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New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 40 - LIFE/HEALTH/ANNUITY FORMS › Section 11:4-40.8 - Certificate of assumption form approval procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In addition to those items set forth at 11:4-40.5, insurers seeking approval of certificates of assumption shall include, if applicable, the following items in the submission to the Department:
1. A clear indication whether the assuming and ceding insurers are authorized in this State for the lines of business being assumed;
2. A general description of the type of business being assumed;
3. A list of the forms and filing dates with which the certificate will be used, together with a copy of the Department's filing letters applicable to these forms;
4. For forms intended for use with group business, the provisions of the form must be consistent with both the group contract and certificate form;
5. Evidence of approval of both the transaction and the forms, if required, by the state of domicile of the assuming and ceding insurers;
6. All communications between either the assuming or ceding insurer with the policyholders, including letters, memoranda, identification cards, advertisements or other material;
7. Affirmative consent of the owner is not required, but if obtained, the consent form shall be part of the submission. The certificate of assumption form shall not include a provision indicating that consent of the policyholder is deemed or implied as the result of some positive or negative action;
8. A certification by the assuming insurer that it will adhere to all conditions and representations which were part of the original filing of the forms being assumed;
9. Certifications by the assuming and ceding insurers that any communications by a policyholder with the ceding insurer will have the same legal status as a communication which is sent directly to the assuming insurer. Additionally, the ceding insurer shall certify that it will maintain systems to forward all communications of this nature to the assuming insurer;
10. The certificate of assumption form shall include the following:
i. An appropriate title, such as Certificate of Assumption;
ii. The business address of both the ceding and assuming insurers;
iii. Clear directions regarding the submission of payments and claims; and
iv. The signature of an officer of the insurer, and a statement that the form is to be attached to and made part of the policy; and
11. If health insurance or credit insurance is being assumed, the assuming insurer shall agree that rate revisions will be based on the experience since the original issue date. It is the responsibility of the assuming insurer to obtain and maintain the necessary experience data.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 40 - LIFE/HEALTH/ANNUITY FORMS › Section 11:4-40.9 - File and use eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An insurer may deliver or issue for delivery in this State a form providing life, health or annuity benefits, and accompanying rates if applicable, without obtaining prior approval from the Commissioner pursuant to this subchapter provided the form is set forth in this section as a type eligible for file and use and is filed with the Commissioner pursuant to the procedures set forth at 11:4-40.1 0, or the form is specifically exempt from compliance with this subchapter.
(b) The following types of non-variable individual life insurance forms shall be eligible for file and use pursuant to this section:
1. Scheduled premium term policies without cash values, other than universal/flexible-factor forms, multiple-life forms with survivorship benefits, limited death benefit forms, policies with re-entry options, single premium forms, field issued forms or funeral insurance;
2. Accidental death benefit;
3. Business exchange/substitute insured;
4. Cost of living benefit;
5. Option to purchase additional insurance;
6. Waiver of premium;
7. Spouse and/or child rider; and
8. Applications.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 40 - LIFE/HEALTH/ANNUITY FORMS › Section 11:4-40.10 - File and use procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An insurer seeking to file and use a form specified at 11:4-40.9 to be eligible for file and use shall, in addition to the items set forth at 11:4-40.5(b), submit the following to the Department:
1. A certification memorandum signed and acknowledged by a responsible officer of the insurer, which shall include the following:
i. A statement that the certification is filed pursuant to P.L. 1995, c.73, section 17;
ii. A statement that the responsible officer signing the certification memorandum is authorized to execute the document;
iii. A statement that the responsible officer signing the certification memorandum is familiar with the insurer's filing and all laws, regulations, bulletins and published guidelines applicable to the particular type of form, and that the form complies with all laws, regulations, bulletins and published guidelines applicable to the particular type of form;
iv. A statement that the insurer intends for the Department to rely on the certification in accepting the filing made pursuant to this subsection;
v. A statement that the responsible officer signing the certification memorandum is aware of the penalties for submitting an improper certification or false filing;
vi. A statement that the responsible officer signing the certification memorandum has supervised and is responsible for the completion and submission to the Department of the checklist required for the particular type of form; and
vii. A statement that the insurer shall not use the form before receipt of the form is acknowledged by the Department.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 40 - LIFE/HEALTH/ANNUITY FORMS › Section 11:4-40.11 - Service fees

