New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter A - Life, Accident and Health Insurance › Part 52 - Minimum Standards For Form, Content And Sale Of Health Insurance, Including Standards Of Full And Fair Disclosure › Section 52.17 - Rules relating to content of forms for individual insurance

Current through Register Vol. 46, No. 28, July 10, 2024
The following provisions shall apply to individual
					 insurance:
(a) General rules.
(1) The first page of the policy shall
				  indicate whether the policy is renewable or nonrenewable.
(2) Provisions respecting renewability by the
				  insurer shall appear on the first page of the policy or reference shall be made
				  thereto in a brief description on the first page.
(3) Any reduction in benefits because of the
				  attainment of an age limit shall have a reference to such reduction set forth
				  on the first page or specification page of the policy. For purposes of this
				  requirement, a reduction in a benefit period is a reduction in benefits
				  requiring such reference.
(4)
				  Except with respect to the actual provisions, any description required to be
				  contained on the first page of the policy shall also be contained on the filing
				  back of the policy, if any.
(5) The
				  term noncancellable or noncancellable 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 age 65 or, as an alternative
				  with respect to policies defined in section
				  52.8 
				  of this Part, until receipt of retirement benefits under the Social Security
				  Act of the United States. During such period the insurer has no right to make
				  unilaterally any change in any provision of the policy while the policy is in
				  force.
(6) Except as provided in
				  paragraph (5) of this subdivision, 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 age 65 or, as an alternative with respect to
				  policies defined in section
				  52.8 
				  of this Part, until receipt of retirement benefits under the Social Security
				  Act of the United States. During such 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.
(7) The words guaranteed
				  renewable shall not be used in a policy unless the insurer's right to change
				  rates is also stated in such a way that it is not minimized or made
				  obscure.
(8) Accident benefits
				  shall not be predicated upon loss occurring through accidental means or violent
				  and external means.
(9) In any
				  policy which provides for a suspension of coverage while the covered person is
				  in military service, the policy shall provide that, upon written request, the
				  insurer will refund any unearned premiums for the period of such suspension.
				  Upon termination of military service of no longer than five years, the person
				  must have the right to renew his coverage on the same basis as before
				  suspension of coverage took effect, without restriction as to preexisting
				  conditions except those applicable on the date coverage was suspended. Such
				  renewal shall take effect on the date military service terminates, subject to
				  written application and payment of the required premium within 60 days after
				  such date.
(10) Family policies may
				  provide for a new contestable period for each new member added, but shall not
				  provide for a new contestable period for the policy.
(11) Special nurse benefits may be provided
				  either with a maximum amount or on a copayment basis, or both.
(12) Rider or endorsement forms used to
				  reduce or eliminate coverage after policy issuance shall provide for signed
				  acceptance by the insured.
(13)
				  Riders or endorsements relinquishing any right of an insurer on a class or
				  classes of similar policies may be used when transferring coverage on such
				  policies within a company or between companies.
(14) Riders or endorsements providing a
				  benefit for which a specific premium is charged shall show the premium on the
				  application, rider, or elsewhere in the policy.
(15) Termination of a policy of hospital,
				  surgical or medical expense insurance shall be without prejudice to any
				  continuous loss which commenced while the policy was in force, but the
				  extension of benefits beyond the period while the policy was in force may be
				  predicated upon the continuous total disability of the insured, or limited to
				  the extent of the benefit period, if any, or payment of the maximum benefit. If
				  no specific benefit period is provided, an extended benefit period of at least
				  12 months must be included in the contract. A loss shall commence when a
				  medical service, whether or not covered by the policy, is rendered for the
				  condition causing total disability.
(16) Different maximum daily hospital
				  benefits or durations of coverage contained in the same policy shall not be
				  based on the type of room accommodation, but may be based on the level of care
				  unit (such as intensive care or extended care) to which a covered person is
				  assigned.
(17) Surgical fee
				  schedules shall provide benefits for various surgical procedures which bear a
				  rational relationship and reasonable relativity to each other, based on the
				  nature of the procedure. Schedules conforming to the relativities of the State
				  of New York Certified Surgical Fee Schedule shall be deemed to meet the
				  requirements of this paragraph.
(18) Surgical schedules contained in the
				  policy shall include a provision providing coverage for procedures not
				  specifically listed in the schedules and not otherwise excluded by the policy,
				  and benefits therefor shall be consistent with the benefits for comparable
				  procedures.
(19) Multiple surgical
				  procedures performed during the same operative session and through the same
				  incision shall be reimbursed in an amount not less than that stated in the
				  schedule for the most expensive procedure then being performed. Multiple
				  surgical procedures performed during the same operative session but through
				  different incisions shall be reimbursed in an amount not less than that stated
				  in the schedule for the most expensive procedure then being performed, and with
				  regard to the less expensive procedures in an amount at least equal to 50
				  percent of the scheduled amount for these procedures, unless a different amount
				  is specifically set forth in the State of New York Certified Surgical Fee
				  Schedule.
