reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3015 - Policy Definition of Medicare

Current through Reg. 49, No. 28; July 12, 2024
A definition of "Medicare" shall be included in any
					 hospital, surgical, or medical expense policy which relates its coverage to
					 eligibility for Medicare or Medicare benefits. The term Medicare may not be
					 defined as more restrictive than:
(1)
				  "the Health Insurance for the Aged Act, Title XVIII of the Social Security
				  Amendments of 1965 as amended"; or
(2) "Title I, Part I of Public Laws 89-97 as
				  Enacted by the Eighty-Ninth Congress of the United States of America and
				  popularly known as the Health Insurance for the Aged Act, as
				  amended."
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3016 - Policy Definition of Mental or Nervous Disorders

Current through Reg. 49, No. 28; July 12, 2024
A definition of "mental or nervous disorder" as used in a
					 policy may not be more restrictive than a neurosis, psychoneurosis,
					 psychopathy, psychosis, or mental or emotional disease or disorder of any
					 kind.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3017 - Policy Definition of One Period of Confinement - Continuous Hospital Confinement

Current through Reg. 49, No. 28; July 12, 2024
One period of confinement-continuous hospital confinement
					 means consecutive days of in-hospital service received as an inpatient, or
					 successive confinements when discharge from and readmission to the hospital
					 occurs within a period of time not more than 90 days or three times the maximum
					 number of days of in-hospital coverage provided by the policy to a maximum of
					 180 days.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3019 - Policy Definition of Noncancellable

Current through Reg. 49, No. 28; July 12, 2024
(a) The term "noncancellable" may be used
				  only in a policy which the insured has the right to continue 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. The insurer may
				  not unilaterally make any change in any provision of the policy while the
				  policy is in force. Except in the limited circumstances delineated in
				  subsection (b) of this section, an insurer shall not use the phrase
				  "noncancellable and guaranteed renewable" in relation to coverage that meets
				  the above definition, unless it also meets the definition of "guaranteed
				  renewable" set forth in §
										3.3020(a)
				  of this title (relating to Policy Definition of Guaranteed Renewable and
				  Limited Guarantee of Renewability) and §
										3.3038
				  of this title (relating to Mandatory Guaranteed Renewability Provisions for
				  Individual Hospital, Medical or Surgical Coverage; Exceptions) of this
				  subchapter.
(b) In regards to
				  policies offering excepted benefits, an insurer may continue to issue through
				  May 31, 1998, policies from printed stock existing on the day before the
				  effective date of this subchapter that are noncancellable, as defined in
				  subsection (a) of this section, and that refer to the policy as "noncancellable
				  and guaranteed renewable," as was allowed by rule before the effective date of
				  this subchapter. An insurer may not print any new noncancellable policies on or
				  after the effective date of this subchapter which use policy language
				  describing the policy as "noncancellable and guaranteed renewable," unless such
				  policy also meets the definition of guaranteed renewable set forth in §
										3.3020(a)
				  of this title (relating to Policy Definition of Guaranteed Renewable and
				  Limited Guarantee of Renewability) and §
										3.3038
				  of this title (relating to Mandatory Guaranteed Renewability Provisions for
				  Individual Hospital, Medical or Surgical Coverage; Exceptions) of this
				  subchapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3021 - Policy Definition of Complication of Pregnancy

Current through Reg. 49, No. 28; July 12, 2024
Complications of pregnancy shall be treated, in all cases,
					 as any other sickness. Complications of pregnancy mean:
(1) conditions, requiring hospital
				  confinement (when the pregnancy is not terminated), whose diagnoses are
				  distinct from pregnancy but are adversely affected by pregnancy, including, but
				  not limited to, acute nephritis, nephrosis, cardiac decompensation, missed
				  abortion, and similar medical and surgical conditions of comparable severity,
				  but shall not include false labor, occasional spotting, physician prescribed
				  rest during the period of pregnancy, morning sickness, hyperemesis gravidarum,
				  pre-eclampsia and similar conditions associated with the management of a
				  difficult pregnancy not constituting a nosologically distinct complication of
				  pregnancy; and
(2) non-elective
				  cesarean section, termination of ectopic pregnancy, and spontaneous termination
				  of pregnancy, occurring during a period of gestation in which a viable birth is
				  not possible.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3038 - Mandatory Guaranteed Renewability Provisions for Individual Hospital, Medical, or Surgical Coverage; Exceptions