Current through Register Vol. 56, No. 14, July 15, 2024
A form submitted by an insurer to the Commissioner for either prior approval or file and use pursuant to this subchapter shall be accompanied by the service fee(s) set forth at N.J.A.C. 11:1-32 unless the insurer is exempt from the payment of such fees pursuant to section 13 of P.L. 1995, c.156, enacted on June 30, 1995.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 40A - '40 STATES' FILE AND USE STANDARDS AND PROCEDURES › Section 11:4-40A.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to implement P.L. 2001, c. 237 (17B:25-18.4 ), which establishes a special procedure whereby insurers may forego prior approval of certain life insurance, annuity and variable contract forms.
(b) This subchapter shall apply to all individual life insurance, individual annuity, group annuity, group life, variable life and variable annuity contract forms to be issued by an insurer authorized to do business in this State. This subchapter shall not apply to any health insurance policy, or contract forms or benefits, including specified disease or critical illness policies, contracts or benefits. This subchapter shall not apply to individual and group annuity or life insurance forms approved by the Interstate Insurance Product Regulation Commission created pursuant to the Interstate Insurance Product Regulation Compact established by P.L. 2010, c. 120.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 40A - '40 STATES' FILE AND USE STANDARDS AND PROCEDURES › Section 11:4-40A.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, as used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise:
"Annuity" means all contracts meeting the definition set forth at 17B:17-5.
"Available for sale or use" means that the insurer has complied with the state's laws, regulations, and procedures to allow the insurer to sell or use the form in that state.
"Commissioner" means the Commissioner of the Department of Banking and Insurance.
"Department" means the Department of Banking and Insurance.
"Form," "contract form" and "policy form" mean all annuity contract forms; all life insurance policy and contract forms; all variable contract forms; and all group insurance certificates as defined within this subchapter, including endorsements, riders and application forms.
"Health insurance" means all policies, contracts and benefits meeting the definition set forth at 17B:17-4, including specified disease and critical illness policies, contracts and benefits as defined at N.J.A.C. 11:4-53.
"Improper certification" means providing any misrepresentation or false statement material to a certification form.
"Life insurance" means all policies and contracts meeting the definition set forth at 17B:17-3.
"Responsible officer of the insurer" means a corporate officer of the level of vice president or higher, or of equivalent title within the insurer's structure, who is either the actuary of the insurer with responsibility for the type of form filed, or the individual with responsibility for managing the form filing process for the insurer with regard to the type of form filed.
"Unique product features or design" means that the contract language that expresses the methodology used to calculate values, benefits and rates is materially the same. Nonmaterial differences include unique requirements mandated by a state's law (for example, mandated use of a unisex mortality table); synonyms used (for example, "period" instead of "term," "face amount" instead of "insurance amount"); and quantitative differences of no more than 10 percent (for example, one policy contains a $ 50.00 charge, while another contains a $ 55.00 charge). Standard contract provisions are not considered part of the unique product feature or design.
"Variable contracts" means all contracts meeting the definition set forth at 17B:28-1 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 40A - '40 STATES' FILE AND USE STANDARDS AND PROCEDURES › Section 11:4-40A.3 - Eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Forms submitted to the Commissioner on the basis that they have been made available for sale or use in 40 states, subject to state variations that do not alter the unique features or design of the product, shall be eligible for sale or use pursuant to the requirements of this subchapter. Notwithstanding eligibility, any such form shall comply with New Jersey law regarding standard contract provisions as identified below.
1. Individual Life:
i. Free Look as set forth in 17B:25-2.1;
ii. Grace Period as set forth in 17B:25-3;
iii. Incontestability as set forth in 17B:25-4, 16 and 17;
iv. Entire Contract as set forth in 17B:25-5;
v. Misstatement of Age as set forth in 17B:25-6;
vi. Dividends as set forth in 17B:25-7;
vii. Policy Loan as set forth in 17B:25-8;
viii. Reinstatement as set forth in 17B:25-9;
ix. Payment of Premium as set forth in 17B:25-10;
x. Automatic Premium Loan Notice as set forth in 17B:25-10.1;
xi. Payment of Claims as set forth in 17B:25-11;
xii. Beneficiary as set forth in 17B:25-12;
xiii. Nonforfeiture Benefits as set forth in 17B:25-19(a) and (l);
xiv. Title as set forth in 17B:25-14; and
xv. Period in Which to Commence Cause of Action as set forth in 17B:25-15;
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 40A - '40 STATES' FILE AND USE STANDARDS AND PROCEDURES › Section 11:4-40A.4 - Filing procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Filings pursuant to 11:4-40A.3(a)  shall include the following:
1. For each form submitted, a separate certification memorandum, signed by a responsible officer of the insurer, which shall include: a statement that the form has been made available for sale or use in 40 states, subject to state variations that do not alter the unique features or design of the product; the form number of the form to which it applies; and a notary signature to be shown outside of the seal.
i. The certification shall be acknowledged by a responsible officer of the insurer. The acknowledgement process shall be the same as that which applies to documents for recording instruments conveying or affecting interests in real estate in this State pursuant to 46:14-2.1 et seq;
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 40A - '40 STATES' FILE AND USE STANDARDS AND PROCEDURES › Section 11:4-40A.5 - Penalties

