New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter A - Life, Accident and Health Insurance › Part 49 - Fraternal Benefit Societies › Section 49.1 - Accident and health certificates

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Every authorized fraternal benefit
				  society doing business in New York and which obligates itself for the payment
				  of accident and health benefits is required to issue a certificate of insurance
				  covering such benefits to each member who becomes insured.
(b) The forms of accident and health
				  insurance certificates issued or issued for delivery in this State by any
				  fraternal benefit society providing benefits described in subsections (i), (j),
				  (k), (o), (p) or (q) of section 4501  of
				  the Insurance Law shall conform in substance to the provisions of subsections
				  (b), (c), (d) and (f) of section 3216 of said law, except as follows:
(1) Wherever required the word "certificate"
				  or any appropriate designation may be substituted for "policy," the words
				  "insured member" or any other appropriate designation may be substituted for
				  "insured" and the word "assessment" or any other language appropriately
				  indicating required payments by insured members may be substituted for
				  "premium."
(2) It shall be a
				  sufficient compliance with section 3216(c)(1) if the certificate indicates the
				  amount of premium payable by the insured member provided that it contains the
				  statement required by subsection (g) of section 4504  of the Insurance Law and that it is
				  also recited that such insured member shall be obligated to pay any additional
				  amounts required pursuant to the constitution and bylaws of such society then
				  in force or thereafter lawfully enacted, except that in the case of hospital,
				  medical or surgical expense benefits or any combination thereof, any statement
				  as to additional rates or assessments shall also conform to the requirements of
				  section 4512  of the Insurance Law.
(3) Section 3216 (c)(9)  of the
				  Insurance Law shall be inapplicable.
(4)
(i)
				  Section 3216 (c)(3)  of the
				  Insurance Law shall be inapplicable:
(ii) The persons coverable under a family
				  certificate providing accidental death benefits issued pursuant to subsection
				  (i) of section 4501  of
				  the Insurance Law shall conform to those described in subsection (b) of section 4505  of the Insurance Law.
(iii) Paragraphs (4) and (5) of section
				  3216(c) shall be applicable to certificates issued pursuant to section 4505 (b)  of the Insurance
				  Law, provided that such person who is no longer within the definition of the
				  family is otherwise eligible to become and does become an insurance member of
				  the society.
(5) The
				  following words:
"This certificate, together with any riders or endorsements
					 attached hereto, the articles of incorporation, constitution and bylaws of the
					 society, and the application and declaration of insurability, if any, attached
					 hereto, shall constitute the entire contract of insurance, as of the date of
					 issuance, between the society and the insured member, except as it may be
					 lawfully modified by any changes, additions or amendments to said articles of
					 incorporation, constitution or bylaws duly made or enacted subsequent to the
					 issuance of this certificate and except that no change, addition or amendment
					 shall destroy or diminish benefits which the society contracted to give the
					 members as of the date of issuance."
shall be substituted for provision (1)(A) of subsection (d)
					 of section 3216:
"This policy including the endorsements and the attached
					 papers, if any, constitutes the entire contract of insurance." (as specified in
					 provision [1] [A] of subsection [d]).
(6) Provision (1)(B) of subsection (d) of
				  section 3216 shall be omitted in all certificates which are governed by section 4512  of the Insurance Law.
(7) An appropriate rephrasing of provision
				  (1)(l) of subsection (d) of section 3216 in accordance with the constitution
				  and bylaws of the society within the limits provided in section 4508  of
				  the Insurance Law, shall be permitted.
(8) In all certificates using a provision as
				  specified in section 3216(d)(2)(A), wherever a society requires a uniform
				  payment from all insured members regardless of classification of occupation,
				  and prorates benefits in event of change of occupation upon a basis of a
				  percentage of the benefits payable, appropriate rephrasing of such provision
				  will be permitted.