reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 16 - MINIMUM STANDARDS FOR INDIVIDUAL HEALTH INSURANCE › Section 11:4-16.2 - Applicability and scope

Current through Register Vol. 56, No. 14, July 15, 2024
This regulation shall apply to all individual health insurance policies delivered or issued for delivery in this State on or after the effective date hereof except that it shall not apply to conversion policies issued pursuant to a contractual conversion privilege or to credit health insurance. As used herein, policy means the entire contract between the insurer and the insured including all policies, certificates, riders, applications and endorsements which are required to be filed pursuant to 17B:26-1 and N.J.S.A. 17:44A-21. The requirements contained in this regulation shall be in addition to any other applicable regulations previously adopted. Nothing in this regulation shall be construed to limit the commissioner's authority to disapprove policies pursuant to N.J.S.A. 17B:26-1h, which in the opinion of the commissioner contain provisions that are unjust, unfair, inequitable, misleading or contrary to law or public policy of this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 16 - MINIMUM STANDARDS FOR INDIVIDUAL HEALTH INSURANCE › Section 11:4-16.3 - Effective date

Current through Register Vol. 56, No. 14, July 15, 2024
This regulation shall be effective after it has been accepted by the Legislature. Acceptance by the Legislature will occur 60 days after the regulation has been submitted to the Legislature, unless the Legislature passes a concurrent resolution stating in substance that the Legislature does not favor this regulation. This regulation shall be applicable to all individual health insurance policies, not specifically exempt from this regulation, delivered or issued for delivery in this State 120 days after acceptance by the Legislature.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 16 - MINIMUM STANDARDS FOR INDIVIDUAL HEALTH INSURANCE › Section 11:4-16.4 - Policy definitions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except as provided hereafter, no health insurance policy delivered or issued for delivery in this State shall contain definitions respecting the matters set forth below unless such definitions comply with the requirements of this section.
1. "Accident", "accidental injury", "accidental means", shall be defined to employ "result" language and shall not include words which establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characteristics.
i. "Injury" shall not be defined more restrictively than accidental bodily injury sustained by the insured person which is the direct cause of the loss, independent of disease, bodily infirmity or other cause, and which occurs while the insurance is in force.
(1) Such definition may provide that injuries shall not include injuries for which benefits are provided under workers' compensation, employer's liability or similar law, out-of-State automobile insurance coverage as defined at 11:3-37.2 and provided for at 11:3-37.3, or injuries occurring while the insured person is engaged in any activity pertaining to any trade, business, employment, or occupation for wage or profit.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 16 - MINIMUM STANDARDS FOR INDIVIDUAL HEALTH INSURANCE › Section 11:4-16.5 - Prohibited policy provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No policy except a short term, nonrenewable trip policy shall provide coverage solely for specifically identified kind(s) of accident(s); however a policy may provide increased benefits for specifically identified accident(s) for any accident only coverage specified in section 6(g) of this subchapter.
(b) No policy shall provide for the payment of a single premium for the entire term of the policy, except for nonrenewable policies issued for a term of one year or less.
(c) No policy shall provide benefits which duplicate the specific benefits provided by Part A or Part B of Medicare (benefits for which the insured is eligible to enroll).
(d) No policy or rider for additional coverage may be issued as a dividend unless an equivalent cash payment is offered to the policyholder as an alternative to such dividend policy or rider. No such dividend policy or rider shall be issued for an initial term of less than six months.
1. The initial renewal subsequent to the issuance of any policy or rider as a dividend shall clearly disclose that the policyholder is renewing the coverage that was provided as a dividend for the previous term and that such renewal is optional with the policyholder.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 16 - MINIMUM STANDARDS FOR INDIVIDUAL HEALTH INSURANCE › Section 11:4-16.6A - Minimum standards for individual health benefits plans