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If the Commissioner determines that a certification submitted to the Department by an insurer pursuant to this subchapter is an improper certification, the insurer shall be subject to the following penalties specifically determined by the Commissioner in consideration of the severity of the violation based on the potential adverse impact to the public and whether it is the insurer's first such violation:
1. A fine not to exceed $ 50,000; and
2. A maximum penalty of $ 1,000 per policy issued on a form determined to be improperly certified pursuant to this subchapter.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 40A - '40 STATES' FILE AND USE STANDARDS AND PROCEDURES › Section 11:4-40A.6 - Effect on previously acknowledged forms

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any form and certification submitted pursuant to P.L. 2001, c. 237 prior to April 7, 2003, which was acknowledged by the Commissioner but does not meet the requirements of this subchapter, shall be deemed withdrawn July 6, 2003, and the form may not be available for sale or use after that date. Forms deemed withdrawn may be resubmitted pursuant to P.L. 2001, c. 237, but shall include a new form number.
(b) With respect to forms and certifications submitted pursuant to P.L. 2001, c. 237 prior to April 7, 2003, which were acknowledged by the Commissioner and which do meet the requirements of this subchapter, the insurer shall submit a new certification memorandum pursuant to 11:4-40A.4(a)1  by October 4, 2003. The insurer may continue to make the previously acknowledged form available for sale or use during this period. Any condition specified in the Department's prior letter of acknowledgement which is inconsistent with this subchapter is invalidated and of no force or effect.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 41 - STANDARDS FOR INDIVIDUAL LIFE INSURANCE POLICY FORMS › Section 11:4-41.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of these rules is to implement P.L. 1995, c.73 (the Life and Health Insurance and Health Maintenance Organization Form Approval Reform Act) by setting forth the Department's standards for approval of all individual life insurance forms delivered or issued for delivery in this State.
(b) These rules shall apply to all individual life insurance forms issued pursuant to 17B:25-1 et seq. This subchapter shall not apply to individual life insurance forms approved by the Interstate Insurance Product Regulation Commission created pursuant to the Interstate Insurance Product Regulation Compact established by P.L. 2010, c. 120.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 41 - STANDARDS FOR INDIVIDUAL LIFE INSURANCE POLICY FORMS › Section 11:4-41.3 - General standards

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No individual life insurance policy, rider, application or endorsement shall contain provisions which are unjust, unfair, inequitable, misleading, contrary to law or to the public policy of this State.
(b) The following approval standards shall apply to all individual life insurance forms:
1. All forms shall include a provision for a period of time during which the policy may be reviewed and subsequently cancelled by the policyholder free of charge or penalty.
i. This period of free review shall be no less than 10 days, and shall not exceed one year from the date the policy was received by the policyholder.
ii. Policies which provide for a cash value which is equal to the return of all gross premiums paid shall be considered to contain an extended free review period or additional review period. The provision which allows for such a defined cash value is subject to the time limits of (b)1i above.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 41 - STANDARDS FOR INDIVIDUAL LIFE INSURANCE POLICY FORMS › Section 11:4-41.6 - Indexed benefits

