reglab/statecodes huggingface dataset:
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 52.20 - Rules relating to preexisting condition provisions and crediting requirements in policies which provide hospital, surgical or medical expense coverage

Current through Register Vol. 46, No. 28, July 10, 2024
(a) General rules.
(1) Individual health insurance policies and
				  group and blanket accident and health insurance policies which provide
				  hospital, surgical or medical expense coverage may include preexisting
				  condition provisions which are at least as favorable to the covered person as
				  those set forth in this section.
(2) The requirements of this section shall
				  not be applicable to any individual, group or blanket insurance policy in
				  relation to its provision of "excepted benefits" as defined in section 2791(c)
				  of the Federal Public Health Service Act (42
				  U.S.C. section 300gg-91 [c]) and meeting the
				  requirements for exception as set forth in section 2721(c) or (d) of the
				  Federal Public Health Service Act (42 U.S.C. section
				  300gg-21 [c] and [d]) or section 2763(a) or
				  (b) of the Federal Public Health Service Act (42 U.S.C. section
				  300gg-63 [a] and [b]). However, this
				  exemption shall not be applicable to any policy providing hospital or surgical
				  indemnity benefits with specific dollar amounts that exceed the amounts
				  required to meet the definitions of basic hospital and basic medical insurance
				  in sections
				  52.5 and
				  52.6  of
				  this Part.
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 52.22 - Volunteer firefighter enhanced cancer insurance

Current through Register Vol. 46, No. 28, July 10, 2024
(a) General
				  Municipal Law section
				  205-c c requires every leg ally organized
				  fire district, department or company in this state to provide and maintain for
				  each eligible volunteer firefighter an enhanced cancer disability benefit
				  insurance program. The law requires the Division of Homeland Security and
				  Emergency Services' Office of Fire Prevention and Control to promulgate
				  regulations, in consultation with the Department of Financial Services and the
				  Workers' Compensation Board, to implement General Municipal Law section
				  205-c c. Those regulations are contained
				  in 9 NYCRR 210. This section establishes the minimum requirements for policies
				  issued in satisfaction of those requirements.
(b) Definitions. As used in this section:
(1) Active volunteer firefighter shall have
				  the meaning set forth in 9 NYCRR 210.
(2) Cancer means a disease caused by an
				  uncontrolled division of abnormal cells in a part of the body or a malignant
				  growth or tumor resulting from the division of abnormal cells affecting the
				  prostate or breast, tymphatic, hematological, digestive, urinary, neurological,
				  or reproductive systems, or melanoma.
(3) Insured firefighter means a volunteer
				  firefighter covered under the policy and who meets the eligibility requirements
				  for coverage set forth in 9 NYCRR 210.
(4) Total disability shall have the meaning
				  set forth in 9 NYCRR 210.
(5)
				  Volunteer firefighter enhanced cancer insurance means a blanket insurance
				  policy or certificate that provides cancer benefits to volunteer firefighters
				  in accordance with General Municipal Law section
				  205-c c.
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 52.23 - Coordination of benefits

Current through Register Vol. 46, No. 28, July 10, 2024
(a) This
				  section is intended to establish uniformity in the permissive use of
				  overinsurance provisions and to avoid claim delays and misunderstandings that
				  could otherwise result from the use of inconsistent or incompatible provisions
				  among plans.
(b) A coordination of
				  benefits (COB) provision is one that is intended to avoid claims payment delays
				  and duplication of benefits when a person is covered by two or more plans
				  providing benefits or services for medical, dental or other care or treatment.
				  It avoids claims payment delays by establishing an order in which plans pay
				  their claims and providing the authority for the orderly transfer of
				  information needed to pay claims promptly. It avoids duplication of benefits by
				  permitting a reduction of the benefits of a plan when, by the rules established
				  by this section, it does not have to pay its benefits first.
(c) This section permits, but does not
				  require, plans to include COB provisions.
(d) If a plan includes a COB provision, it
				  must be consistent with this section. A plan that does not include such a
				  provision may not take the benefits of another plan into account when it
				  determines its benefits. There are two exceptions:
(1) a contract holder's coverage that is
				  designed to supplement a part of a basic package of benefits may provide that
				  the supplementary coverage shall be excess to any other parts of the plan
				  provided by the contract holder; and
(2) any noncontributory group or blanket
				  insurance coverage which is in force on January 1, 1987 which provides excess
				  major medical benefits intended to supplement any basic benefits on a covered
				  person may continue to be excess to such basic benefits.
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 52.24 - Rules relating to coverage for the diagnosis and treatment of alcoholism and alcohol abuse in group (including group remittance policies issued by article 43 corporations) and school blanket health insurance policies