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This section sets forth the minimum standards that are prescribed for individual health insurance policies that are health benefits plans.
(b) All individual health benefits plans shall comply with N.J.A.C. 11:20.
(c) No individual benefits plan shall be delivered or issued for delivery in this State that does not also meet the following required minimum standards for the specified categories:
1. In a policy that provides a second surgical opinion benefit, the following conditions must be met:
i. The benefit includes a definition of elective surgery that is sufficiently clear to permit the average insured to distinguish between "elective" and "nonelective" surgery;
ii. Second surgical opinions will be rendered only by specialists who are clearly qualified in their field, who are independent of the physician who makes the original recommendation for surgery, and who have no financial interest in the outcome (for or against surgery) of their recommendations. "Clearly qualified" will be deemed satisfied by board certification in the field of proposed surgery or in the field of medical specialization concerned with the organ involved. "Independent" will be assumed if names of qualified second opinion specialists are provided by the insurer, although the insurer may provide other methods of designating specialists that result in an equal degree of independence. "No financial interest" will be deemed to exist if the specialist providing a second opinion is prohibited from performing the recommended surgery, if his or her remuneration is not dependent on the nature of his or her recommendation, and if he or she has no financial involvement of any nature in a partnership, corporation, or office with the first physician recommending surgery, or the facility and/or location at which the surgery will occur;
iii. A second surgical opinion cannot be mandatory, unless the insurer is able to provide to the insured names of qualified specialists who are within convenient access to the insured. "Mandatory" means that payment of claims for elective surgery is conditioned on having obtained a second opinion; and
iv. If the policy requires the insured to pay for any part of the second surgical opinion (copayment, deductible, and/or maximum amount), the premium for the policy cannot exceed the premium payable for a comparable policy without second surgical opinion benefits, and the insurer shall disclose to the insured that his or her out-of-pocket expenses may exceed the expenses that would result from an otherwise comparable policy without a second surgical opinion benefit. See N.J.A.C. 11:4-16.8(d), (e), and (f) for disclosure requirements; and
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 16 - MINIMUM STANDARDS FOR INDIVIDUAL HEALTH INSURANCE › Section 11:4-16.7 - Application forms

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Application forms shall not include provisions, statements or questions that:
1. Pertain to race, creed, color, national origin or ancestry of the proposed insured, except for hospital-medical insurance application forms for the purpose of collecting demographic data. No application form may include any provision or statement the effect of which is to discriminate against the proposed insured on the basis of race, creed, color, or national ancestry in a manner prohibited by law;
2. Change the terms of the policy to which it is attached;
3. State that the applicant has not withheld any information or concealed any facts; or
4. Require the applicant to agree that an untrue or false answer material to the risk shall render the contract void.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 16 - MINIMUM STANDARDS FOR INDIVIDUAL HEALTH INSURANCE › Section 11:4-16.9 - Forms submission requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) General rules include:
1. Within 120 days after the effective date of this regulation, each issuer shall submit a list of all individual health insurance forms currently filed which meet the requirements contained herein. An executive officer of the company shall certify that the forms listed comply with this regulation.
2. Each form submitted for filing by the commissioner shall be accompanied by an individual health insurance report as specified in (c) below.
3. Each submission shall include a description of the marketing arrangements for the form(s). This description should specify the intended use and purpose of the form, the methods by which the form will be sold, and the segment of the general public that is expected to make up the largest portion of applicants. If the form will be solicited by mail or any mass marketing scheme, the submission shall also include copies of advertising materials.
4. The application form and any riders, endorsements or amendments which are required to be attached at issue shall be included with the submission.
5. Each form shall be filled in with hypothetical data as for specimen issue.
6. Each rider, amendment or endorsement shall specify the forms with which it will be used and shall indicate any changes in benefits, coverages, exclusions or rates that will result.
7. A rubber stamp endorsement shall be shown on a specimen policy page as it will appear in actual use.
8. Wording in any form which is to be considered variable shall be appropriately indicated, and any alternate wording shall be included with the submission.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 16 - MINIMUM STANDARDS FOR INDIVIDUAL HEALTH INSURANCE › Section 11:4-16.10 - Separability

Current through Register Vol. 56, No. 14, July 15, 2024
If any provision of the regulation or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the regulation and the application of such provision to other persons or circumstances shall not be affected thereby.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 16 - MINIMUM STANDARDS FOR INDIVIDUAL HEALTH INSURANCE › Section 11:4-16.11 - Penalties