Current through Register Vol. 56, No. 14, July 15, 2024
Any form which describes death benefits or credited interest in terms of a published index shall state how death benefits and interest shall be determined upon the discontinuance of the index, and that any substitute index is subject to Department approval.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 41 - STANDARDS FOR INDIVIDUAL LIFE INSURANCE POLICY FORMS › Section 11:4-41.7 - Standards for pre-existing conditions exclusions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pre-existing condition exclusions shall only be permitted in the case of benefits for disability, as follows:
1. The insurer shall not be liable for a disability resulting from any pre-existing condition which is disclosed in the application and excluded by rider.
2. The insurer shall be liable from the effective date of the policy for a disability resulting from any pre-existing condition which is in an application and not excluded by rider.
3. The insurer shall not be liable for any pre-existing condition which is not disclosed in the application because the application did not include such a question and because of which the insured becomes disabled during the first two years of the effective date of the policy. The insurer shall be liable if the insured recovers from such disability and becomes disabled again from the same pre-existing condition after two years from the effective date of the policy.
4. The insurer shall be liable for any pre-existing condition which is not disclosed in the application because the application did not include such a question and because of which the insured becomes disabled two or more years after the effective date of the policy.
5. The insurer may contest a material misrepresentation made by the insured in the application.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 41 - STANDARDS FOR INDIVIDUAL LIFE INSURANCE POLICY FORMS › Section 11:4-41.8 - Standards for field issue contracts

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Use of the same form for field issue and home office issue contract shall be permitted when the contract terms are written so as to make the difference in the administrative aspect of the issuance and delivery process negligible.
(b) The following requirements shall apply to field issue contracts:
1. The application shall not be substituted for or obscure the policy face page.
2. The application and policy shall not be featured as one form. Separate identifying form numbers and submissions for the application and policy form are required.
3. Submissions of field issue forms shall include a certification from an officer of the insurer that the insurer will be bound by all information recorded by the agent on the application, including, but not limited to, the initial interest rate and the initial interest rate guarantee period, even in the case of errors.
4. Coverage under the form shall be effective no later than the date the policy is delivered to the owner. The form may not provide a delayed or deferred effective date or be conditionally effective.
5. Suicide and contestability provisions shall commence no later than the effective date of coverage.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 41 - STANDARDS FOR INDIVIDUAL LIFE INSURANCE POLICY FORMS › Section 11:4-41.9 - Standards for other insured coverage

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following standards shall apply to other insured coverage, which provides coverage to an insured other than the policy's primary insured:
1. The form shall clearly describe what happens to the insurance on the other insured upon the death of the primary insured.
2. If coverage on the other insured terminates upon the death of the primary insured, then the form shall provide for the return of the unearned premium (or cost of insurance). Alternatively, the form may continue coverage on the other insured for the remainder of the period purchased by the premium (or cost of insurance).
3. The form may continue the coverage on the other insured by waiver of premium (or cost of insurance).
4. The form may continue the coverage on the other insured through paid-up term insurance. In such a case, the form shall include the following:
i. A description of the basis for calculating the cash value of such paid-up insurance;
ii. A statement that the paid-up insurance may be surrendered at any time for its cash value; and
iii. A statement that if the paid-up insurance is surrendered within 30 days after a policy anniversary, the value available shall not be less than the anniversary value.
5. The form may continue coverage on the other insured as paid-up term insurance evidenced by a separate policy to be issued by the insurer.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 41 - STANDARDS FOR INDIVIDUAL LIFE INSURANCE POLICY FORMS › Section 11:4-41.10 - Standards for survivorship forms

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following requirements shall apply to survivorship forms, which provide that the death benefit is payable on the last surviving insured:
1. For any survivorship form with cash values, the values shall be calculated using exact ages, sexes and underwriting classifications. Equivalent ages or approximations may be used and will be reviewed on a case-by-case basis.
2. The form or actuarial memorandum shall describe any modifications to the published tables. If the actuarial memorandum is used to describe the modification(s), then the form shall state that a detailed statement is on file with the Department.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 41 - STANDARDS FOR INDIVIDUAL LIFE INSURANCE POLICY FORMS › Section 11:4-41.11 - Standards for re-entry or requalification features

