New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 53 - MINIMUM STANDARDS FOR SPECIFIED DISEASE AND CRITICAL ILLNESS COVERAGES › Section 11:4-53.3 - General standards

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No carrier shall deliver or issue for delivery in this State any specified disease or critical illness policy unless its policy form, and its rates where required by 17B:26-1, have been approved by the Commissioner pursuant to the procedures set forth at N.J.A.C. 11:4-40.
(b) The following approval standards shall apply to all specified disease and critical illness policies delivered or issued for delivery in this State:
1. No policy shall be sold or offered for sale other than as specified disease or critical illness coverage pursuant to this subchapter.
2. Any policy that conditions payment upon pathological diagnosis of a covered disease shall also provide that if the pathological diagnosis is medically inappropriate or life threatening, a clinical diagnosis will be accepted instead.
3. An individual policy containing specified disease coverage shall be guaranteed renewable for life.
4. Except as permitted by 17B:26-19 regarding other insurance with this carrier, benefits shall be paid regardless of other coverage.
5. Except in the case of direct response carriers, no policy shall be delivered or issued for delivery in this State unless the outline of coverage form set forth as Exhibit A in the Appendix to this subchapter, incorporated herein by reference, describing the policy's benefits, limitations and exclusions, and anticipated loss ratio, is delivered to the applicant at the time application is made, and written acknowledgment of receipt or certification of delivery of such outline of coverage is provided to the carrier. Direct response carriers shall deliver the requisite outline of coverage no later than at the time the policy is issued or delivered.
6. The only permissible preexisting condition limitations are those that exclude coverage for no more than six months after the effective date of coverage under the policy, for a condition for which medical advice was given or treatment was recommended by, or received from, a licensed health care provider within the six-month period immediately preceding the effective date of coverage.
7. If a policy contains any limitations with respect to preexisting conditions, such limitations shall appear as a separate paragraph in the policy and shall be labeled as "Preexisting Condition Limitations."
8. The first page of every policy shall contain, in at least 14 point type but not less than the size of type used for policy captions, and in capital letters, a prominent statement, as follows: "THIS IS A LIMITED POLICY (OR CERTIFICATE). IT PAYS BENEFITS FOR (NAME OF SPECIFIED DISEASES) ONLY AND DOES NOT PROVIDE COVERAGE FOR ANY OTHER MEDICAL CONDITIONS. YOU SHOULD MAINTAIN SEPARATE COMPREHENSIVE HEALTH COVERAGE. READ THIS POLICY CAREFULLY WITH THE OUTLINE OF COVERAGE."
9. Application forms shall include a question to determine whether the applicant has other coverage providing benefits for hospital and medical services and supplies. If the applicant does not respond affirmatively to such question, the policy shall not be issued.
10. Every policy shall be issued only to persons who are covered by insurance that provides benefits for hospital and medical services and supplies.
11. No policy shall provide for a reduction of benefits upon attainment of any age or other condition, or upon the occurrence of any event(s).
12. No policy shall provide for a probationary or waiting period during which no coverage is provided under the policy.
13. Every policy shall have a notice prominently printed on the first page or attached thereto stating in substance that the insured shall have the right to return the policy within 30 days of its delivery and to have the premium or subscription charge or fees refunded if, after examination of the policy, the insured is not satisfied for any reason.