Current through Register Vol. 56, No. 14, July 15, 2024
If after notice and hearing the commissioner finds that a person has violated this regulation, a penalty, in addition to any other penalty, not exceeding $ 2,000 for each violation may be imposed and shall be collected and enforced pursuant to N.J.S.A. 2A:58-1 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 17 - HEALTH INSURANCE SOLICITATION › Section 11:4-17.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
The purpose of this rule is to eliminate unfair and deceptive practices in the promotion, solicitation, and sale of individual health insurance.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 17 - HEALTH INSURANCE SOLICITATION › Section 11:4-17.2 - Applicability and scope

Current through Register Vol. 56, No. 14, July 15, 2024
This regulation shall apply to all individual health insurance policies delivered or issued for delivery in this state on or after the effective date hereof except that it shall not apply to conversion policies issued pursuant to a contractual conversion privilege or to credit health insurance. This regulation shall be in addition to any other applicable regulations previously adopted.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 17 - HEALTH INSURANCE SOLICITATION › Section 11:4-17.4 - Unfair and deceptive acts

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No person shall engage in any unfair, deceptive, misleading, or unreasonably confusing practice in the promotion, solicitation or sale of individual health insurance.
(b) The following acts and practices shall be deemed prima facie evidence of a violation of this regulation and of demonstrated unworthiness on the part of any licensee or insurer:
1. Any act tending to induce an applicant or other person to purchase duplicative coverage;
2. Encouraging an applicant to omit pertinent underwriting information from an application for health insurance;
3. Any act tending to induce a prospective insured to sign a blank or incomplete application or form;
4. Failure to disclose upon initial contact with a prospective applicant the licensee's affiliation with an insurance company.
5. Any representations, expressed or implied, unless the licensee has been specifically authorized in writing by the organization, that the licensee is affiliated with or authorized by any civic, social, government or other organization;
6. Making any false or misleading statements as to the length of time an insurance offering may or may not be available;
7. The sale of any policy withdrawn from or disapproved for filing as not in compliance with the New Jersey insurance laws or regulations;
8. Selling Medicare supplement insurance to any person not eligible for Medicare;
9. Falsely answering any question or signing any certification in an application or in any other form required to be completed by the licensee; or
10. Failure to remit, within seven business days, the amount of premium collected from an applicant that is due the company.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 17 - HEALTH INSURANCE SOLICITATION › Section 11:4-17.6 - Complaint record to be maintained

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
									17B:30-13.2 requires the maintenance of complaint records. The following requirements prescribed the minimum information to be maintained in order to comply with the statute.
1. The minimum information required to be contained in a person's complaint record is set forth in (b) below. Refinements and additions to the information specified may, of course, be maintained in such complaint record.
2. Subsection (b) below is the suggested format for the complaint record required to be maintained. Refinements, deviations from or additions to this suggested format are permitted so long as the minimum information contemplated by such format can be obtained for Insurance Department review within a reasonable time following a request therefor by an authorized representative of the Department.
3. Subsection (c) below contains an explanation of the various headings, codes, and other notations contained in (b) below. The codes are used in order to simplify both the identification of the action underlying the complaint and the keeping of the records.
4. The complaint record shall be kept on a calendar year basis and the number of complaints by line of insurance, function, reason, disposition and state of origin shall be compiled at least annually.
5. "Complaint" shall mean a written communication primarily expressing a grievance.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 17 - HEALTH INSURANCE SOLICITATION › Section 11:4-17.7 - Penalties

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any person who, after notice and hearing, is determined by the Commissioner to be in violation of this regulation shall be liable to a penalty not exceeding $ 2,000 for each violation. In addition to, or in lieu thereof, the Commissioner may revoke or suspend the license or certificate of authority of any such agent, broker, consultant, or insurer.
(b) An insurer may be held legally accountable for violations of this regulation by any of its agents. If any agent is fined pursuant to this regulation, an equivalent fine may be levied against the insurer responsible for the agent's actions.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 17 - HEALTH INSURANCE SOLICITATION › Section 11:4-17.8 - Separability

Current through Register Vol. 56, No. 14, July 15, 2024
If any provision of the regulation or the application thereof to any person or circumstance shall be held invalid for any reason, the remainder of this regulation and the application of such provision to other persons or circumstances shall not be affected thereby.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 17 - HEALTH INSURANCE SOLICITATION › Section 11:4-17.9 - Effective date