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following standards shall apply to coverage which provides a re-entry or requalification feature:
1. The Department shall require a certification that the insurer will not attempt to defeat the requalification provision by markedly altering its underwriting standards between the time of issue and the time of requalification. In this context, a change in the underwriting standards refers to the level of expected mortality needed to requalify, and not to the tests or information used to arrive at this estimate of expected mortality.
2. The percentage of insureds requalifying shall not be used as a basis for changing any indeterminate premium.
3. The current premiums for insureds not requalifying shall be based on realistic assumptions which reflect the anti-select nature of this risk pool.
4. The provision describing requalification shall state whether such requalification is contestable or subject to a new suicide period.
5. If requalification involves a reduction in premium on the same policy to a level below the premium which would have been charged without underwriting, then only the difference in the policy face amount which is attributable to the difference in premium shall be contestable for up to two years following the date of re-entry, if any right to contest is reserved.
6. If requalification requires issuance of a new policy at current rates, the entire contract may be contestable for up to two years following the date of requalification, if so stated. Such a transaction shall be a replacement and the insurer shall be required to satisfy the requirements of N.J.A.C. 11:4-2. Insurers shall include specimen copies of disclosure forms with their forms submission to the Department.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 41 - STANDARDS FOR INDIVIDUAL LIFE INSURANCE POLICY FORMS › Section 11:4-41.12 - Standards for custom design products

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pursuant to (b) below, the Department shall permit the use of a single policy form to provide more than one product where there are alternative plans. The submission shall include specimen issues of the schedule pages and any related tables of values for each alternative plan.
(b) The use of single policy forms to provide more than one product shall be permitted under the following circumstances:
1. Whole life coverage where the only difference is the length of the premium paying period.
2. Decreasing term plans where the only difference is the length of the term period. The Department shall permit different amortization schedules to be used with each term period.
3. Level term plans where the only difference is the length of the term.
4. Other alternative plans that are substantially similar in product design to the primary plan submitted. Determination of substantial similarity shall be within the sole discretion of the Commissioner.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 41 - STANDARDS FOR INDIVIDUAL LIFE INSURANCE POLICY FORMS › Section 11:4-41.13 - Effect on previously filed forms

Current through Register Vol. 56, No. 14, July 15, 2024
Forms which have been filed by the Commissioner pursuant to 17B:25-18 containing provisions not in compliance with these rules shall be deemed withdrawn as of December 31, 1996.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 41 - STANDARDS FOR INDIVIDUAL LIFE INSURANCE POLICY FORMS › Section 11:4-41.14 - Standards for smoker/nonsmoker and/or tobacco/nontobacco reclassification

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The standards set forth in this section shall apply to individual life insurance policies that:
1. Classify insureds explicitly by smoking and/or tobacco use habits, resulting in premium, cost or benefit differences; and
2. Permit a reclassification resulting in a change in premiums, costs or benefits of an in-force policy based upon a change in smoking and/or tobacco use habits.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 42 - GROUP LIFE, GROUP HEALTH AND BLANKET INSURANCE: GENERAL STANDARDS FOR CONTRACT PROVISIONS › Section 11:4-42.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter sets forth standards for provisions contained in group life, group health and blanket insurance contract, policy and certificate forms to assure that the provisions are not unjust, unfair, inequitable, misleading, confusing or unreasonably restrictive and that the coverage provided is not so limited as to provide no substantial economic value.
(b) This subchapter shall apply to all group life, group health and blanket insurance contracts and policies delivered or issued for delivery in this State on or after April 15, 1996, including any group life, group health and blanket insurance policies and contracts the forms of which the Commissioner has determined are eligible for file and use in accordance with N.J.A.C. 11:4-40. This subchapter shall not apply to group life insurance forms approved by the Interstate Insurance Product Regulation Commission created pursuant to the Interstate Insurance Product Regulation Compact established by P.L. 2010, c. 120.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 42 - GROUP LIFE, GROUP HEALTH AND BLANKET INSURANCE: GENERAL STANDARDS FOR CONTRACT PROVISIONS › Section 11:4-42.3 - Applicability of other standards

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The standards contained in this subchapter shall be in addition to any other rules and statutes applicable to group health insurance, group life insurance and blanket insurance contracts, policies and certificates.
(b) If a group insurance contract, policy or certificate contains provisions typically found in individual life or health insurance policies that the Department determines appropriate for use in group policies, the Commissioner may apply the rules and statutes governing individual policies when reviewing such provisions notwithstanding that they are contained in a group contract, policy or certificate.
(c) Nothing in this subchapter shall be construed to limit the authority of the Commissioner to disapprove contracts, policies and certificates pursuant to 17B:27-25 and 17B:27-49, 17:48-8, 17:48A-9 and 17:48E-13 which, in the opinion of the Commissioner, contain provisions that are unjust, unfair, inequitable, misleading, contrary to law or to the public policy of this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 42 - GROUP LIFE, GROUP HEALTH AND BLANKET INSURANCE: GENERAL STANDARDS FOR CONTRACT PROVISIONS › Section 11:4-42.4 - General standards

