Connecticut Administrative Code › Title 38a - Insurance Department › 505 - Individual Accident and Sickness Insurance Minimum Standards › Section 38a-505-13 - Specified disease policies

Current through July 10, 2024
(a) A "specified
			 disease policy" means an individual health insurance policy delivered or issued
			 for delivery in this state which pays benefits for the diagnosis or treatment
			 of one or more specifically named diseases, conditions or syndromes in
			 accordance with section
			 38a-505-13(c)
			 of the Regulations of Connecticut State Agencies. As used in this section,
			 "condition" includes specifically named diseases, conditions or syndromes
			 unless the context otherwise requires. Any specified disease policy shall meet
			 the general requirements in subsection (b) of this section and the minimum
			 benefit standards pursuant to subsection (c) of this section.
(b)
General Requirements
:
The following requirements shall apply to specified disease
				policies in addition to all other requirements applicable to individual
				accident and sickness policies.
(1)
			 Policies covering a single specified condition or combination of specified
			 conditions may not be sold or offered for sale other than as specified disease
			 policies.
(2) Any policy issued
			 pursuant to this section which conditions payment upon pathological diagnosis
			 of a covered condition, shall also provide that if such a pathological
			 diagnosis is medically inappropriate, a clinical diagnosis shall be accepted in
			 lieu thereof.
(3) Notwithstanding
			 any other provision of this section, specified disease policies described in
			 Section
			 38a-505-13(c)(1)
			 and Section
			 38a-505-13(c)(2)
			 of the Regulations of Connecticut State Agencies shall provide benefits to any
			 covered person not only for a specified condition but also for any other
			 condition directly caused or aggravated by the specified condition or its
			 treatment.
(4) Specified disease
			 policies shall be at least guaranteed renewable.
(5) No policy issued pursuant to this section
			 shall contain a waiting or probationary period greater than thirty (30) days.
			 Premiums paid shall be refunded if the insured is diagnosed with a covered
			 condition during the waiting or probationary period.
(6) Payment of benefits may be conditioned
			 upon a covered person receiving medically necessary care or
			 treatment.
(7) Any application for
			 a specified disease policy shall contain a prominent statement above the
			 signature of the applicant that a person who is already covered by Medicaid
			 should not purchase this coverage. Such statement shall be in bold face type or
			 contrasting color.
(8) The benefits
			 of a specified disease policy shall be paid regardless of other
			 coverage.
(9) Benefit payments
			 under specified disease policies described in Section
			 38a-505-13(c)(1)
			 and Section
			 38a-505-13(c)(2)
			 of the Regulations of Connecticut State Agencies shall begin with the first day
			 of care or confinement after the effective date of the policy if such care or
			 confinement is for a covered condition even though the diagnosis of a covered
			 condition is made at some later date (but not retroactive more than ninety (90)
			 days from the date of diagnosis) if the initial care or confinement was for
			 diagnosis or treatment of such covered condition.
(10) Specified disease policies shall provide
			 a thirty (30) day free look. Notice of the thirty (30) day free look shall
			 appear on the face page of the policy in bold face equal to at least fourteen
			 (14) point type.
(11) Specified
			 disease policies shall contain a prominent statement on the first page of the
			 policy in bold face type at least equal to fourteen (14) point type as follows:
			 "CAUTION" This policy provides limited coverage. It is not a major medical
			 policy. Read it carefully. It only pays benefits for treatment (or diagnosis)
			 of (specified disease).
(12) The
			 premiums for a policy shall be reasonable in relation to benefits and shall not
			 be excessive or inadequate. The insurer shall establish premiums for specified
			 disease policies in accordance with generally accepted actuarial principles and
			 practices so as to return to policyholders in the form of aggregate benefits
			 provided under the policy during the period for which rates are computed at
			 least sixty-five per cent (65%) of the aggregate premiums earned. The insurer
			 may also charge an annual policy fee of up to thirty dollars ($30.00), which
			 fee shall be excluded from premium for the purposes of the sixty-five per cent
			 (65%) calculation. Each insurer shall annually report by June 30 earned
			 premiums and incurred claims for the prior calendar year for each approved
			 specified disease policy form in a format acceptable to the insurance
			 commissioner.
(13) "Preexisting
			 condition" shall not be defined to be more restrictive than the following:
			 Preexisting condition means a condition for which medical advice or treatment
			 was recommended by a physician or received from a physician within a twelve
			 (12) month period preceding the effective date of the coverage of the insured
			 person. No policy shall exclude for a loss due to a preexisting condition for a
			 period greater than twelve (12) months following policy issue.