Current through Register Vol. 46, No. 28, July 10, 2024
In accordance with sections 3221 (l)(6)-(7) and
					 4303 (k)-(l)  of the
					 Insurance Law, the following rules shall apply:
(a) Definitions.
(1) For the purposes of this section and
				  sections 3221 (l)(6)-(7) and
				  4303 (k)-(l)  of the
				  Insurance Law, the following definition shall apply:
(i) Coverage for inpatient hospital care, as
				  referred to in the aforementioned sections of the Insurance Law, means
				  reimbursement for hospitalization on an expense-incurred basis.
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 52.25 - Rules relating to the content and sale of forms for long term care insurance, nursing home insurance only, home care insurance only, and nursing home and home care insurance

Current through Register Vol. 46, No. 28, July 10, 2024
The following shall be applicable to long term care
					 insurance, nursing home insurance only, home care insurance only, and nursing
					 home and home care insurance and shall be in addition to other requirements of
					 this Part.
(a) Definitions.
(1) For purposes of this section, custodial
				  care services means help in transferring, eating, dressing, bathing, toileting
				  and other such related activities.
(2) For purposes of this section, home care
				  services shall have the same meaning as defined in subsection 1 of section 3602  of the Public Health Law.
(3) For purposes of this section, nursing
				  home shall have the same meaning as defined in subsection 2 of section 2801  of the Public Health Law.
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 52.26 - Rules relating to exclusion of medicare benefits

Current through Register Vol. 46, No. 28, July 10, 2024
Subject to sections 3216 (c), 4235 (f), 4304 (d), 4304 (e)(1)-(3) and
					 4305 (d)(1)  of the
					 Insurance Law, the following rules shall apply to provisions with respect to
					 Medicare:
(a) Policies may provide for
				  termination of coverage upon eligibility for Medicare by reason of age only. An
				  exception to this rule is subject to approval by the superintendent, and will
				  be considered only if:
(1) the insurer offers
				  conversion to a Medicare supplement contract;
(2) the conversion contract plus Medicare
				  provide the same or greater benefits for the same or lesser premium than the
				  original contract plus Medicare would have provided; and
(3) the insurer provides that the insured can
				  obtain, without evidence of insurability and without limitations as to
				  preexisting conditions, the same or similar coverage as that in the original
				  contract in the event Medicare coverage ceases.
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 52.27 - Rules relating to the sale of health insurance and settlement of health insurance claims

Current through Register Vol. 46, No. 28, July 10, 2024
The following are limitations affecting the underwriting,
					 rating or administration of claims relating to policies or contracts providing
					 hospital and/or medical expense or indemnity benefits. No insurer shall when
					 underwriting, rating or administering claims relating to such policies or
					 contracts:
(a) request any applicant
				  to submit to a body fluid test for evidence of human immunodeficiency virus
				  (HIV), antibodies to or antigens of the probable causative agent of acquired
				  immune deficiency syndrome (AIDS);
(b) request of any applicant or insured
				  whether they have obtained a body fluid test for evidence of human
				  immunodeficiency virus (HIV), antibodies to or antigens of the probable
				  causative agent of acquired immune deficiency syndrome (AIDS) or the result of
				  such test; or
(c) consider or use
				  the result of any body fluid test for evidence of human immunodeficiency virus
				  (HIV), antibodies to or antigens of the probable causative agent of acquired
				  immune deficiency syndrome (AIDS), regardless of the sources of or method used
				  to obtain such result.
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 52.28 - Medicare supplement insurance reporting form and refund calculation form

