New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 17 - HEALTH INSURANCE SOLICITATION › Section 11:4-17.3 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter shall have the following meanings unless the context clearly indicates otherwise.
"Duplicative coverage" means a transaction wherein health insurance is to be purchased and it is known or should be known to the licensee or the insurer in the case of a direct response solicitation, that the insurance will provide coverage which, when combined with existing coverage, is likely to result in total claim payments, in the event of loss, in amounts greater than the actual amount of loss.
"Health benefits plan" means a hospital and medical expense insurance policy, health service corporation contract, hospital service corporation contract, medical service corporation contract, health maintenance organization subscriber contract, or other plan for medical care delivered or issued for delivery in this State. For purposes of this subchapter, health benefits plan shall not include one or more, or any combination of, the following: coverage only for accident or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; stop loss or excess risk insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; and other similar insurance coverage, as specified in Federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. Health benefits plan shall not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance, or are otherwise not an integral part of the plan: limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and such other similar, limited benefits as are specified in Federal regulations. Health benefits plan shall not include hospital confinement indemnity coverage if the benefits are provided under a separate policy, certificate, or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health benefits plan maintained by the same plan sponsor, and those benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor. Health benefits plan shall not include the following if it is offered as a separate policy, certificate, or contract of insurance: Medicare supplemental health insurance as defined under Section 1882(g)(1) of the Federal Social Security Act ( 42 U.S.C. §
										1395ss(g) (1) ); and coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code ( 10 U.S.C. §§
										1071 et seq.); and similar supplemental coverage provided to coverage under a group health plan.
"Licensee" means any person licensed as an insurance agent, broker or consultant pursuant to N.J.S.A. 17:22A-1et seq.
"Policy" means the entire contract between the insurer and the insured, including, but not limited to, the policy, certificate, riders, endorsements, amendments and the application which are required to be filed pursuant to 17B:26-1 and N.J.S.A. 17:44A-21.
"Replacement" means a transaction wherein individual health insurance is to be purchased and it is known or should be known to the licensee or the insurer in the case of a direct response solicitation that due to the transaction previously existing health insurance has been, or will be, lapsed, cancelled or otherwise terminated.
"Sales materials" means any and all promotional materials and any other informational material used in connection with the promotion, solicitation, or sale of health insurance.