Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 36 - Accident and Health Insurance › Rule 191-36.7 - Required Disclosure Provisions

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
General rules.
a. Each individual policy of accident and
				sickness insurance or hospital, medical, or dental service corporation
				subscriber contract shall include a renewal, continuation, or nonrenewal
				provision. The language or specifications of the provision must be consistent
				with the type of contract to be issued. This provision shall be appropriately
				captioned, shall appear on the first page of the policy, and shall clearly
				state the duration, where limited, of renewability and the duration of the term
				of coverage for which the policy is issued and for which it may be
				renewed.
b. Except for riders or
				endorsements by which the insurer effectuates a request made in writing by the
				policyholder or exercises a specifically reserved right under the policy, all
				riders or endorsements added to a policy after date of issue or at
				reinstatement or renewal which reduce or eliminate benefits or coverage in the
				policy shall require signed acceptance by the policyholder. After date of
				policy issue, any rider or endorsement which increases benefits or coverage
				with a concomitant increase in premium during the policy term must be agreed to
				in writing signed by the insured, except if the increased benefits or coverage
				is required by law.
c. Where a
				separate additional premium is charged for benefits provided in connection with
				riders or endorsements, the premium charge shall be set forth in the
				policy.
d. A policy which provides
				for the payment of benefits based on standards described as "usual and
				customary," "reasonable and customary," or words of similar import shall
				include a definition and explanation of the terms "usual and customary" or
				"reasonable and customary" in its accompanying outline of coverage.
e. If a policy contains any limitations with
				respect to preexisting conditions the limitations must appear as a separate
				paragraph of the policy and be labeled as "Preexisting Condition
				Limitations."
f. All accident only
				policies shall contain a prominent statement on the first page of the policy or
				attached to it, in either contrasting color or in boldface type at least equal
				to the size of type used for policy captions, as follows:
"This is an accident only policy and it does not pay benefits
				  for loss from sickness."
g.
				All policies, except single premium nonrenewable policies and as otherwise
				provided in this paragraph, shall have a notice prominently printed on the
				first page of the policy or attached to it stating in substance that the
				policyholder shall have the right to return the policy within ten days of its
				delivery and to have the premium refunded if, after examination of the policy,
				the policyholder is not satisfied for any reason.
h. If age is to be used as a determining
				factor for reducing the maximum aggregate benefits made available in the policy
				as originally issued, such fact must be prominently set forth in the outline of
				coverage.
i. If a policy contains a
				conversion privilege, it shall comply, in substance, with the following: The
				caption of the provision shall be "Conversion Privilege," or words of similar
				import. The provision shall indicate the persons eligible for conversion, the
				circumstances applicable to the conversion privilege, including any limitations
				on the conversion, and the person by whom the conversion privilege may be
				exercised. The provision shall specify the benefits to be provided on
				conversion or may state that the converted coverage will be as provided on a
				policy form then being used by the insurer for that purpose.
j. Insurers issuing policies which provide
				hospital or medical expense coverage on an expense-incurred or indemnity basis
				other than incidentally, to a person(s) eligible for Medicare by reason of age,
				shall provide to the policyholder a Medicare supplement buyer's guide in the
				form of the booklet "Choosing a Medigap Policy: A Guide to Health Insurance for
				People with Medicare" developed jointly by the National Association of
				Insurance Commissioners and the Centers for Medicare and Medicaid Services of
				the U.S. Department of Health and Human Services. Delivery of the buyer's guide
				shall be made whether or not the policy qualifies as a "Medicare supplement
				coverage" in accordance with 191-Chapter 37. Except in the case of direct
				response insurers, delivery of the buyer's guide shall be made at the time of
				application and acknowledgment of receipt of certification of delivery of the
				buyer's guide shall be provided to the insurer. Direct response insurers shall
				deliver the buyer's guide upon request but not later than at the time the
				policy is delivered.
k. Outlines of
				coverage delivered in connection with policies defined in this chapter as
				Hospital Confinement Indemnity, Specified Disease or Limited Benefit Health
				Insurance Coverages to persons eligible for Medicare by reason of age shall
				contain, in addition to the requirements of 36.7(6), 36.7(10) and 36.7(12), the
				following language which shall be printed on or attached to the first page of
				the outline of coverage:
This policy IS NOT A MEDICARE SUPPLEMENT policy. If you are
				  eligible for Medicare review the Choosing a Medigap Policy: Guide to Health
				  Insurance for People with Medicare, issued by the Centers for Medicare and
				  Medicaid Services, available from the company.
l. If payment will not be made for services
				performed by a chiropractor acting within the scope of the chiropractor's
				license when those services would be compensable if performed by a medical
				doctor, then a statement that services performed by a chiropractor are not
				compensable shall be included in all outlines of coverage delivered in
				accordance with this chapter.
m.
				Disclosure requirements. All insurers shall include in contracts and evidence
				of coverage forms a statement disclosing the existence of any prescription drug
				formularies. Upon request, all insurers offering policies under this chapter
				that include a prescription drug formulary shall inform policyholders, and
				prospective policyholders at time of issuance, whether a prescription drug
				specified in the request is included in such formulary.
All insurers shall also disclose the existence of any
				  contractual arrangements providing rebates received by them for prescription
				  drugs or durable medical equipment. Durable medical equipment means equipment
				  that can stand repeated use and is primarily and customarily used to serve a
				  medical purpose and is generally not useful to a person who is not sick or
				  injured or used by other family members and is appropriate for home use for the
				  purpose of improving bodily functions or preventing further deterioration of
				  the medical condition caused by sickness or injury.