Current through Register Vol. 46, No. 28, July 10, 2024
The data required by section
					 52.44(c) 
					 of this Part shall be submitted to the superintendent in the following
					 form:
(a) Medicare supplement refund
				  calculation form.
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(b) Reporting form for the calculation of
				  benchmark ratio since inception for group policies or certificates delivered or
				  issued for delivery in New York State.
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(c) Reporting form for the calculation of
				  benchmark ratio since inception for individual policies delivered or issued for
				  delivery in New York State.
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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 52.30 - Preliminary review

Current through Register Vol. 46, No. 28, July 10, 2024
Printer's proofs, typewritten or other legible copy of
					 forms may be submitted for preliminary review prior to submission for
					 approval.
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 52.32 - Conditions for prefiled group coverage

Current through Register Vol. 46, No. 28, July 10, 2024
Group insurance coverage, except coverage filed to
					 specifically comply with article 9 of the Workers' Compensation Law, may be
					 provided prior to the filing or approval of forms, provided that the conditions
					 contained in this section are met. Failure to meet any of the conditions within
					 the time specified shall be a violation of the Insurance Law, unless reasons
					 for delay, including its probable extent, satisfactory to the department are
					 submitted to the department within the respective times specified.
(a) A copy of a letter of confirmation sent
				  to the policyholder by the insurer shall be submitted to the department within
				  30 days after the date the insurer agrees to provide insurance, setting forth,
				  inter alia:
(1) the effective date of
				  coverage;
(2) the nature and extent
				  of the benefits or change in benefits as then known;
(3) that the contractual forms may be
				  executed and issued for delivery only after filing with or approval thereof by
				  the department; and
(4) an
				  understanding that, if such forms are not filed or approved or are disapproved,
				  the parties will be returned to the status quo insofar as possible, or the
				  coverage will be modified retroactively to meet all requirements necesssary for
				  approval.
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 52.33 - Letter of submission

Current through Register Vol. 46, No. 28, July 10, 2024
A letter of submission in duplicate (single copy for
					 individual forms intended for delivery by domestic insurers exclusively outside
					 New York) shall be included in the filing, signed by a representative of the
					 company authorized to submit forms for filing or approval, containing the
					 following:
(a) the identifying form
				  number of each form submitted;
(b)
				  if the form is a policy, the kind of accident and health by reference to the
				  statutory and regulatory authority therefor; and the kind of policy as defined
				  in section
				  52.5,
				  52.6,
				  52.7,
				  52.8,
				  52.9,
				  52.10
				  or
				  52.11 
				  of this Part;
(c) a statement
				  whether the form is new or supersedes an approved or filed form or
				  forms;
(d) if the form supersedes
				  an approved or filed form, the form number and date of approval or filing of
				  the superseded form and any material differences from the superseded form. If
				  approval of the superseded form is still pending, the form number, control
				  number assigned by the department and the submission date;
(e) if the form had previously been submitted
				  for preliminary review, a reference to the previous submission and a statement
				  setting out either:
(1) that the form agrees
				  precisely with the previous submission; or
(2) the differences from the form submitted
				  for preliminary review;
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 52.40 - Procedures and requirements for filing of rates

Current through Register Vol. 46, No. 28, July 10, 2024
The following provisions shall apply with respect to
					 rates:
(a) General.
(1) Supporting material for all rate filings
				  shall be separately set forth in an actuarial memorandum or covering letter
				  accompanying the rates being filed.
(2) All policies, forms, manuals, schedules
				  and other material submitted shall be in duplicate.
(3) Rate changes, additions and deletions
				  shall be made by substituting, deleting or adding numbered pages to the rate
				  manual or schedule of rates.
(4) If
				  a rate filing precedes the filing of a form, reference should be made to the
				  rate control number when the form is submitted. Subsequent correspondence
				  should refer to both control numbers.
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 52.41 - Gross premium differentials based on sex

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The following requirements are
				  established to limit maximum gross premium differentials between males and
				  females for all accident and health policies or coverages where the insurance
				  premium is paid by the insured:
(1) Net or
				  gross premium assumptions may differentiate between the sexes only for factors
				  based on differences in morbidity or mortality between males and
				  females.
(2) Lapse and average size
				  assumptions may not differ between males and females unless the insurer
				  demonstrates to the satisfaction of the superintendent that the difference has
				  a relationship to the morbidity or mortality assumptions such that the
				  resulting rates are not unfairly discriminatory.
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 52.42 - Health maintenance organization (HMO) contract forms and premium rates

