient insured in a transplant operation
			 may specify the limits for the specific benefit relating to donors, or shall
			 provide reimbursement of the expense of the live donor to the extent that the
			 benefits remain and are available under the recipient's policy, after benefits
			 for the recipient's own expenses have been paid.
H) Preexisting condition exclusions are only
			 allowed with respect to excepted benefits and grandfathered health plans. Any
			 such preexisting condition exclusion shall be administered in accordance with
			 50 Ill. Adm. Code 2005. When a definition of preexisting conditions is required
			 by 50 Ill. Adm. Code
			 2005.50,
			 for purposes of readability, it may be summarized in the appropriate policy
			 provision by a definition reading substantially as follows:
"A preexisting illness (condition) means any condition that was
				diagnosed or treated by a physician within 24 months prior to the effective
				date of the coverage, or produced symptoms within 12 months prior to the
				effective date of coverage that would have caused an ordinarily prudent person
				to seek medical diagnosis or treatment."
I) 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. Disability income benefits, if
			 provided, shall not require the loss to commence less than 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 the disability commences if the
			 accident occurred while the policy was in force.
J) Specific dismemberment benefits shall not
			 be in lieu of other benefits unless the specific dismemberment benefit equals
			 or exceeds the other benefits.
K)
			 Any accident only policy providing benefits that vary according to the type of
			 accidental cause shall prominently set forth in the outline of coverage the
			 circumstances under which benefits payable are less than the maximum amount
			 payable under the policy.
L) With
			 respect to excepted benefit policies and grandfathered health plans, nonrenewal
			 of the policy shall be without prejudice to any continuous loss that commenced
			 while the accident and sickness 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 covered person limited to a period of one
			 year for health care benefits, limited to the duration of the policy benefit
			 period (if any), and/or limited to the payment of the maximum benefits. The
			 extension of benefits requirement does not apply to single premium nonrenewal
			 policies.
M) "Total Disability" or
			 "Totally Disabled", for the purposes of this Section, means the complete
			 incapacity of the covered person as the result of an injury or sickness:
i) to engage in any occupation for pay or
			 profit, or if not employed, to engage in the normal activities of a person of
			 the same age; and
ii) that requires
			 the regular care of a physician other than a covered person.
N) Extension and limitation of
			 coverage means if a covered person is totally disabled on his/her coverage
			 termination date the coverage provided for that covered person by the policy
			 and any attached riders will be extended. During the extended coverage the
			 applicable policy and rider provisions, exclusions, exceptions and limitations
			 will be the same as would have applied had coverage not terminated for the
			 covered person. This extension is limited to confinement and/or expenses
			 incurred:
i) for the injury or sickness that
			 caused the total disability;
ii)
			 during the uninterrupted continuance of the total disability; and
iii) during the 12 months following the
			 covered person's coverage termination date.
O) All policies issued, whether or not the
			 policy contains the refund provision, shall be administered to provide a refund
			 of any unearned premiums upon death of any insured member from date of death if
			 the company receives a written request for unearned premium from the policy
			 owner or the person entitled to the unearned premium.