(20) In major medical
				  insurance policies and policies providing major medical type benefits, the
				  benefit period and the maximum amount payable during the benefit period shall
				  be such that the maximum can reasonably be expected to be incurred during the
				  benefit period, unless the policy maximum is designed to protect against
				  catastrophic loss.
(21) In major
				  medical insurance policies and policies providing major medical type benefits,
				  if a benefit period commences with the first expense used to satisfy a
				  deductible, and under the policy terms no further benefits become payable for
				  the same cause after the termination of such period, no benefit period shall
				  end before the expiration of nine months after the deductible is satisfied,
				  except when the benefit period is determined by a calendar date unrelated to
				  the incidence of the first expense.
(22) No policy shall be designated "basic" or
				  "major medical" unless it provides at least the minimum benefits in section
				  52.5,
				  52.6 or
				  52.7  of
				  this Part, respectively. Policies meeting the definition of section
				  52.8,
				  52.9 or
				  52.10 
				  of this Part shall not be designated in any manner inconsistent with the
				  applicable definition, or which would encourage misrepresentation of the actual
				  coverages provided.
(23) Where a
				  policy is written that provides at least the coverages required for both basic
				  hospital insurance under section
				  52.5  of
				  this Part and basic medical insurance under section
				  52.6, the
				  allowable deductible may be applied to the combined coverage.
(24) Where a policy is written that provides
				  at least the coverages required for both basic hospital insurance under section
				  52.5  of
				  this Part and basic medical insurance under section
				  52.6, the
				  required anesthetic coverage may be provided as part of the miscellaneous
				  hospital benefit instead of a separate anesthetic benefit, provided that the
				  limit of the miscellaneous hospital benefit is sufficient to meet the combined
				  minimum requirements of both the miscellaneous hospital benefit of basic
				  hospital insurance and the anesthesia benefit of basic medical
				  insurance.
(25)
(i) Unilateral modifications by an insurer to
				  existing accident and health coverage shall be made in accordance with
				  applicable laws upon at least 30 days' prior written notice to the
				  policyholder.
(ii) An insurer may
				  unilaterally modify the coverage for a policy of hospital, surgical or medical
				  expense insurance only at the time of coverage renewal.
(iii) Where a policyholder is contractually
				  required to provide prior written notice to terminate coverage, the notice
				  referred to in subparagraph (i) of this paragraph must be provided to such
				  policyholder no less than 14 days prior to the date by which the policy holder
				  is required to provide notice to terminate coverage.
(26) Except as specifically permitted by
				  statute or regulation, no policy shall require the loss from accidental injury
				  to commence within less than 30 days after the date of an accident, nor shall
				  any such policy which the insurer may cancel or refuse to renew require that it
				  be in force at the time loss commences if the accident occurred while the
				  policy was in force.
(27) No policy
				  shall exclude, limit or reduce coverage for a loss due to a preexisting
				  condition for a period greater than 12 months following the effective date,
				  where the application for such insurance does not seek disclosure of prior
				  illness, disease or physical conditions, or prior medical care and treatment,
				  and such preexisting condition is not specifically excluded, limited or reduced
				  in accordance with section
				  52.16(e) 
				  of this Part.
(28) Policies issued
				  to persons aged 65 or older, other than those defined in sections
				  52.11,
				  52.12
				  and
				  52.13 
				  of this Part, shall not contain any provision which excludes, limits or reduces
				  coverage for a loss due to a preexisting condition for a period greater than
				  six months following the effective date, unless the preexisting condition is
				  specifically excluded, limited or reduced in accordance with section
				  52.16(e) 
				  of this Part.
(29) When rates are
				  based on attained age, other than for policies which provide hospital, medical
				  or surgical expense benefits, the policy shall include the applicable schedule
				  of rates.
(30) A family policy
				  shall provide that adopted children and stepchildren dependent upon the insured
				  be eligible for coverage on the same basis as natural children.
(31) A family policy covering a proposed
				  adoptive parent, on whom the child is dependent, shall provide that such child
				  be eligible for coverage on the same basis as a natural child during any
				  waiting period prior to the finalization of the child's adoption.
(32)
(i)
				  Insurers issuing accident and health policies which provide hospital or medical
				  coverage on an expense incurred or indemnity basis to a person(s) eligible for
				  Medicare shall provide to those applicants a Guide to Health Insurance for
				  People with Medicare in the form developed jointly by the National Association
				  of Insurance Commissioners and the Health Care Financing Administration and in
				  a type size no smaller than 12-point type. Delivery of the guide shall be made
				  whether or not such policies are advertised, solicited or issued as Medicare
				  supplement insurance as defined in this regulation. Except in the case of
				  direct response insurers, delivery of the guide shall be made to the applicant
				  at the time of application and written acknowledgment of receipt of the guide
				  shall be obtained by the insurer. Direct response insurers shall deliver the
				  guide to the applicant upon request but in no event later than at the time the
				  policy is delivered. If the guide has not been made available from the Health
				  Care Financing Administration at the time that the insurer is required to
				  deliver such guide, then the insurer shall provide the applicant with a notice
				  that the guide is presently unavailable and that it will be delivered to the
				  applicant at such time that it is available to the insurer.