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Requirements for prior approval of forms and rates.
(1) Contracts, certificates, applications,
				  riders and endorsements used by an HMO to provide benefits and their proposed
				  rates must be filed with and approved by the superintendent in accordance with
				  section 4308  of the Insurance Law.
(2) Reasonable differentials between group
				  and direct payment rates may be established to reflect differences in marketing
				  costs as well as different administrative costs in collecting payments from
				  direct pay contract holders.
(3)
				  The premium adjustments of all community rated contracts are subject to the
				  provisions of section 4308  of the Insurance Law.
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 52.43 - Standards for maintaining experience data

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The following rules shall apply with
				  respect to experience data for individual insurance.
(1) Maintaining experience. Premium and loss
				  data shall be recorded for each policy form and, where more than one coverage
				  may be provided at the option of the insured under a single policy form, for
				  each major combination of coverage and each age group (i.e., under age 65 and
				  age 65 and over) on the following basis for each calendar year:
(i) premiums written or paid;
(ii) each reserve component (i.e., the
				  increase in premium reserves, policy reserves, and claim reserves and
				  liability);
(iii) earned premiums
				  by duration, in durations corresponding to the expected loss ratios in section
				  52.40(d)(1)(x) 
				  of this Part. Approximations by duration may be used when included as part of
				  the filing under section
				  52.40(d)(1) 
				  of this Part, or by separate prior approval;
(iv) paid losses;
(v) incurred losses;
(vi) the interest assumptions used in the
				  applicable expected future loss ratio calculations; and
(vii) dividends incurred, as used in the
				  policy experience exhibit.
Other than subparagraphs (vi) and (vii), the above terms
					 are as defined in the current New York Instructions for Completion of the Life
					 and Accident and Health Annual Statement. For policies issued on an attained
					 age rating basis, or where benefits or premiums are changed at attained age 65,
					 experience must be separately maintained for those under age 65 and age 65 and
					 over. Experience, by age, need not be maintained for certain coverages, such as
					 travel accident, with the prior consent of the superintendent.
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 52.44 - Standards for annual filing of experience data

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Policies issued after June 21,
				  1981, at ages 65 and over.
In order to monitor the claims experience of all policies,
					 other than a group or group remittance policy which provides continued coverage
					 for persons beyond age 65, issued to persons aged 65 or over, including
					 Medicare supplement insurance, insurers must file with the superintendent
					 experience data annually in accordance with the following rules:
(1) The experience data shall be submitted to
				  the superintendent by May first of each year.
(2) The experience data shall consist of the
				  following for each calendar year since inception, for all calendar years
				  combined, and for all years accumulated at the interest assumptions used in the
				  applicable expected future loss ratio calculation:
(i) written or paid premiums;
(ii) each reserve component
				  (
i.e.,
the increase in premium reserves, policy reserves, and
				  claim reserves and liabilities, and the assumptions used in computing these
				  reserves);
(iii) earned
				  premium;
(iv) paid
				  claims;
(v) incurred
				  claims;
(vi) dividends to
				  policyholders; and
(vii) premium
				  refund or credit as required by subdivision (c) of this section.
The above terms are as defined in the current instructions
					 for
Completion of the Life and Accident and Health Annual
					 Statement.
(3) The experience data required by paragraph
				  (2) of this subdivision shall be submitted to the superintendent in the
				  following form and shall clearly specify whether the experience reported is
				  nationwide or for New York State only:
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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 52.45 - Minimum loss ratio standards