Current through Register Vol. 56, No. 14, July 15, 2024
This regulation shall be effective after it has been accepted by the Legislature. Acceptance by the Legislature will occur 60 days after the regulation has been submitted to the Legislature, unless the Legislature passes a concurrent resolution stating in substance that the Legislature does not favor this regulation.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 18 - INDIVIDUAL HEALTH INSURANCE RATE FILINGS › Section 11:4-18.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
The purpose of this subchapter is to record the policies and practices which the commissioner has traditionally applied to assure that individual health insurance benefits are reasonable in relation to the premiums charged, as required by N.J.S.A. 17B:26-1h, and to further expand those policies and practices in order to comply with the additional requirements of 17B:26-45.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 18 - INDIVIDUAL HEALTH INSURANCE RATE FILINGS › Section 11:4-18.2 - Applicability and scope

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter shall apply to all individual health insurance policies delivered or issued for delivery in this State, except that it shall not apply to conversion policies issued pursuant to a contractual conversion privilege, it shall not apply to credit health insurance as defined by N.J.S.A. 17B:29-2b, and it shall not apply to individual health benefits plans as defined by N.J.S.A. 17B:27A-2et seq. Nothing in this subchapter may be construed so as to limit or waive the responsibilities otherwise imposed on insurers, with respect to the form and content of individual health insurance policies, by N.J.S.A. 17B:26.1 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 18 - INDIVIDUAL HEALTH INSURANCE RATE FILINGS › Section 11:4-18.3 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise.
1. Terms related to policy renewability are:
i. "Collectively renewable insurance" means all insurance which is made available on any individual basis under mass enrollment procedures to persons under a plan sponsored by an employer, association, or union, or to a group of individuals supplying materials to a central point of collection or handling a common product or commodity, under which the insurer has agreed that renewal will not be refused, subject to any specific age limit, while the insured remains a member of the group specified in the agreement, unless the insurer simultaneously refuses to renew all policies in the same group or all policies bearing the same form number.
ii. "Guaranteed renewable insurance" means all individual insurance which grants an insured the right to continue the policy in force by the timely payment of premiums until at least age 50, or in the case of a policy issued after age 44 for at least five years from the date of issue of the policy, during which period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force, except that the insurer may make changes in premium rates by classes.
iii. "Nonrenewable for stated reasons only insurance" means all individual insurance which limits the insurer's right of nonrenewal to stated reasons.
iv. "Noncancellable insurance" or "noncancellable and guaranteed renewable insurance" means all individual insurance which gives the insured the right to continue the insurance in force by the timely payment of premiums set forth in the policy until at least age 50, or in the case of a policy issued after age 44 for at least five years from its date of issue, during which period the insurer has no right to make unilaterally any change in any provision of the policy while it is in force.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 18 - INDIVIDUAL HEALTH INSURANCE RATE FILINGS › Section 11:4-18.4 - Rate submission requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each insurer shall include with each submission of new or revised rates the following information and material:
1. An actuarial memorandum which shall include the following:
i. The anticipated loss ratio;
ii. The specific formulas and methodology used in calculating gross premiums;
iii. An explanation and documentation supporting the premium assumptions;
iv. The objective basis for rate differentials; and
v. A certification signed by the company's Actuary that the information given in the actuarial memorandum is appropriate and that the benefits provided are reasonable in relation to the premiums charged.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 18 - INDIVIDUAL HEALTH INSURANCE RATE FILINGS › Section 11:4-18.5 - Loss ratio standards

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For new forms, the benefits provided are presumed reasonable in relation to the premiums charged if the anticipated loss ratio meets the following standards:
1. For over 65 coverage, the ratio is at least 65 percent;
2. For accident only coverage, the ratio is at least 50 percent;
3. For short term nonrenewable trip policies which do not cover loss due to sickness, the ratio is at least 40 percent;
4. For coverage other than as listed in 1, 2 and 3 above and which are:
i. Collectively renewable insurance, the ratio is at least 60 percent;
ii. Guaranteed renewable insurance or nonrenewable for stated reasons only insurance, the ratio is at least 55 percent;
iii. Noncancellable insurance or noncancellable and guaranteed renewable insurance, the ratio is at least 50 percent.
5. For any insurance not listed in (a)1 through (a)4 above, the ratio is at least 55 percent.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 18 - INDIVIDUAL HEALTH INSURANCE RATE FILINGS › Section 11:4-18.6 - Annual review of calendar year experience data on filed individual health insurance policy forms

