New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 34 - STANDARDS FOR ACCIDENT-ONLY, SPECIFIED DISEASE, HOSPITAL INDEMNITY, DISABILITY INCOME, SUPPLEMENTAL, AND NON-SUBJECT WORKER EXCEPTED BENEFITS › Section 13.10.34.8 - GENERALLY APPLICABLE PROVISIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A plan subject to this rule shall comply with these
				  provisions:
A.
Probationary
				periods
A plan shall not include a probationary or waiting period during
				which no coverage is provided for a covered benefit after the coverage
				effective date. A probationary period does not include an eligibility-waiting
				period during which no premium is paid, or an elimination period for a
				disability income plan.
B.
Riders and other supplements
A rider, amendment, endorsement or
				other supplement shall explicitly state which benefits the carrier has amended
				or supplemented from the original plan.
C.
Preexisting conditions
An
				individual plan, or plan sold through an association or group described in
				Paragraph (2) or (4) of Subsection A of Section
				59A-23-3
				NMSA 1978, shall not exclude coverage for a loss due to a preexisting condition
				unless the application or enrollment form includes a conspicuous notice about
				the scope and applicability of any such exclusion that will apply in the
				coverage, and that notice also appears in the plan document issued to the
				covered person at the start of the free look period.
D.
Return of premium
A plan may
				include a return of premium or cash value benefit if authorized by the
				superintendent following an evaluation of the potential impact on the carrier's
				reserves and ability to service policy obligations. Nothing in this rule
				requires a carrier to seek authorization from the superintendent to return
				premiums unearned through termination or suspension of coverage, retroactive
				waiver of premium paid during a medical condition, payment of dividends on
				participating policies, or experience rating refunds.
E.
Exclusions
A plan shall not
				exclude any type, circumstance or cause of loss that would not otherwise be
				covered, and the plan exclusions shall not, individually or collectively,
				unreasonably or deceptively alter the scope of coverage. Subject to the
				foregoing, a plan may exclude coverage for the following conditions,
				circumstances and causes of loss:
(1)
				preexisting conditions;
(2) loss
				resulting from or contributed to by:
(a) war
				or act of war (whether declared or undeclared); participation in a felony, riot
				or insurrection; service in the armed forces or units auxiliary to
				it;
(b) suicide (sane or insane),
				attempted suicide or intentionally self-inflicted injury within two years of
				the effective date of coverage;
(c)
				aviation, other than travel as a fare paying passenger on a commercial carrier;
				or
(d) incarceration or detention
				due to illegal activity.
(3) loss for which benefits are provided
				under Medicare or other governmental program (except Medicaid), a state or
				federal workers' compensation program, employers liability or occupational
				disease law, or motor vehicle no-fault law;
(4) participation in an illegal
				activity;
(5) voluntary intoxication
				by any legal or illegal drug, including alcohol;
(6) specifically named high-risk physical
				activities;
(7) international
				territorial limitations;
(8)
				occupational injury or disease;
(9)
				normal pregnancy or childbirth;
(10)
				foreign travel or residency; or
(11)
				any other type, circumstance or cause of loss if the carrier satisfies the
				superintendent that the exclusion promotes a legitimate underwriting or public
				policy objective or is required to comply with any state or federal
				law.