Current through Register Vol. 46, No. 28, July 10, 2024
The standards referred to in section
					 52.40  and other applicable
					 sections of this Part shall be as follows:
(a)
Individual insurance.
The minimum loss ratio for such individual insurance shall
					 be determined according to the following table:
Renewal
								  clause
*
Type of
								  coverage
OR
CR
GR
NC
NR
Insurance, as defined in sections
								  52.5,
								  52.6,
								  52.7  of this Part and other
								  hospital, medical, surgical coverage, including hospital indemnity
60%
55%
55%
50%
50%
Insurance, as defined in sections
								  52.12 and
								  52.13  of this Part
NA
NA
60%
NA
NA
Loss of income and other
60%
55%
50%
50%
50%
(1) OR
				  (Optionally Renewable): renewal is at the option of the insurance
				  company.
(2) CR (Conditionally
				  renewable): renewal can be declined by the insurance company only for stated
				  reasons other than deterioration of health.
(3) GR (Guaranteed Renewable): as defined in
				  sections 52.17(a)(6) and
				  52.25(b)(1)  of
				  this Part.
(4) NC (Noncancellable):
				  as defined in section
				  52.17(a)(5)  of
				  this Part.
(5) NR (Nonrenewable):
				  short-term nonrenewable with a maximum duration of one year and no contractual
				  renewal provision. It is expected that the minimum loss ratios applicable to
				  certain policy forms in this classification may be modified under subdivision
				  (g) of this section.
except that if the policy form, other than long term care
					 insurance, nursing home insurance only, home care insurance only, and nursing
					 home and home care insurance, has an average annual premium less than $180, the
					 minimum loss ratio shall be five percentage points less than otherwise
					 applicable. The average annual premium per policy shall be computed by the
					 insurer based on an anticipated distribution of business by all applicable
					 criteria having a price difference, such as age, sex, amount, dependent status,
					 rider frequency, etc.
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 52.47 - Monitoring of experience data submitted under section 52.44(a) of this part

Current through Register Vol. 46, No. 28, July 10, 2024
The superintendent shall monitor the experience data
					 submitted in accordance with section
					 52.44(a) 
					 of this Part, for the purpose of assuring compliance with the minimum loss
					 ratio standards of this Part. If, after considering the data submitted by an
					 insurer in accordance with section
					 52.44(a),
					 and such other data as may have been furnished, the superintendent finds the
					 applicable loss ratio standard will not be met over the past and future
					 lifetime of the policy form, the superintendent will notify the insurer that a
					 plan for assuring compliance with such applicable minimum loss ratio standard
					 must be submitted within 90 days to the superintendent. The insurer's plan may
					 utilize premium reductions, dividends, benefit increases, premium refunds or
					 credits, or any combination of these or other methods such that the loss ratio
					 standard described can reasonably be expected to be achieved; however, such
					 plan is subject to approval by the superintendent. In most instances, benefit
					 increases may not be included as part of the insurer's plan without offering
					 the alternative option of appropriate premium reduction. Failure to submit such
					 a plan within the required time period will be a violation of this regulation
					 and will subject the insurer to the penalties of section 109  of the Insurance Law.
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 52.51 - Applications

Current through Register Vol. 46, No. 28, July 10, 2024
The following provisions shall apply to applications for
					 insurance:
(a) No application shall
				  contain questions as to race of the applicant.
(b) Questions regarding past or present
				  health of any person phrased with reference to specific diseases or general
				  health shall be asked to the best of the applicant's knowledge and belief.
				  Questions phrased as to factual information, such as doctor visits or hospital
				  confinements, need not be so qualified.
(c) No application shall contain a provision
				  which changes the terms of the policy to which it is attached.
(d) No application shall contain a statement
				  that the applicant has not withheld any information or concealed any
				  facts.
(e) No application shall
				  contain an agreement that an untrue or false answer material to the risk shall
				  render the contract void.
(f) No
				  application shall contain an agreement that acceptance of any policy issued
				  upon the application will constitute a ratification of any changes or
				  amendments made by the insurer and inserted in the application, except in
				  conformity with section 3204 (d)  of the Insurance
				  Law.
(g) Applications for
				  conversion policies may not contain questions as to the health of the person or
				  persons entitled to conversion.
(h)
				  Applications for policies subject to section 3216(d)(2)(D)-(E) shall contain a
				  question or questions requiring information with respect to such other
				  insurance.
(i) If an insurer
				  includes in a policy the optional standard provision "Other Insurance in this
				  Insurer", a statement describing the provision in the policy shall be included
				  in the application, or provided at the time of application by separate
				  notice.
(j) When a policy includes
				  a provision with respect to preexisting conditions, a statement describing the
				  provision in the policy shall be included in the application, or provided at
				  the time of application by delivery of the disclosure statement required by
				  section
				  52.54  of
				  this Part.
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 52.53 - Conditional receipts and interim insurance agreements