Current through Reg. 49, No. 28; July 12, 2024
(a) Except as
				  provided by this section, all individual hospital, medical, or surgical
				  coverage (as defined in §
										3.3002(b)(12) of
				  this title (relating to Definitions)) must be renewed or continued in force at
				  the option of the insured.
(b)
				  Medicare eligibility or entitlement is not a basis for nonrenewal or
				  termination of individual hospital, medical, or surgical coverage; however,
				  such coverage sold to an insured before the insured attains Medicare
				  eligibility may contain a clause that excludes payments for benefits under the
				  policy to the extent that Medicare pays for such benefits.
(c) Individual hospital, medical, or surgical
				  coverage may only be discontinued or nonrenewed based on one or more of the
				  following circumstances:
(1) the policyholder
				  has failed to pay premiums or contributions in accordance with the terms of the
				  policy, including any timeliness requirements;
(2) the policyholder has performed an act or
				  practice that constitutes fraud, or has made an intentional misrepresentation
				  of material fact, relating in any way to the policy, including claims for
				  benefits under the policy;
(3) the
				  insurer is ceasing to offer individual hospital, medical, or surgical coverage
				  under the particular type of policy, or is ceasing to offer any form of
				  individual hospital, medical, or surgical coverage in this state or in the
				  insurer's service area, in accordance with subsections (d) and (e) of this
				  section;
(4) in regard only to
				  coverage offered by an issuer under Insurance Code Chapter 842, concerning
				  Group Hospital Service Corporations, or Chapter 1301, concerning Preferred
				  Provider Benefit Plans, the insured no longer resides, lives, or works in the
				  service area of the issuer, or area for which the issuer is authorized to do
				  business, but only if coverage is terminated uniformly without regard to any
				  health-status-related factor of covered individuals.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3039 - Other Mandatory Policy Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) Each
				  individual policy of accident and sickness insurance, including a policy issued
				  by a company subject to Insurance Code Chapter 842, that is delivered, issued
				  for delivery, or renewed in Texas on or after January 1, 1988, must contain a
				  benefit provision which states, "All benefits payable under this policy on
				  behalf of a dependent child insured by this policy for which benefits for
				  financial and medical assistance are being provided by the Texas Health and
				  Human Services Commission will be paid to the Texas Health and Human Services
				  Commission " whenever:
(1) the Texas Health
				  and Human Services Commission is paying benefits under Human Resources Code
				  Chapter 31 or Chapter 32, i.e., financial and medical assistance service
				  programs administered pursuant to the Human Resources Code; and
(2) the parent who purchased the individual
				  policy has possession or access to the child pursuant to a court order, or is
				  not entitled to access or possession of the child and is required by the court
				  to pay child support.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3040 - Prohibited Policy Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) No
				  policies or riders for additional coverage may be issued as a dividend unless
				  an equivalent cash payment is offered to the policyholder as an alternative to
				  such a dividend policy or rider.
(b) All riders or endorsements added after
				  date of issue, except those by which the insurer effectuates a request made in
				  writing by the policyholder or exercises a specifically reserved right under
				  the policy or those which increase benefits, shall require signed acceptance by
				  the policyholder.
(c) A disability
				  policy or a specified disease policy may contain a "return of premium" or "cash
				  value benefit" so long as:
(1) the policy
				  provides for return of 100% of all premiums paid less the claims paid by the
				  time the insured attains age 65;
(2) the policy contains a reasonable
				  nonforfeiture benefit and provides for the value to be paid automatically upon
				  lapse or death;
(3) the surrender
				  value percentages are not less than those calculated assuming 1958 CSO
				  Mortality, 5.0% interest, five-year preliminary term;
(4) an acceptable method of reserving is
				  approved by this department concurrent with approval of the policy. Reserves
				  should equal or exceed the cash value at all durations;
(5) the nonforfeiture values are calculated
				  assuming a zero percent future claim offset;
(6) the nonforfeiture values are defined for
				  all policy years (nonforfeiture values may be shown only for the first 20
				  policy years, but under these conditions the contract must define the method
				  used to determine the nonforfeiture values after the 20th contract
				  year);
(7) the interim
				  nonforfeiture values are defined when premiums are paid within a contract year
				  (i.e., date premium paid as a death benefit);
(8) the policy does not require the insured
				  to wait until a certain attained age without providing any interim
				  nonforfeiture benefits; and
(9) the
				  policy does not tie the return of premium to anything less than 100% of the
				  premiums paid less claims paid.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3050 - Standards for Renewability Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Each policy subject to this subchapter:
(1)
				  Shall include a renewal, continuation, or nonrenewal provision, consistent with
				  the requirements of this subchapter. The language or specifications of such
				  provision must be consistent with the type of contract to be issued (e.g.,
				  guaranteed renewable, noncancellable, limited guarantee of renewability,
				  limited renewability at the option of the insurer, single term nonrenewable,
				  etc.). Such provision must be appropriately captioned and commence or be
				  referenced on the first page of the policy. All limitations on renewability
				  must be clearly stated.
(2) Which
				  contains a provision reserving the right of the insurer to increase the premium
				  charged for such policy at the time such policy is renewed shall have printed
				  at the top of the first page of such policy, and may not be preceded by any
				  language except the company name, logo, or masthead (and address if shown) in
				  not less than 10 point type, a statement that the premium may be increased upon
				  the renewal date.
(3) Which
				  contains a provision reserving the right of the insurer to nonrenew the policy
				  upon the insured's attaining a certain age or a provision whereby the policy
				  terminates upon attainment of a certain age shall have printed at the top of
				  the first page of such policy, and may not be preceded by any language except
				  the company name, logo, or masthead (and address, if shown) in not less than 10
				  point type, a statement that such policy may be subject to nonrenewal upon
				  attainment of a certain age or that the policy will be terminated upon
				  attainment of a specified age. This requirement may be combined into one
				  statement with the requirement in paragraph (2) of this subsection, if the
				  policy is subject to change in premium upon renewal and to nonrenewal or
				  termination upon the insured's attainment of a specified age.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3051 - Initial and Subsequent Conditions of Eligibility Provision