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each insurer shall maintain records of premiums, claims, and reserves on each policy form as required for the accident and health policy experience exhibit.
(b) If the incurred/earned loss ratios for a particular policy form, based on a substantial volume of reasonably mature business, do not meet the standards set forth in section 5 of this subchapter, the insurer will be required to explain why the premiums should not be regarded as unreasonably high in relation to the benefits provided. After consideration of the explanation and any additional information furnished by the insurer, the department will inform the insurer if the benefits provided are considered unreasonable in relation to the premiums charged. If within 90 days thereafter the insurer does not reduce the premiums or increase the benefits provided in the policy such that the standards set forth in section 5 of this subchapter are met, the department may commence proceedings as provided by law for withdrawal of the filing of the form.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 18 - INDIVIDUAL HEALTH INSURANCE RATE FILINGS › Section 11:4-18.7 - Rate manual

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each insurer shall maintain on file with the department an up-to-date rate manual for all individual health insurance policies, riders, and endorsements currently available for sale in New Jersey. Such manual shall include:
1. Name of the insurer on each page;
2. Table of contents or index; and
3. Identification by form number of each policy, rider, and endorsement to which the rates apply.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 18 - INDIVIDUAL HEALTH INSURANCE RATE FILINGS › Section 11:4-18.8 - Separability

Current through Register Vol. 56, No. 14, July 15, 2024
If any provisions of this regulation or the application thereof to any person or circumstance shall be held invalid, the invalidity shall not affect the provisions or application of this regulation which can be given effect without the invalid provision or application, and for this purpose, the provisions of this regulation are separable.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 18 - INDIVIDUAL HEALTH INSURANCE RATE FILINGS › Section 11:4-18.9 - Penalties

Current through Register Vol. 56, No. 14, July 15, 2024
If, after notice and hearing the commissioner finds that a person has violated this regulation a penalty, in addition to any other penalty, not exceeding $ 2,000 for each violation may be imposed and shall be collected and enforced pursuant to N.J.S.A. 2A:58-1 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 18 - INDIVIDUAL HEALTH INSURANCE RATE FILINGS › Section 11:4-18.10 - Compliance

Current through Register Vol. 56, No. 14, July 15, 2024
All policies of insurance previously filed with the Commissioner which are not in compliance with this subchapter as of the operative date shall be deemed to be withdrawn from filing and disapproved. No new policy of insurance shall be delivered or issued for delivery in this State until the policy has been filed with the Commissioner.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 19 - OPTIONAL COVERAGE FOR PREGNANCY AND CHILDBIRTH BENEFITS › Section 11:4-19.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
The purpose of this subchapter is to prevent the exclusion of pregnancy-related surgery and sterilization procedures from certain second surgical opinion programs and to make maternity coverage available to insureds.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 19 - OPTIONAL COVERAGE FOR PREGNANCY AND CHILDBIRTH BENEFITS › Section 11:4-19.2 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter shall apply to all group and individual health insurance policies as well as hospital and medical service corporation contracts delivered or issued for delivery in this State, except that this subchapter does not apply to individual or group health benefits plans, or to health service corporation contracts, for which the provisions of pregnancy and childbirth benefits are not optional.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 19 - OPTIONAL COVERAGE FOR PREGNANCY AND CHILDBIRTH BENEFITS › Section 11:4-19.2A - 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.
"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.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 19 - OPTIONAL COVERAGE FOR PREGNANCY AND CHILDBIRTH BENEFITS › Section 11:4-19.3 - Second surgical opinions

Current through Register Vol. 56, No. 14, July 15, 2024
Every health insurer and medical service corporation offering individual and group policies in this State, with the exception of hospital service corporations, shall include in its programs for second surgical opinions, coverage for pregnancy-related surgery and sterilization procedures.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 19 - OPTIONAL COVERAGE FOR PREGNANCY AND CHILDBIRTH BENEFITS › Section 11:4-19.4 - Maternity benefits option