Current through Register Vol. 46, No. 28, July 10, 2024
Except as otherwise stated herein an insurer must issue
					 either a conditional receipt or interim insurance agreement if premium is paid
					 prior to delivery of the policy and the insurer requires a determination of
					 insurability as a condition precedent to the issuance of a policy. The
					 following rules shall apply to conditional receipts and interim insurance
					 agreements:
(a) A conditional receipt
				  which requires a determination of insurability as a condition precedent to
				  coverage shall include an agreement:
(1) to
				  provide coverage subject to any reasonable limit regarding the amount of
				  insurance specified in the receipt, contingent upon insurability; and
(2) to provide that such insurability be
				  determined as of a date no later than the date of completion of all parts of
				  the application, including completion of the first medical examination if one
				  is required by the company's underwriting rules, and the required premium has
				  been paid. Completion of a second medical examination may be required as a
				  condition precedent to coverage if initially required by the company's
				  underwriting rules because of the amount of insurance applied for or the age of
				  the proposed insured.
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 52.54 - Disclosure requirements

Current through Register Vol. 46, No. 28, July 10, 2024
(a) No
				  individual accident and health insurance policy shall be delivered or issued
				  for delivery in this State, unless the appropriate disclosure form in sections
				  52.55
				  through
				  52.62 
				  of this Part is completed as to such policy and accompanies or is incorporated
				  in such policy when delivered, or unless such appropriate disclosure form is
				  delivered to the applicant at the time application is made and acknowledgment
				  of receipt or certification of delivery of such disclosure form is provided to
				  the insurer. The appropriate disclosure form for policies providing hospital
				  coverage which does not meet the standards of section
				  52.5 or
				  52.7  of
				  this Part shall be that statement contained in section
				  52.59 
				  of this Part. The appropriate disclosure form for policies providing coverage
				  which meets the standards of both sections
				  52.5 and
				  52.6  of
				  this Part shall be the statement contained in section
				  52.57 
				  of this Part. The appropriate disclosure form for policies providing coverage
				  which meets the standards of both sections
				  52.5 and
				  52.7  or
				  sections
				  52.6 and
				  52.7  or
				  sections
				  52.5,
				  52.6 and
				  52.7 
				  shall be the statement contained in section
				  52.58 
				  of this Part.
(b) The expected
				  benefit ratio required in the statement contained in sections
				  52.55
				  through
				  52.61,
				  52.65
				  and
				  52.66 
				  of this Part shall be:
(1) a number which is
				  greater than or equal to the applicable minimum loss ratio of section
				  52.45 
				  of this Part, and is less than or equal to the expected future loss ratio filed
				  for the policy form;
(2) where no
				  expected future loss ratio has been filed with a previously approved policy
				  form, but an anticipated loss ratio has been filed, a number which is greater
				  than or equal to the currently applicable minimum loss ratio and is less than
				  or equal to the anticipated loss ratio filed for the policy form;
(3) where no anticipated loss ratio or
				  expected future loss ratio has been filed with a previously approved policy
				  form, the minimum loss ratio permitted for the policy form as set forth in
				  section
				  52.45;
				  and
(4) where different loss ratios
				  are expected for different classes within the same form, the limits specified
				  in paragraphs (1) through (3) of this subdivision, based on the expected
				  aggregate premium of all classes under the policy form.
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 52.55 - Required disclosure statement for policies meeting standards of section 52.5 of this part

Current through Register Vol. 46, No. 28, July 10, 2024
To comply with section
					 52.54  of
					 this Part, policies of individual insurance meeting the standards of section
					 52.5  of
					 this Part shall use the following statement only, except that appropriate
					 policy identification may be included:
COMPANY NAME
BASIC HOSPITAL INSURANCE
REQUIRED DISCLOSURE STATEMENT
This policy meets the minimum standards for basic hospital
					 insurance as defined by the New York State Insurance Department and pays [FN*]
					 (, subject to ________[FN**] deductible,) (the semi-private room and board and
					 miscellaneous hospital charges) (the semi-private room and board charges up to
					 a maximum of $________ per day and miscellaneous hospital charges up to a
					 maximum of $________) ( ________% of the semi-private room and board charges)
					 ($________ per day for room and board charges and miscellaneous hospital
					 charges up to a maximum of $________) for not more than. ________days for each
					 continuous hospital confinement, and outpatient hospital services for surgery
					 and for accidental injury when performed within ________hours following
					 accidental injury (up to a maximum of $________) This policy:
1.
(is) (is
				  not) renewable to eligibility for Medicare by reason of age.
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 52.56 - Required disclosure statement for policies meeting standards of section 52.6 of this part