Current through Reg. 49, No. 28; July 12, 2024
A family policy providing hospital, surgical, medical
					 expense, hospital confinement indemnity, or accident only insurance shall
					 include provisions which specify the indemnity and qualifications applicable to
					 those family members who may become insured under the policy initially or by
					 subsequent addition.
(1) Eligible
				  family members may include:
(A) the
				  insured;
(B) the insured's
				  spouse;
(C) children of the insured
				  or of the insured's spouse who are over a specified age and under a specified
				  age not to exceed 25, unless a dependency test is specified; and
(D) any other person dependent upon the
				  insured.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3052 - Standards for Termination of Insurance Provision

Current through Reg. 49, No. 28; July 12, 2024
(a) A policy subject to this subchapter must
				  include termination provisions that specify as to each eligible family member,
				  as set out in §
										3.3051
				  of this title (relating to Initial and Subsequent Conditions of Eligibility
				  Provision), the age, or event, if any, upon which coverage under the policy
				  will terminate.
(b) In regard to
				  individual hospital, medical or surgical coverage, a policy may only contain
				  the following bases for termination of coverage:
(1) the bases for nonrenewal contained in
				  §
											3.3038
				  of this title (relating to Mandatory Guaranteed Renewability Provisions for
				  Individual Hospital, Medical or Surgical Coverage; Exceptions);
(2) in regard to policies covering a spouse
				  of the primary insured or dependents:
(A)
				  Coverage of the spouse may terminate upon the dissolution of the marriage
				  through divorce or other lawful means, subject to this section, §
												21.407 of
				  this title (relating to Continuance of Coverage) and other applicable law;
				  and
(B) Coverage of a dependent may
				  terminate upon the dependent's attainment of a limiting age, subject to
				  Insurance Code §
												1201.059,
				  this section, and other applicable law.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3054 - Preexisting Conditions Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				  policy must clearly disclose the intent of the insurer as to the applicability
				  or nonapplicability of coverage to preexisting conditions. In accordance with
				  §
										3.3018
				  of this title (relating to Policy Definition of Preexisting Condition), a
				  policy offering individual hospital, medical or surgical coverage also must
				  clearly disclose and explain the conditions under which Texas law requires an
				  insurer to not apply a preexisting condition provision, or to limit application
				  of the provision, to an individual who has previous creditable coverage. If
				  coverage of the policy is not to be applicable to preexisting conditions, the
				  policy shall specify, in substance, that coverage applies only to accidental
				  bodily injuries resulting from accidents occurring after the effective date of
				  coverage and sicknesses which first manifest themselves subsequent to the
				  effective date of coverage or expiration of any applicable probationary
				  period.
(b) In regards to
				  individuals who are not exempt from preexisting condition provisions under
				  §
										3.3018
				  of this title (relating to Policy Definition of Preexisting Condition):
(1) If an insurer elects to use a simplified
				  application form for individual applicants, the policy must cover any loss
				  occurring after 12 months which results from any preexisting condition not
				  specifically excluded from coverage by the terms of the policy.
(2) No individual policy of accident and
				  sickness insurance delivered or issued for delivery in this state to a person
				  age 65 or over may contain a provision excluding from coverage any loss due to
				  a preexisting condition, not specifically excluded from coverage by name or
				  specific description in an exclusion endorsement or rider effective on the date
				  of the loss, for a period in excess of six months from the effective date of
				  the coverage under the policy; provided, however, that if the commissioner
				  finds that the public interest would be served thereby, it may authorize a
				  policy provision excluding coverage for preexisting conditions for a period in
				  excess of six months but in no event shall such period exceed one
				  year.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3055 - Standards for Probationary or Waiting Period Provision