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each insurer issuing plans that are not health benefits plans shall make available benefits coverage for maternity care without regard to the marital status of its policyholders, subscribers, or other persons thereunder covered for expenses incurred in pregnancy and childbirth.
(b) The amount of or type of benefit coverage for maternity care expenses incurred in pregnancy and childbirth shall be provided to the same extent as benefits coverage is provided in policies and contracts for any other covered illness. Where a fixed amount of benefit coverage for surgery is prescribed by a policy or contract, benefit coverage for pregnancy-related surgical procedures shall be commensurate to that for surgery of comparable difficulty and severity.
(c) Policies which provide normal pregnancy and childbirth benefits shall cover pregnancy if conception occurs after the effective date of coverage or after a probationary period of not more than 30 days after the effective date of the coverage.
(d) Each insurer is required to give a single notice of the option to select maternity benefits coverage to its policyholders or subscribers. While no notice of the availability of such coverage is required to be made at every renewal of a policy, the coverage itself must be made available at renewal, for the option of selection by the insured.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 20 - BLINDNESS; PARTIAL BLINDNESS OR OTHER PHYSICAL OR MENTAL IMPAIRMENTS; UNFAIR DISCRIMINATION › Section 11:4-20.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
The purpose of this subchapter is to eliminate unfair discrimination in the underwriting, insuring and rating of individuals who are normal insurance risks in spite of blindness, partial blindness, or other physical or mental impairments.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 20 - BLINDNESS; PARTIAL BLINDNESS OR OTHER PHYSICAL OR MENTAL IMPAIRMENTS; UNFAIR DISCRIMINATION › Section 11:4-20.2 - Unfair discriminatory acts or practices

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following are hereby identified as acts or practices which constitute unfair discrimination between individuals of the same class:
1. Refusing to insure, or refusing to continue to insure, or limiting the amount, extent or kind of coverage available to an individual, or charging an individual a different rate for the same coverage solely because of blindness, partial blindness or other physical or mental impairments, except where the refusal, limitation or rate differential is based on sound, actuarial principles or is related to actual or reasonably anticipated experience.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 21 - LIMITED DEATH BENEFITS FORMS › Section 11:4-21.1 - Purpose; scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to establish guidelines for the filing and review of limited death benefit policy forms which will:
1. Make life insurance available to people who are otherwise uninsurable;
2. Assure that limited death policies are not sold by producers in preference to full death benefit policies and that the applicant understands that he or she may qualify for a full death benefit policy;
3. Reduce through disclosure the likelihood of misunderstanding arising where the sales presentation emphasizes the underwriting feature while minimizing or ignoring the limitation on death benefits at early durations; and
4. Set standards for the advertising of limited death benefit policy forms so as to eliminate unfair, misleading or deceptive advertising practices.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 21 - LIMITED DEATH BENEFITS FORMS › Section 11:4-21.2 - 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.
"Advertising" means any advertising materials and sales presentations in the following categories:
1. Printed and published material, audiovisual material, and descriptive literature of an insurer used in direct mail, newspapers, magazines, radio and television scripts, billboards and similar displays;
2. Descriptive literature and sales aids of all kinds issued by an insurer or producer, including, but not limited to, circulars, leaflets, booklets, depictions, illustrations, and form letters;
3. Material used for the recruitment, training and education of an insurer's sales personnel, producers, solicitors, and brokers which is designed to be used or used to induce the public to purchase, increase, modify, reinstate, or retain a policy; and
4. Prepared sales talks, presentations and material for use by sales personnel, producers, solicitors and brokers.
"Department" means the New Jersey Department of Banking and Insurance.
"Full death benefit policy" means any individual life insurance policy, group life insurance policy, group life insurance certificate, or fraternal benefit society certificate delivered or issued for delivery in this State which provides the full face amount as the death benefit at all times following the inception date of the policy and which provides a death benefit greater than premiums accumulated at the nonforfeiture interest rate used to determine nonforfeiture values under the policy during the limited death benefit period defined at 11:4-21.3(g).
"Limited death benefit policy" means any individual life insurance policy, group life insurance policy, group life insurance certificate, or fraternal benefit society certificate delivered or issued for delivery in this State which limits death benefits during a period following the inception date of the policy as an alternative to underwriting. Limited death benefit policies include those single pay and limited pay life insurance policy forms where, at any issue age, the premium or premiums accumulated at the nonforfeiture interest rate used to determine nonforfeiture values under the policy are equal to or in excess of the guaranteed death benefit during the limited death benefit period defined at 11:4-21.3(g), regardless of whether the form is underwritten. Limited death benefit policies also include those funeral insurance policies as defined at N.J.S.A. 17B:17-5.1a that meet the requirements set forth in 11:4-21.1(b).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 21 - LIMITED DEATH BENEFITS FORMS › Section 11:4-21.3 - General requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No limited death benefit policy shall be issued in this State unless the insurer has, at the time of application, obtained from the applicant a signed and dated statement attesting that the applicant understands that he or she may qualify for a full death benefit policy which provides full benefits from inception. A copy of this statement must be submitted to the Department for review prior to its use.
(b) All advertising for a limited death benefit policy shall prominently explain the nature of the limited death benefit policy and state the duration of the limited death benefit period.
(c) Any advertising of a limited death benefit policy which makes reference to a specific premium rate must provide:
1. For other than radio and television, a listing of the rates and benefits for all available ages (male and female); and
2. For radio and television, instructions in the procedure to be followed by the applicant to learn what benefits and rates are available.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 21 - LIMITED DEATH BENEFITS FORMS › Section 11:4-21.4 - Severability