Current through Register Vol. 46, No. 28, July 10, 2024
To comply with section
					 52.54  of
					 this Part, policies of individual insurance meeting the standards of section
					 52.6  of
					 this Part shall use the following statement only, except that appropriate
					 policy identification may be included:
COMPANY NAME
BASIC MEDICAL INSURANCE
REQUIRED DISCLOSURE STATEMENT
This policy meets the minimum standards for basic medical
					 insurance as defined by the New York State Insurance Department and pays [FN*]
					 (________% [FN**]of the doctor's reasonable charges for anesthesia, in-hospital
					 medical and surgical services.) (a maximum of $________for surgery) (anesthesia
					 up to ________% of the surgical coverage) (in-hospital medical service up to
					 $________per day for ________days.) (surgical, anesthetic and in-hospital
					 medical service in full for persons whose income is below $________per year.)
					 (surgical, anesthetic and in-hospital medical services in full.) This
					 policy:
1.
(is) (is not) renewable to eligibility for
				  Medicare by reason of age.
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 52.57 - Required disclosure statement for policies meeting standards of both sections 52.5 and 52.6 of this part

Current through Register Vol. 46, No. 28, July 10, 2024
To comply with section
					 52.54  of
					 this Part, policies of individual insurance meeting the standards of both
					 sections
					 52.5 and
					 52.6  of
					 this Part shall use the following statement only, except that appropriate
					 policy identification may be included:
COMPANY NAME
BASIC HOSPITAL AND MEDICAL INSURANCE
REQUIRED DISCLOSURE STATEMENT
This policy meets the minimum standards for basic hospital
					 insurance and basic medical insurance as defined by the New York State
					 Insurance Department and pays[FN*] (, subject to a $________[FN**]deductible,)
					 (the semi-private room and board and miscellaneous hospital charges) (the
					 semi-private room and board charges up to a maximum of $________per day and
					 miscellaneous hospital charges up to a maximum of $________) ( ________% of the
					 semi-private room and board charge) ($________per day for room and board
					 charges and miscellaneous hospital charges up to a maximum of $________) for
					 not more than ________days for each continuous hospital confinement, and
					 outpatient hospital services for surgery and for accidental injury when
					 performed within________hours following accidental injury (up to a maximum of
					 $________) and ( ________% of the doctor's reasonable charges for anesthesia,
					 in-hospital medical and surgical services.) (a maximum of $________for surgery)
					 (anesthesia up to ________% of the surgical coverage) (in-hospital medical
					 service up to $________per day for________days.) (surgical, anesthetic and
					 in-hospital medical service in full for persons whose insurance is below $
					 ________per year.) (surgical, anesthetic and in-hospital medical services in
					 full.) This policy:
1.
(is) (is not) renewable to eligibility for
				  Medicare by reason of age.
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 52.58 - Required disclosure statement for policies meeting standards of section 52.7 of this part

Current through Register Vol. 46, No. 28, July 10, 2024
To comply with section
					 52.54  of
					 this Part, policies of individual insurance meeting the standards of section
					 52.7  of
					 this Part shall use the following statement only, except that appropriate
					 policy identification may be included:
COMPANY NAME
MAJOR MEDICAL INSURANCE
REQUIRED DISCLOSURE STATEMENT
This policy meets the minimum standards for major medical
					 insurance as defined by the New York State Insurance Department and pays for
					 hospital and medical care subject to a copayment by you of ________% [FN*] and
					 a deductible [FN**] (equal to the benefits paid under other insurance or
					 $________, whichever is greater) (equal to the benefits paid under other
					 insurance plus $________) (of $ ________per person) (of $________per family)
					 (of $________per illness) (of $________per benefit period) (of $ ________per
					 year) and a total maximum limit of $ ________(This policy defines "covered
					 charges"[FN***]which has the effect of reducing the amount of the actual
					 charges which otherwise would be covered.) (Covered charges are limited to a
					 maximum of $________per day for hospital room and board,) ($ ________ for
					 miscellaneous hospital charges) (and $ ________for surgery.) This
					 policy:
1.
(is) (is not) renewable to eligibility for
				  Medicare by reason of age.
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 52.60 - Required disclosure statement for policies meeting definition of section 52.8 of this part