Current through Reg. 49, No. 28; July 12, 2024
A probationary or waiting period, if one is specified in
					 the policy, is that period of time commencing with the date a person is
					 initially insured under the policy to the date the coverage or coverages of the
					 policy shall become effective as to such person.
(1) A probationary or waiting period shall
				  not apply to any loss resulting from accidental injuries as defined in the
				  policy; however, a policy may specify a probationary or waiting period for
				  coverage of sickness which shall not exceed 30 days except as follows:
(A) for pregnancy, childbirth, miscarriage,
				  or complications of pregnancy, the probationary or waiting period when
				  expressed in terms of the inception of the pregnancy shall be no more than 30
				  days;
(B) six months for losses
				  resulting from hernia, disorder of reproductive organs, varicose veins,
				  hemorrhoids, appendix, tonsils, adenoids, and gall bladder;
(C) 120 days for coverages under specified
				  disease insurance.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3056 - Standards for Limitations Provision

Current through Reg. 49, No. 28; July 12, 2024
The limitations on the risk undertaken, whether applicable
					 to amounts, durations of benefits (age, or other matters) must be specified
					 with clarity and certainty in the appropriate provision of the
					 contract.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3058 - Standards for Elimination Period Provision

Current through Reg. 49, No. 28; July 12, 2024
Elimination period shall relate to the initial period of
					 time, during the continuance of a condition insured against, for which such
					 benefit will not be paid. Such periods must be clearly expressed in the policy
					 schedule of benefits page and clearly expressed or referenced in the benefit
					 provision to which such elimination period applies.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3059 - Standards for Recurrent Disabilities Provision

Current through Reg. 49, No. 28; July 12, 2024
A policy may contain provisions relating to recurrent
					 disability; provided, however, a recurrent disability provision may not specify
					 that such disabilities be separated by a period greater than six
					 months.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3060 - Standards for Conversion Privileges Provision

Current through Reg. 49, No. 28; July 12, 2024
(a) If a policy contains a conversion
				  privilege, the caption shall be "Conversion Privilege," or words of similar
				  import. The provision shall indicate the persons eligible for conversion. The
				  circumstances applicable to the conversion privilege, including any limitations
				  on the conversion, and the person by whom the conversion privilege may be
				  exercised, shall be described. The provision may indicate that the privilege is
				  subject to the underwriting standards of the insurer relating to
				  overinsurance.
(b) A business
				  overhead expense policy issued on either a guaranteed renewable basis, or on a
				  non-cancellable basis, or renewable at the option of the company basis may
				  contain a conversion privilege exercisable upon termination of the business
				  interest, or it may provide for its continuation as a loss of time
				  policy.
(c) A policy issued
				  pursuant to the exercise of a conversion privilege contained in an individual
				  family or other individual policy, the converted policy, or a rider attached
				  thereto shall reflect the relative rights of each person covered under the
				  converted policy.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3061 - Standards for Requirements for Replacement Provision

