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 52.16 - Prohibited provisions and coverages

Current through Register Vol. 46, No. 28, July 10, 2024
(a) No policy or certificate shall provide benefits for specified diseases, or for procedures or treatments unique to specified diseases, and no policy or certificate shall provide additional benefits for such specified diseases or procedures, unless the policy or certificate meets the standards set forth in section 52.15  or section 52.22  of this Part.
(b) No policy shall provide a return of premium or cash value benefit, except return of unearned premium upon termination or suspension of coverage, retroactive waiver of premium paid during disability, payment of dividends on participating policies, experience rating refunds, nonforfeiture values permitted for long-term care insurance, nursing home and home care insurance or nursing home insurance only, or a return of premium benefit upon death permitted for long-term care insurance, nursing home insurance only, home care insurance only, or nursing home and home care insurance. This prohibition applies to an accidental death benefit where the amount of the benefit equals the total premium paid to date of death.
(c) No policy shall limit or exclude coverage by type of illness, accident, treatment or medical condition, except as follows:
(1) preexisting conditions or diseases, as defined in section 52.2(u)  of this Part or section 3232 or 4318  of the Insurance Law, except for congenital anomalies of a covered dependent child; subject to limitations set forth in subdivision (f) of this section, sections 52.17(a)(27)-(28), 52.18(a)(5) and 52.20  of this Part;
(2) mental or emotional disorders, alcoholism and drug addiction, except that coverage must be made available or provided pursuant to section 52.7  of this Part and sections 3221 and 4303  of the Insurance Law. Medicare supplement insurance issued pursuant to section 52.11  of this Part and Part 58 of this Title shall not include limitations or exclusions which are more restrictive than those of Medicare for this type of benefit;
(3) pregnancy, except to the extent coverage is required pursuant to sections 3216, 3221, 3232, 4303, and 4318  of the Insurance Law, and except for complications of pregnancy as defined in section 52.2(e)  of this Part, other than for policies defined in section 52.8  of this Part;
(4) illness, accident, treatment or medical condition arising out of:
(i) war or act of war (whether declared or undeclared); participation in a felony, riot or insurrection; service in the Armed Forces or units auxiliary thereto;
(ii) suicide, attempted suicide or intentionally self-inflicted injury;
(iii) aviation, other than as a fare-paying passenger on a scheduled or charter flight operated by a scheduled airline; and
(iv) with respect to blanket insurance, interscholastic sports;
(5) cosmetic surgery, except that cosmetic surgery shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child which has resulted in a functional defect. However, if the policy provides hospital, surgical or medical expense coverage, including a policy issued by a health maintenance organization, then coverage and determinations with respect to cosmetic surgery must be provided pursuant to Part 56 of this Title (Regulation 183);
(6) foot care, in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain or symptomatic complaints of the feet; unless the policy is issued as Medicare supplement insurance pursuant to section 52.11  of this Part and Part 58 of this Title, in which case the policy shall not include limitations or exclusions more restrictive than those of Medicare for this type of benefit;
(7) care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column; unless the policy is issued as Medicare supplement insurance pursuant to section 52.11  of this Part and Part 58 of this Title, in which case the policy shall not include limitations or exclusions more restrictive than those of Medicare for this type of benefit;
(8) treatment provided in a government hospital; benefits provided under Medicare or other governmental program (except Medicaid), any State or Federal workers' compensation, employers' liability or occupational disease law; benefits to the extent provided for any loss or portion thereof for which mandatory automobile no-fault benefits are recovered or recoverable; services rendered and separately billed by employees of hospitals, laboratories or other institutions; services performed by a member of the covered person's immediate family; and services for which no charge is normally made;
(9) dental care or treatment, except for such care or treatment due to accidental injury to sound natural teeth within 12 months of the accident and except for dental care or treatment necessary due to congenital disease or anomaly;
(10) eyeglasses, hearing aids, and examination for the prescription or fitting thereof;
(11) rest cures, custodial care and transportation, unless the policy is issued as Medicare supplement insurance pursuant to section 52.11  of this Part and Part 58 of this Title, in which case the policy shall not include limitations or exclusions more restrictive than those of Medicare for this type of benefit; and
(12) coverage while the insured is outside the United States, its possessions or the countries of Canada and Mexico.