New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 16 - MINIMUM STANDARDS FOR INDIVIDUAL HEALTH INSURANCE › Section 11:4-16.8 - Required disclosure provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) General disclosure requirements are as follows:
1. Each individual policy of health insurance shall include a renewal, continuation, or nonrenewal provision. The language or specifications of such provision must be consistent with the type of contract issued. Such provision shall be appropriately captioned, shall appear on the first page of the policy, and shall clearly state the duration where limited, of renewability and the duration of the term of coverage for which the policy is issued and for which it may be renewed.
2. Except for riders or endorsements by which the insurer effectuates a request made in writing by the policyholder, exercises a specifically reserved right under the policy, or is required to reduce or eliminate benefits to avoid duplication of Medicare benefits, all riders or endorsements added to a policy after the date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require signed acceptance by the insured. After the date of policy issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term, shall be agreed to in a written instrument signed by the insured, except if the increased benefits or coverage is required by law.
3. Where riders or endorsements which reduce or eliminate coverage are attached to the policy at issue, the policy shall contain on the first page or specification page either a prominent warning or the full text of the rider or endorsement.
4. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, such premium charge shall be set forth in the policy.
5. The words "guaranteed renewable" shall not be used in a policy unless the insurer's right to change premium rates is clearly stated in the caption of the renewal provision or in the brief description of the policy.
6. In a policy which provides for payment of benefits based on standards specified as "usual, customary and reasonable", such standards shall be defined in the policy and explained in the outline of coverage. Such standards shall not be more restrictive than:
i. "Usual" means the fee ordinarily charged by the provider for a particular service or supply.
ii. "Customary" means the range of usual fees charged by providers for the same service or supply under like circumstances within the geographic or socio-economic area where the service or supply is performed or furnished. The range of usual fees charged by the physicians shall consider training and experience.
iii. "Reasonable" means a fee above usual and customary which is justified by unusual complexity of the treatment required.
7. A policy which provides for the payment of benefits based on standards described as "usual and customary", "reasonable and customary", or other words of similar import shall include a definition of such terms and an explanation of such terms in its accompanying outline of coverage.
8. If a policy contains any limitations with respect to preexisting conditions, such limitations must appear as a separate paragraph in the policy and shall be labelled as "Pre-existing Condition Limitation".
9. If age is to be used as a determining factor for reducing the benefits available in the policy as originally issued, such fact must be prominently set forth in the policy and in the outline of coverage.
10. All policies, except short-term nonrenewable policies, Medicare supplement policies and as otherwise provided in this paragraph, shall have a notice prominently printed on the first page of the policy or attached thereto stating in substance that the policyholder shall have the right to return the policy within 10 days of its delivery and to have the premium refunded if, after examination of the policy, the policyholder is not satisfied for any reason. With respect to Medicare supplement policies and policies issued pursuant to a direct response solicitation, the policy shall have a notice prominently printed on the first page of the policy or attached thereto stating in substance that the policyholder shall have the right to return the policy within 30 days of its delivery and to have the premium refunded if, after examination of the policy, the policyholder is not satisfied for any reason.
11. An accident only policy shall contain a prominent statement on the first page of the policy or attached thereto in either contrasting color or in boldface type at least equal to the size of type used for policy captions as follows: "This is an accident only policy. It does not pay benefits for loss from sickness."
12. If a policy contains a conversion privilege, the caption of the provision shall be "conversion privilege" or words of similar import. The provision shall indicate the persons eligible for conversion, the circumstances applicable to the conversion privilege, including any limitations on the conversion, and the person by whom the conversion privilege may be exercised. The provision shall specify the benefits to be provided on conversion or may state that the converted coverage will be as provided on a policy form then being used by the insurer for that purpose.
13. Where a policy provides a benefit that is payable while the insured is participating in a rehabilitation program the policy shall specify the type of rehabilitation program allowed and any limitations or restrictions on the program.
14. An informational brochure entitled "Guide to Health Insurance for People with Medicare", hereinafter referred to as "the Guide", for persons eligible for Medicare, is intended to improve the buyer's understanding of Medicare and ability to select the most appropriate coverage. The Guide shall be furnished by each insurer to each such Medicare eligible person in connection with the purchase of health insurance policy, other than a short-term nonrenewal policy, regardless of whether the policy purchased is advertised, solicited or issued as a Medicare supplement policy meeting the requirements of N.J.A.C. 11:4-23.
15. To ensure uniformity in content, form and printing, the Guide has been made available through the Publications Department of the National Association of Insurance Commissioners, Kansas City, MO.
16. Delivery of the Guide shall be made at the time of application except in the case of direct response solicitations where the Guide shall be delivered with the policy. Acknowledgment of receipt of the Guide shall be obtained by all insurers.