(ii) For the purposes of this paragraph, form
				  means the language, format, type size, type proportional spacing, bold
				  character, and line spacing.
(33)
(i)
				  Any accident and health insurance policy, other than a Medicare supplement
				  policy, a policy issued pursuant to a contract under section 1876 of the
				  Federal Social Security Act (42 U.S.C. section
				  1395 et seq.), or disability income policy,
				  delivered or issued for delivery in this State to persons eligible for Medicare
				  shall notify insureds under the policy that the policy is not a Medicare
				  supplement policy. The notice shall either be printed on or attached to the
				  first page of the disclosure statement delivered to insureds to comply with
				  section
				  52.54  of
				  this Part or to the first page of the policy delivered to insureds. The notice
				  shall be in no less than 12-point type and shall contain the following
				  language:
"THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY. If you
					 are eligible for Medicare, review the Guide to Health Insurance for People with
					 Medicare available from the company."
(ii) Where applicable, applications provided
				  to persons eligible for Medicare for the accident and health insurance policies
				  described in subparagraph (i) of this paragraph shall disclose, using the
				  applicable statement prescribed in
				  42 U.S.C. section
				  1395 ss(d)(3)(D), the extent to which the
				  policy duplicates Medicare. The disclosure statement shall be provided as a
				  part of, or together with, the application for the policy.
(34) At the time of an event described in
				  42 U.S.C. section
				  1395 ss(s)(3)(B) or (F) [FN*] because of
				  which an individual loses coverage or benefits due to the termination of the
				  policy or the individual ceases enrollment under the policy, the insurer of the
				  policy from which termination or disenrollment occurs shall provide the
				  individual with written notification of his or her rights and of the
				  obligations of issuers of Medicare supplement insurance policies under Part 58
				  of this Title. If an individual loses coverage or benefits due to termination
				  of the policy, such notification must be provided contemporaneously with the
				  notification of termination. If an individual ceases enrollment under the
				  policy, such notification must be provided within 10 working days of the
				  insurer receiving notification of disenrollment.
(35) Insurers issuing policies and contracts
				  subject to the provisions of section 4303 (s)  of the Insurance
				  Law shall use standards and guidelines no less favorable than those established
				  and adopted by the American Society for Reproductive Medicine in relation to
				  the following:
(i) the determination of
				  infertility for purposes of compliance with section 4303 (s)(3)  of the
				  Insurance Law;
(ii) the
				  identification of experimental procedures and treatments not covered for the
				  diagnosis and treatment of infertility;
(iii) the identification of the required
				  training, experience and other standards for health care providers for the
				  provision of procedures and treatments for the diagnosis and treatment of
				  infertility; and
(iv) the
				  determination of appropriate medical candidates by the treating physician.
Said standards and guidelines are taken from The American
					 Society for Reproductive Medicine's Practice Committee Opinions on The
					 Definition of Experimental, The Definition of Infertility, The Guidelines for
					 the Provision of Infertility Services and The Revised Minimum Standards for
					 Invitro Fertilization, Gamete Intrafallopian Transfer and Related Procedures.
					 These Practice Committee Opinions were approved by the Practice Committee of
					 the American Society for Reproductive Medicine (formerly The American Fertility
					 Society) on March 27, 1993 and approved by the Board of Directors of the
					 American Society for Reproductive Medicine (formerly The American Fertility
					 Society) on May 17, 1993. The Practice Committee Opinions can be obtained from
					 The American Society for Reproductive Medicine formerly The American Fertility
					 Society, 1209 Montgomery Highway, Birmingham, AL 35216-2809 and are available
					 for public inspection and copying from the New York State Insurance Department
					 at either 25 Beaver Street, New York, NY 10004 or One Commerce Plaza, Albany,
					 NY 12257.
(36)
				  Repealed
(37) Repealed
(38) An insurer issuing a policy subject to
				  the provisions of Insurance Law sections
				  1120,
				  3216(i)(17),
				  3217-g,
				  4303(j) or
				  4306-f or Public Health Law section
				  4406-f that provides coverage for direct
				  access to screening and referral for maternal depression performed by a
				  provider of obstetrical, gynecologic, or pediatric services of the mother's
				  choice, shall provide coverage for the screening and referral for maternal
				  depression under the mother's policy. However, if the infant is covered under a
				  different policy than the mother and the screening and referral are performed
				  by a provider of pediatric services, coverage for the screening and referral
				  shall also be provided under the policy in which the infant is
				  covered.