Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 36 - Accident and Health Insurance › Rule 191-36.6 - Accident and Sickness Minimum Standards for Benefits

Current through Register Vol. 47, No. 3, July 24, 2024
The following minimum standards for benefits are prescribed
				  for the categories of coverage noted in the following subrules. No individual
				  policy of accident and sickness insurance or nonprofit hospital, medical or
				  dental service corporation contract shall be delivered or issued for delivery
				  in this state which 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 and the outline of
				  coverage complies with the appropriate outline in 36.7(12).
Nothing in this rule shall preclude the issuance of any
				  policy or contract combining two or more categories of coverage set forth in
				  this chapter.
Nonprofit hospital and medical service associations are
				  subject to this chapter. When such associations are prohibited from issuing
				  subscriber contracts which include all of the benefits required in 36.6(2) or
				  36.6(5), they shall include so much of those benefits as are permitted and they
				  shall be issued in conjunction with another contract including at least the
				  remainder of the minimum benefit required. In such event, the combination of
				  contracts will be considered to have been issued in compliance with this
				  chapter.
(1)
General
				rules.
a. A "noncancelable,"
				"guaranteed renewable," or "noncancelable 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. The terms "noncancelable," "guaranteed
				renewable," or "noncancelable and guaranteed renewable" shall not be used
				without further explanatory language in accordance with the disclosure
				requirements of 36.7(1)
"a. "
The terms "noncancelable" or
				"noncancelable and guaranteed renewable" may be used only in a policy which the
				insured has the right to continue in force by the timely payment of premiums
				set forth in the policy until the age of 65 or to eligibility for Medicare,
				during which period the insurer has no right to make unilaterally any change in
				any provision of the policy while the policy is in force: Provided, however,
				any accident and health or accident only policy which 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 60 if, at age 60 the insured has
				the right to continue the policy in force at least to age 65 while actively or
				regularly employed. Except as provided above, the term "guaranteed renewable"
				may be used only in a policy which the insured has the right to continue in
				force by the timely payment of premiums until the age of 65 or to eligibility
				for Medicare, during which period the insurer has no right to make unilaterally
				any change in any provision of the policy while the policy is in force, except
				that the insurer may make changes in premium rates by classes: Provided,
				however, any accident and health or accident only policy which 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 60 if, at age 60,
				the insured has the right to continue the policy in force at least to age 65
				while actively and regularly employed.
c. In a family policy covering both husband
				and wife, the age of the younger spouse must be used as the basis for meeting
				the age and durational requirements of the definitions of "noncancelable" 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 as to the younger
				spouse, to the age or for the durational period as specified in said
				definition.
d. When accidental
				death and dismemberment coverage is part of the insurance coverage offered
				under the contract, the insured shall have the option to include all insureds
				under the coverage and not just the principal insured.
e. If a policy contains a status type
				military service exclusion or a provision which suspends coverage during
				military service, the policy shall provide, upon receipt of written request,
				for refund of premiums as applicable to the person on a pro-rata
				basis.
f. In the event the insurer
				cancels or refuses to renew, policies providing pregnancy benefits shall
				provide for an extension of benefits as to pregnancy commencing while the
				policy is in force and for which benefits would have been payable had the
				policy remained in force.
g.
				Policies providing skilled, or convalescent, or extended care benefits
				following hospitalization shall not condition the benefits upon admission to
				the nursing facility within a period of less than 14 days after discharge from
				the hospital.
h. Family coverage
				shall continue for any dependent child who is incapable of self-sustaining
				employment due to mental retardation or physical handicap on the date that the
				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 31
				days of the 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 the child,
				or that a separate converted policy be issued at the option of the insured or
				policyholder.
i. 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.
j. A policy may contain a provision relating
				to recurrent disabilities; provided, however, that no provision shall specify
				that a recurrent disability be separated by a period greater than six
				months.
k. 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 which 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.
l. Specific dismemberment benefits shall not
				be in lieu of other benefits unless the specific benefit equals or exceeds the
				other benefits.
m. Any accident
				only policy providing benefits which vary according to the type of accidental
				cause shall prominently set forth in the outline of coverage the circumstances
				under which benefits are payable which are lesser than the maximum amount
				payable under the policy.
n.
				Termination of the policy shall be without prejudice to coverage for any
				continuous loss which 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, or payment of the maximum
				benefits.
o. Rescinded IAB
				11/27/91, effective 1/1/92.