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The face page of every certificate issued under a blanket insurance policy or a group policy providing health insurance or life insurance delivered or issued for delivery in New Jersey shall state that it is subject to the laws of the State of New Jersey.
(b) Group policies and certificates providing health or blanket insurance that include convalescent or extended care benefits following hospitalization shall not condition such benefits upon admission to the convalescent or extended care facility within a period of less than 14 days after discharge from the hospital.
(c) Group policies and certificates that provide disability benefits shall provide that a period of disability begins on the date that disability commences.
1. A period of disability shall not be based on the date of first medical treatment.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 42 - GROUP LIFE, GROUP HEALTH AND BLANKET INSURANCE: GENERAL STANDARDS FOR CONTRACT PROVISIONS › Section 11:4-42.5 - Prohibited provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Group policies and certificates providing health, life, or blanket insurance shall not limit or exclude benefits because a covered person suffers a loss due to domestic violence.
1. No application or evidence of coverage form shall include questions regarding domestic violence.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 42 - GROUP LIFE, GROUP HEALTH AND BLANKET INSURANCE: GENERAL STANDARDS FOR CONTRACT PROVISIONS › Section 11:4-42.6 - Provisions for aggregate limits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Group health, group life insurance and blanket insurance policies and certificates that provide accident coverage and which include an aggregate limit on the benefits payable in connection with any single accident shall provide that the aggregate limit shall apply on a per conveyance basis for accidents in which a conveyance is involved, and, for accidents in which no conveyance is involved, the policy or contract may provide that the aggregate limit shall apply to each accident.
(b) Each certificate issued under a policy which includes aggregate limit(s) shall include information sufficient for each covered person to determine under which conditions he or she shall have full coverage and when his or her coverage will be reduced by the aggregate limit(s), including, but not limited to:
1. The amount of aggregate limit;
2. The amount of benefits for each separate class of covered persons subject to the same aggregate limit shall be carried over from the group (master) policy to each individual certificate.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 42 - GROUP LIFE, GROUP HEALTH AND BLANKET INSURANCE: GENERAL STANDARDS FOR CONTRACT PROVISIONS › Section 11:4-42.7 - Provisions for offsets in group policies and certificates providing disability income insurance