Current through Register Vol. 46, No. 28, July 10, 2024
To comply with section
					 52.54  of
					 this Part, policies of individual insurance meeting the definition of section
					 52.8 
					 of this Part shall use the following statement only, except that appropriate
					 policy identification may be included:
COMPANY NAME
DISABILITY INCOME INSURANCE
REQUIRED DISCLOSURE STATEMENT
This policy provides disability income insurance. It does
					 NOT provide basic hospital, basic medical or major medical insurance, as
					 defined by the New York State Insurance Department. This policy:
( Accurately list benefits, exclusions, reductions and
					 limitations of the policy in a manner which does not encourage
					 misrepresentation of the actual coverage provided.)
This disclosure statement is a very brief summary of your
					 policy.
The policy itself sets forth the rights and obligations of
					 both you and the Insurance Company. It is therefore important that you READ
					 YOUR POLICY carefully.
The expected benefit ratio for this policy is ________%.
					 This ratio is the portion of future premiums which the company expects to
					 return as benefits, when averaged over all people with this
					 policy.
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 52.61 - Required disclosure statement for policies meeting definition of section 52.9 of this part

Current through Register Vol. 46, No. 28, July 10, 2024
To comply with section
					 52.54  of
					 this Part, policies of individual insurance meeting the definition of section
					 52.9  of this
					 Part shall use the following statement only, except that appropriate policy
					 identification may be included:
COMPANY NAME
ACCIDENT INSURANCE
REQUIRED DISCLOSURE STATEMENT
This policy provides insurance only for ACCIDENTS. It does
					 NOT provide basic hospital, basic medical or major medical insurance, as
					 defined by the New York State Insurance Department.
IMPORTANT NOTICE--THIS POLICY DOES NOT PROVIDE COVERAGE FOR
					 SICKNESS.
This policy:
(Accurately list benefits, exclusions, reductions and
					 limitations of the policy in a manner which does not encourage
					 misrepresentation of the actual coverage provided.)
This disclosure statement is a very brief summary of your
					 policy.
The policy itself sets forth the rights and obligations of
					 both you and the Insurance Company. It is therefore important that you READ
					 YOUR POLICY carefully.
The expected benefit ratio for this policy is to ________%.
					 This ratio is the portion of future premiums which the company expects to
					 return as benefits, when averaged over all people with this
					 policy.
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 52.62 - Required disclosure statement for policies meeting definition of section 52.10 of this part

Current through Register Vol. 46, No. 28, July 10, 2024
To comply with section
					 52.54  of
					 this Part, policies of individual insurance meeting the definition of section
					 52.10 
					 of this Part, which provide only dental insurance coverage, shall use the
					 following statement only, except that appropriate policy identification may be
					 included:
COMPANY NAME
DENTAL INSURANCE
REQUIRED DISCLOSURE STATEMENT
This policy provides dental insurance only and pays for
					 dental care subject to a copayment by you of to ________%[FN*] and a deductible
					 of ($ to ________ per person)[FN**] ($________ per family) ($________ per year)
					 ($ ________ per benefit period) and a total maximum of $________
This policy:
( Accurately list benefits, exclusions, reductions and
					 limitations of the policy in a manner which does not encourage
					 misrepresentation of the actual coverage provided.)
This disclosure statement is a very brief summary of your
					 policy.
The policy itself sets forth the rights and obligations of
					 both you and the Insurance Company. It is therefore important that you READ
					 YOUR POLICY carefully.
The expected benefit ratio for this policy is ________%.
					 This ratio is the portion of future premiums which the company expects to
					 return as benefits, when averaged over all people with this policy.
[FN*] Omit reference to year if, in lieu of dollar amounts,
					 deductibles and fractions of the deductibles are set forth in the
					 summary.
[FN**] In lieu of listing specific dollar amounts, insurers
					 may refer to the Part A or Part B deductibles and appropriate fractions
					 thereof.