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 52.15 - Specified disease coverage

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				  Specified disease coverage is a policy or certificate which pays benefits on an
				  indemnity basis for the diagnosis and treatment of a specifically named disease
				  or diseases which are life threatening in nature and could cause a person to
				  incur substantial financial out-of-pocket expenses for the diagnosis and
				  treatment of a specifically named disease or diseases.
(b) General rules.
(1) A policy or certificate covering a single
				  specified disease or combination of specified diseases may not be sold or
				  offered for sale other than as specified disease coverage pursuant to this
				  section. All forms of the specified disease or diseases must be
				  covered.
(2) Any policy or
				  certificate issued pursuant to this section which conditions payment upon
				  pathological diagnosis of a covered disease, shall also provide that if such a
				  pathological diagnosis is medically inappropriate, a clinical diagnosis will be
				  accepted in lieu thereof. Any type of medically appropriate diagnosis shall be
				  accepted.
(3) An individual policy
				  containing specified disease coverage shall be at least guaranteed renewable
				  for life.
(4) Except for any policy
				  or certificate provision regarding other insurance with the insurer providing
				  specified disease coverage, benefits for specified disease coverage shall be
				  paid regardless of other coverage.
(5) Except in the case of direct response
				  insurers, no specified disease policy or certificate shall be delivered or
				  issued for delivery in this Sate unless the appropriate disclosure form in
				  section
				  52.66 
				  of this Part describing the policy's or certificate's benefits, limitations and
				  exclusions, and expected benefit ratio is delivered to the applicant at the
				  time application is made and written acknowledgment of receipt or certification
				  of delivery of such disclosure form is provided to the insurer. Direct response
				  insurers shall deliver the requisite disclosure form at the time the policy or
				  certificate is delivered.
(6) The
				  only permissible preexisting condition limits are those which exclude coverage
				  for no more than six months after the effective date of coverage under the
				  policy or certificate, for a condition for which medical advice was given or
				  treatment was recommended by, or received from, a licensed health care provider
				  within six months before the effective date of the coverage.
(7) The only permissible limitations and
				  exclusions are those set forth in section
				  52.16 
				  of this Part.
(8) An insurer shall
				  file its overinsurance rules with the Insurance Department. Overinsurance shall
				  be deemed to exist when an insured has more than one specified disease policy
				  or certificate for the same specified disease whether it is with the same or a
				  different insurer. In no event may an insurer issue a specified disease policy
				  or certificate to any person which will result in that person being covered for
				  eight or more specified diseases.
(9) Every specified disease policy or
				  certificate shall contain, on the first page of the policy or certificate in
				  boldface type, in at least 14-point size but not less than the size of type
				  used for policy captions, a prominent statement, as follows: "This is a limited
				  policy (or certificate). It pays benefits for (name of specified disease)
				  treatment only. Read it carefully with the Required Disclosure
				  Statement."
(10) No advertisement
				  of a policy or certificate shall imply coverage beyond the terms of the policy
				  or certificate. Synonymous terms shall not be used to refer to any disease so
				  as to imply broader coverage than is the fact.
(11) A specified disease policy or
				  certificate where a benefit is a lumpsum payment for the diagnosis of a
				  specified disease without further coverage for treatment of the disease can
				  only be offered if it meets the requirements set forth in subdivision (d) of
				  this section.
(12) Specified
				  disease coverage shall only be issued to persons who are covered by either at
				  least major medical insurance as defined in section
				  52.7  of
				  this Part, or at least basic hospital insurance and basic medical insurance as
				  defined in sections
				  52.5 and
				  52.6  of
				  this Part.
(13) Application forms
				  shall include a question designed to elicit information as to whether the
				  applicant has at least major medical insurance, or at least basic hospital
				  insurance and basic medical insurance in force on the date of the
				  application.
(14) No later than 30
				  days following delivery of the policy or certificate, the insurer must ask the
				  insured person(s) in a written request whether the insured person(s) has in
				  force at least major medical insurance, or at least basic hospital insurance
				  and basic medical insurance on the effective date of the specified disease
				  coverage. Where the insured person(s) responds to the insurer in writing that
				  such underlying coverage is not in force on the effective date of the specified
				  disease coverage, the policy or certificate shall be voided from its beginning
				  with a full premium refund. The method by which the insurer implements the
				  requirements of this paragraph must be approved by the
				  superintendent.
(15) Application
				  forms shall include questions designed to elicit:
(i) whether, as of the date of the
				  application, the applicant has in force or application(s) pending for another
				  specified disease policy or certificate for the same specified disease with the
				  same or a different insurer; and
(ii) the number of specified diseases for
				  which either the applicant has coverage in force as of the date of application
				  or application(s) pending as of the date of application.
(16) Reductions in benefits such as when
				  certain events occur or ages are reached are not permissible.