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Group policies and certificates providing disability income insurance may provide that benefits shall be offset by other income received by the covered person under the following conditions:
1. Offsets to group disability benefits may not result in a monthly benefit of less than $ 100.00.
2. When other income benefits are paid to the covered person for a specified period of time in a lump sum amount, the other income amount shall be determined by dividing the lump sum amount by the number of months in the specified time period for which the lump sum is applicable, and offsetting such amount on a monthly basis.
3. When other income benefits are paid to the covered person for an unspecified time period in a lump sum amount, the other income shall be offset by dividing the lump sum amount by the number of months of the covered person's expected lifetime and offsetting such amount on a monthly basis.
4. The insurer may require the covered person to sign an agreement promising to reimburse benefit overpayments as a condition of receiving full benefits prior to the date benefits under a Federal plan are received, but the insurer shall not require the covered person to sign any agreement promising to reimburse benefit payments as a condition of receiving full benefits prior to the date other benefits which qualify as other income are received.
i. Any such agreement shall be submitted on an information basis to the Department prior to use in New Jersey.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 42 - GROUP LIFE, GROUP HEALTH AND BLANKET INSURANCE: GENERAL STANDARDS FOR CONTRACT PROVISIONS › Section 11:4-42.8 - Provisions setting forth pre-authorization requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Group policies and certificates providing health insurance in which some portion of the benefits are subject to pre-authorization provisions shall comply with the following:
1. There shall be a caption for the pre-authorization provision in both the policies and certificates that shall clearly state in prominent boldface type that benefits will be reduced for noncompliance with the requirements of the pre-authorization provision.
2. The pre-authorization provision shall include a process by which a covered person shall be able to appeal benefit denials (including, but not limited to, hospitalization admission denials, a reduction of benefits payable, rejected admissions and non-reviewed admissions), which process shall be described in detail and shall state a reasonable time period within which the covered person may expect the insurer (or any entity with which the insurer has contracted to perform such reviews on its behalf) to respond.
3. The penalty for noncompliance shall not exceed 50 percent of the charges which would otherwise be covered under the contract, policy or certificate. Schedules of penalties to be offered to policyholders (outlining the range of penalties for non-compliance with the pre-authorization provision) shall be submitted to the Department with the policy form filing.
4. If the pre-authorization provision incorporates an emergency treatment post-notification requirement with a notice deadline and penalty, the provision shall include a statement that post-deadline notice shall be accepted and the penalty waived if the covered person provides notification as soon as reasonably possible.
5. Inpatient and/or outpatient treatment for alcoholism as described at 17B:27-46.1 shall only be subject to pre-authorization provisions if all inpatient and/or outpatient treatments for other injuries and illnesses are subject to the same review.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 42 - GROUP LIFE, GROUP HEALTH AND BLANKET INSURANCE: GENERAL STANDARDS FOR CONTRACT PROVISIONS › Section 11:4-42.9 - Provisions for pre-existing condition exclusions and limitations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Blanket and group policies and certificates providing life insurance or accidental death and dismemberment insurance benefits shall not subject such benefits to pre-existing condition exclusions and limitations.
(b) Group policies and certificates providing health insurance benefits, other than accidental death and dismemberment and group health benefits plans, may include pre-existing condition exclusions and limitations subject to the following:
1. A pre-existing condition may be defined no more restrictively than as an illness or injury for which the insured received treatment or advice from a physician or used prescription drugs within no more than a two year period prior to the effective date of coverage.
2. No policy, other than a policy providing group disability income insurance shall exclude coverage for a loss due to a pre-existing condition for a period greater than 24 months following the effective date of coverage, nor shall any policy provide any exclusion or limitation applicable to new losses due to a pre-existing condition after the 24-month (or lesser) period. Policies providing group disability income insurance may exclude coverage for losses beginning during the first 24 months after the effective date of coverage due to disabilities and recurrent disabilities which result from a pre-existing condition.
3. A succeeding insurer, in applying a pre-existing condition waiting period in its policy shall credit the covered person for satisfaction of the pre-existing condition waiting period under a prior policy or contract, or any portion thereof if the prior waiting period has not been satisfied in full.
4. No policy shall limit benefits to illnesses or injuries which first manifest themselves while the covered person is covered under the policy.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 42 - GROUP LIFE, GROUP HEALTH AND BLANKET INSURANCE: GENERAL STANDARDS FOR CONTRACT PROVISIONS › Section 11:4-42.10 - Prohibition on subrogation/third party liability provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No policy or certificate providing group health insurance shall limit or exclude health benefits as the result of the covered person's sustaining a loss attributable to the actions of a third party.
(b) Insurers shall file with the Commissioner no later than December 31, 2002, endorsements that remove any subrogation and third party recovery provisions contained in previously filed contract, policy or certificate forms.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 42 - GROUP LIFE, GROUP HEALTH AND BLANKET INSURANCE: GENERAL STANDARDS FOR CONTRACT PROVISIONS › Section 11:4-42.11 - Provisions concerning exclusions and limitations for the use of alcohol and drugs or relating to illegal occupations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A blanket insurance policy or certificate or other group policy or certificate providing health insurance, other than a group health benefits plan, may include an exclusion for losses resulting from the covered person's use of alcohol or drugs, but such exclusion shall be worded no more restrictively than as follows:
"The insurer shall not be liable for any loss sustained or contracted as a consequence of the covered person's intoxication or being under the influence of any narcotic unless administered or consumed on the advice of a physician."
(b) A group policy or certificate providing health insurance may include an exclusion for losses resulting from the covered person's involvement in an illegal activity, but such exclusion shall not be worded more restrictively than as follows:
"The insurer shall not be liable for any loss to which a contributing cause was the covered person's commission of or attempt to commit a felony or to which a contributing cause was the covered person's engagement in an illegal occupation."
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 42 - GROUP LIFE, GROUP HEALTH AND BLANKET INSURANCE: GENERAL STANDARDS FOR CONTRACT PROVISIONS › Section 11:4-42.12 - Provisions for payment of benefits payable for automobile related injuries