Current through Reg. 49, No. 28; July 12, 2024
(a) Application forms shall include a
				  question relating to replacement designed to elicit information as to whether
				  the insurance to be issued is intended to replace any other accident and
				  sickness insurance presently in force. A supplementary application or other
				  form to be signed by the applicant containing such a question or statement may
				  be used.
(b) Upon determining that
				  a sale will involve replacement, an insurer (other than a direct response
				  insurer) or its agent shall furnish the applicant, prior to issuance or
				  delivery of the policy, the notice described in subsection (c) of this section.
				  One copy of such notice shall be provided to the applicant and an additional
				  copy signed by the applicant shall be retained by the insurer. A direct
				  response insurer shall deliver one copy of the notice described in subsection
				  (d) of this section to the applicant upon issuance of the policy. In no event,
				  however, will such a notice be required in the solicitation of the following
				  types of policies:
(1) accident
				  only;
(2) single premium
				  nonrenewable;
(3) conversion to
				  another policy in the same insurer with continuous coverage;
(4) conversion to an individual or family
				  policy to replace group, blanket, or group type coverage.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3062 - Conditional Receipts

Current through Reg. 49, No. 28; July 12, 2024
The following provisions shall apply to conditional
					 receipts.
(1) A conditional receipt
				  which requires a determination of insurability as a condition precedent to
				  coverage shall include an agreement to provide:
(A) coverage subject to any limit regarding
				  the amount of insurance specified in the receipt, contingent upon insurability;
				  and
(B) 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.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3070 - Minimum Standards for Benefits Generally

Current through Reg. 49, No. 28; July 12, 2024
The following minimum standards for benefits are prescribed
					 for the categories noted in §§
										3.3071-
					 3.3077
					 and §
										3.3079
					 of this title (relating to Minimum Standards and Benefits and Readability for
					 Accident and Health Insurance Policies). No individual policy of accident and
					 sickness insurance, or a subscriber contract of a hospital, medical, or dental
					 services corporation, may be delivered or issued for delivery in this state
					 which does not meet the required minimum standards for the specified categories
					 except as otherwise provided by law or this subchapter. Such policies must also
					 meet the requirements of Insurance Code Chapter 1701. Nothing in this section
					 will preclude the issuance of any policy or contract combining two or more of
					 the categories of coverage as set forth in Insurance Code §
										1201.104.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3071 - Minimum Standards for Basic Hospital Expense Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) "Basic hospital expense insurance" is a
				  policy of accident and health insurance which provides coverage for a period of
				  not less than 31 days during any one period of confinement for each person
				  insured under the policy for the expense incurred for necessary treatment and
				  services rendered as a result of an injury or sickness for at least the
				  following:
(1) daily hospital room and board
				  in an amount not less than:
(A) 80% of the
				  charges for semi-private room accommodations; or
(B) $30 per day;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3072 - Minimum Standards for Basic Medical-Surgical Expense Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) "Basic medical-surgical expense coverage"
				  is a policy of accident and sickness insurance which provides coverage for each
				  person insured under the policy for the expenses incurred for the necessary
				  services rendered by a physician for treatment of an injury or sickness for at
				  least the following:
(1) surgical services:
(A) in amounts not less than those provided
				  on a fee schedule based on the relative values contained in the 1969 California
				  Relative Value Schedule or other acceptable value scale of surgical procedures,
				  up to a maximum of at least $500 for any on e procedure; or
(B) not less than 80% of the usual, customary
				  and reasonable charges. Surgical schedules shall include a provision
				  stipulating coverage for procedures not specifically listed in the schedules
				  and not otherwise excluded by the policy, and benefits therefore shall be
				  consistent with the benefits for comparable procedures;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3073 - Minimum Standards for Hospital Confinement Indemnity Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) "Hospital Confinement Indemnity Coverage"
				  is a policy of accident and sickness insurance which provides daily benefits
				  for hospital confinement on an indemnity basis in an amount not less than $15
				  per day or $100 per week and not less than 31 days during any "one period of
				  confinement" for each person insured under the policy. A one day or two day
				  elimination period may be used when "one period of confinement" is not less
				  than 31 days and not more than 364 days. A three day elimination period may be
				  used when "one period of confinement" is 365 days or more. If a hospital
				  confinement policy, whether styled as an indemnity policy or however styled,
				  includes confinement for pregnancy within the scope of its coverage, then the
				  minimum benefits payable for each covered pregnancy shall be the insured loss
				  or expense up to an amount no less than 10 times the minimum daily benefit of
				  the policy.
(b) Hospital
				  confinement indemnity coverage is not required to be guaranteed renewable in
				  accordance with §
										3.3020
				  of this title (relating to Policy Definition of Guaranteed Renewable and
				  Limited Guarantee of Renewability) and §
										3.3038
				  of this title (relating to Mandatory Guaranteed Renewability Provisions for
				  Individual Hospital, Medical or Surgical Coverage; Exceptions) of this
				  subchapter, provided that it meets the criteria for "excepted benefits" defined
				  in relation to such coverage in §
										3.3002(b)(6)(B)(ii)
				  of this title (relating to Definitions).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3075 - Minimum Standards for Disability Income Protection Coverage