Current through Register Vol. 56, No. 14, July 15, 2024
If any provision of this subchapter, or its application to any person or circumstances, is held invalid, the remainder of this subchapter and its application to other persons or circumstances shall not be affected.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 22 - INDIVIDUAL LIFE INSURANCE: USE OF GENDER BLENDED MORTALITY TABLES › Section 11:4-22.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
The purpose of this subchapter is to permit individual life insurance policies to provide the same cash surrender values and paid-up nonforfeiture benefits to both men and women. No change in minimum valuation standards is intended by these rules.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 22 - INDIVIDUAL LIFE INSURANCE: USE OF GENDER BLENDED MORTALITY TABLES › Section 11:4-22.2 - 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:
"1980 CSO Table, with or without Ten Year Select Mortality Factors" means that mortality table, consisting of separate rates of mortality for male and female lives, developed by the Society of Actuaries Committee to Recommend New Mortality Tables for Valuation of Standard Individual Ordinary Life Insurance, incorporated in the 1980 National Association of Insurance Commissioners (NAIC) Amendments to the Model Standard Valuation Law and Model Standard Nonforfeiture Law for Life Insurance, and referred to in those models as the Commissioner's 1980 Standard Ordinary Mortality Table, with or without Ten-Year Select Mortality Factors.
"1980 CSO Table (M), with or without Ten-Year Select Mortality Factors" means that mortality table consisting of the rates of mortality for male lives from the 1980 CSO Table, with or without Ten-Year Select Mortality Factors.
"1980 CSO Table (F), with or without Ten-Year Select Mortality Factors" means that mortality table consisting of the rates of mortality for female lives from the 1980 CSO Table, with or without Ten-Year Select Mortality Factors.
"1980 CET Table" means that mortality table consisting of separate rates of mortality for male and female lives, developed by the Society of Actuaries Committee to Recommend New Mortality Tables for Valuation of Standard Individual Ordinary Life Insurance, incorporated in the 1980 NAIC Amendments to the Model Standard Valuation Law and Model Standard Nonforfeiture Law for Life Insurance, and referred to in those models as the Commissioner's 1980 Extended Term Insurance Table.
"1980 CET Table (M)" means that mortality table consisting of the rates of mortality for male lives from the 1980 CET Table.
"1980 CET Table (F)" means that mortality table consisting of the rates of mortality for female lives from the 1980 CET Table.
"1980 CSO and 1980 CET Smoker and Nonsmoker Mortality Tables" mean the mortality tables with separate rates of mortality for smokers and nonsmokers derived from the 1980 CSO and 1980 CET Mortality Tables by the Society of Actuaries Task Force on Smoker/Nonsmoker Mortality and adopted by the NAIC in December 1983.
"Non-Norris market" means all employer-based plans not included within the definition of "Norris market" set forth in this subchapter.
"Norris market" means all employer-based plans subject to the holding of the 1983 Arizona Governing Committee v. Norris United States Supreme Court decision ( 463 U.S. 1073 ).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 22 - INDIVIDUAL LIFE INSURANCE: USE OF GENDER BLENDED MORTALITY TABLES › Section 11:4-22.3 - Construction of gender blended tables for use in the determination of minimum nonforfeiture benefits and minimum reserves