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A group policy or certificate providing health insurance benefits shall not include any provision that restricts, limits, or excludes coverage of services or expenses, directly or indirectly, that otherwise are eligible under the policy or certificate on the grounds that such expenses or services would be covered under an automobile no-fault medical benefits plan for which the covered person would be eligible, nor shall the policy or certificate include an automobile no-fault medical plan for which the covered person would be eligible in the definition of "plan" in any coordination of benefits provision.
1. A group policy or certificate providing health insurance benefits shall contain the wording which appears in the Appendix to this subchapter, incorporated herein by reference, or any alternate wording that is at least as favorable to the covered person as the language contained in the Appendix, if the insurer intends to adjust its benefits by medical benefits payable under a group, group-type or individual automobile no-fault or traditional fault type contract.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 42 - GROUP LIFE, GROUP HEALTH AND BLANKET INSURANCE: GENERAL STANDARDS FOR CONTRACT PROVISIONS › Section 11:4-42.13 - Conversion of group life insurance coverage to an individual life insurance policy

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An insurer, in providing the conversion right required by 17B:27-19, shall treat the retirement of a covered person under a policy providing group life insurance as a termination of employment and shall permit the covered person to obtain, without evidence of insurability, an individual policy of life insurance.
(b) An insurer shall provide for a right of conversion to an individual policy for the amount of coverage that terminates when a covered person is transferred or transfers from one class of employee to another class of employee.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 43 - INDIVIDUAL ANNUITY CONTRACT FORM STANDARDS › Section 11:4-43.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The subchapter implements P.L. 1995, c.73, by setting forth standards and requirements that individual annuity contract forms delivered or issued for delivery in this State are required to satisfy in order to obtain approval from the Commissioner.
(b) This subchapter shall apply to all individual annuities issued pursuant to 17B:25-18 and P.L. 1995, c.73, sections 16 and 17. This subchapter shall not apply to individual annuity forms approved by the Interstate Insurance Product Regulation Commission created pursuant to the Interstate Insurance Product Regulation Compact established by P.L. 2010, c. 120.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 43 - INDIVIDUAL ANNUITY CONTRACT FORM STANDARDS › Section 11:4-43.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.
"Annuity" means a contract not included within the definition of life insurance as set forth in 17B:17-3, or health insurance as set forth in 17B:17-4, under which an insurer obligates itself to make periodic payments for a specified period of time, such as for a number of years, or until the happening of an event, or for life, or for a period of time determined by any combination thereof.
"Bail-out feature" means a feature whereby the owner may elect to surrender the contract for the cash value without incurring a surrender charge under specified conditions, such as the interest rate(s) credited to the contract falling below a predetermined rate.
"Civil union partner" means any person who participates in a civil union as defined and established pursuant to 37:1-28 et seq. and its implementing rules.
"Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance.
"Deferred annuity" means an annuity where the first annuity payment is due no earlier than one year from the issue date of the contract, and the annuity is not an immediate annuity.
"Department" means the New Jersey Department of Banking and Insurance.
"Field issue" means a contract that the agent, following acceptance of a premium, issues for delivery in the field rather than from the home office.
"Flexible premium" means a contract where the policyholder is permitted to vary the amount and timing of premium payments, subject to any specified limits.
"Immediate annuity" means an annuity where the first annuity payment is due not more than 13 months from the issue date of the contract.
"Insurer" means any person or persons, corporation, partnership, or company authorized or admitted to transact the business of life insurance or annuities in this State pursuant to Title 17B of the New Jersey statutes.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 43 - INDIVIDUAL ANNUITY CONTRACT FORM STANDARDS › Section 11:4-43.3 - General requirements and prohibitions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All individual annuities shall be filed with the Commissioner pursuant to 17B:25-18; P.L. 1995, c.73, sections 16 and 17; and N.J.A.C. 11:4-40 prior to being delivered or issued for delivery in this State.
(b) Individual annuity contract forms shall not contain any provisions which are unjust, unfair, inequitable, ambiguous, misleading, likely to result in misinterpretation or are contrary to law.
(c) All individual annuities shall satisfy the following conditions:
1. If a form guarantees an interest rate of less than three percent during the accumulation phase, the insurer shall include with the submission a demonstration that policy values and benefits are not less than the minimum nonforfeiture amounts specified in N.J.S.A. 17B:25-20g.
2. If a form offers varying interest rate guarantee periods, specimen specification pages shall be submitted for each of the various guarantee periods.
3. The same contract form shall not be issued as both an immediate and a deferred annuity.
4. The form shall contain a provision describing any method for adjusting benefits and values on the basis of misstatement of age or sex. Interest may be applied in determining overpayments and underpayments at a rate specified in the form. The same specified rate shall apply to overpayments and underpayments.