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For any policy of insurance on the life of either a male or female insured delivered or issued for delivery in this State after September 11, 1981, a life insurer which has elected or which elects an operative date under N.J.S.A. 17B:25-19h(xi) may file with the Department of Insurance for use as part of the policy form, the approved gender blended mortality tables as described in (b) below and attached as the Appendix to this subchapter, or a description thereof, to determine minimum cash surrender values and minimum amounts and minimum periods of paid-up nonforfeiture benefits.
1. An approved mortality table which is a blend of the 1980 CSO Table (M) and the 1980 CSO Table (F) with or without Ten-Year Select Mortality Factors may at the option of the company be substituted for the 1980 CSO Table, with or without our Ten-Year Select Mortality Factors; and
2. A mortality table which is of the same blend as used in (a)1 above but applied to form a blend of the 1980 CET Table (M) and the 1980 CET Table (F) may at the option of the company be substituted for the 1980 CET Table.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 22 - INDIVIDUAL LIFE INSURANCE: USE OF GENDER BLENDED MORTALITY TABLES › Section 11:4-22.4 - Construction of Gender Blended Smoker and Nonsmoker Mortality Tables for use in the determination of minimum nonforfeiture benefits and minimum reserves

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In determining minimum cash surrender values, and amounts of paid up nonforfeiture benefits for any policy of insurance on the life of either a male or female insured on a form of insurance with separate rates for smokers and nonsmokers delivered or issued for delivery in this State after the operative date of N.J.S.A. 17B:25-19h(xi) for that policy form in addition to the mortality tables that may be used according to 11:4-22.3:
1. A mortality table which is a blend of the male and female rates of mortality according to the 1980 CSO Smoker Mortality Table, in the case of lives classified as smokers, or the 1980 CSO Nonsmoker Mortality Table, in the case of lives classified as nonsmokers, with or without Ten-year Select Mortality Factors, may at the option of the company be substituted for the 1980 CSO Table, with or without Ten-Year Select Mortality Factors; and
2. A mortality table which is of the same blend as used in (a)1 above but applied to form a blend of the male and female rates of mortality according to the corresponding 1980 CET Smoker Mortality Table or 1980 CET Nonsmoker Mortality Table may at the option of the company be substituted for the 1980 CET Table.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 22 - INDIVIDUAL LIFE INSURANCE: USE OF GENDER BLENDED MORTALITY TABLES › Section 11:4-22.5 - Use of gender blended mortality tables in the non-Norris market

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The preceding rules in this subchapter are intended to address use of gender blended mortality tables as a minimum standard for cash surrender values and paid-up nonforfeiture benefits in the Norris market.
(b) The use of gender blended mortality tables as the basis for cash surrender values and paid-up nonforfeiture benefits in the non-Norris market will be permitted only upon receipt of an actuarial demonstration that the resultant cash values are at least equal to the statutory minimum using the maximum interest rate, maximum initial expense allowance and gender district table specified at 17B:25-19.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 22 - INDIVIDUAL LIFE INSURANCE: USE OF GENDER BLENDED MORTALITY TABLES › Section 11:4-22.6 - Effect on previously filed forms

Current through Register Vol. 56, No. 14, July 15, 2024
Forms which have been filed by the Commissioner pursuant to 17B:25-18 containing provisions not in compliance with these rules shall be deemed withdrawn as of September 18, 1996.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 22 - INDIVIDUAL LIFE INSURANCE: USE OF GENDER BLENDED MORTALITY TABLES › Section 11:4-22.7 - Unfair discrimination

Current through Register Vol. 56, No. 14, July 15, 2024
It shall not be a violation of N.J.S.A. 17B:30-12c. for an insurer to issue the same kind of policy of life insurance on both a sex-distinct and sex-neutral basis.