Current through Reg. 49, No. 28; July 12, 2024
"Disability income protection coverage" is a policy which
					 provides for periodic payments, weekly or monthly, for a specified period
					 during the continuance of disability resulting from either sickness or accident
					 or a combination thereof, which:
(1)
				  provides for periodic payments in an amount of at least $100 per month payable
				  at ages through 62 and $50 per month at ages after 62;
(2) contains an elimination period no greater
				  than:
(A) 90 days in the case of a coverage
				  providing a benefit period of one year or less;
(B) 365 days if the benefit is payable for
				  not less than two years and is payable in an amount of at least $200 per month;
				  or
(C) 180 days in all other cases
				  during the continuance of disability resulting from sickness or
				  injury;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3076 - Minimum Standards for Accident Only Coverage

Current through Reg. 49, No. 28; July 12, 2024
"Accident only coverage" is a policy of accident insurance
					 which provides coverage, singularly or in combination, for death,
					 dismemberment, disability, or hospital and medical care caused by accident.
					 Such coverage provided shall meet the following criteria.
(1) Accidental death and double dismemberment
				  amounts shall be at least $1,000.
(2) Single dismemberment amounts shall be at
				  least $500.
(3) Accidental death
				  and dismemberment benefits shall be payable if the loss occurs within a period
				  of time not less than 90 days from the date of the accident, irrespective of
				  total disability.
(4) Specific
				  dismemberment(s) benefit(s) may not be provided in lieu of other benefits
				  unless the specific dismemberment(s) benefit(s) equals or exceeds the other
				  benefit.
(5) Disability income
				  benefits, where provided, may not require the loss to commence less than 30
				  days after the date of accident nor shall any policy which the insurer cancels
				  or refuses to renew require that it be in force at the time disability
				  commences if the accident occurred while the policy was in force and the
				  disability commenced within the time limit specified in the policy.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3077 - Minimum Standards for Specified Disease and Specified Accident Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) "Specified disease coverage" is a policy
				  written on a guaranteed renewable basis as prescribed in §
										3.3050(b)
				  of this title (relating to Standards for Renewability Provisions) which meets
				  one of the following definitions.
(1) A
				  policy which provides coverages for each person insured under the policy for a
				  specifically named disease (or diseases) with a deductible amount not to exceed
				  5.0% of the aggregate maximum benefit and an overall aggregate benefit limit of
				  no less than $5,000 per person and a benefit period of not less than two years.
				  If the benefits are subject to be scheduled inside dollar limits, such limits
				  shall meet the minimum requirements for major medical coverage as prescribed in
				  §
											3.3074
				  of this title (relating to Minimum Standards for Major Medical Expense
				  Coverage).
(2) A policy which
				  provides coverage for each person insured under the policy for a specifically
				  named disease (or diseases) with no deductible amount and an overall aggregate
				  benefit limit of not less than $25,000 payable at the rate of not less than $50
				  a day while confined in a hospital and a benefit period of not less than 500
				  days.
(3) In lieu of the minimum
				  benefits specified in paragraphs (1) and (2) of this subsection, a specified
				  disease policy or rider, limited to cancer, may provide minimum benefits not
				  less than the following:
(A) $50 a day for
				  the first 10 days of hospitalization without any elimination period, deductible
				  or coinsurance factor and $30 a day for each day of continuous hospitalization
				  thereafter with no limit on the number of days of hospitalization;
(B) x-ray, radium, and cobalt therapy up to a
				  total of $1,500;
(C) attending
				  physician(s) charges in hospital (other than the operating surgeon) of $7.50
				  per day up to a total of $500;
(D)
				  surgical charges in accordance with the 1969 California Relative Value Schedule
				  or other acceptable relative value scale of surgical procedure, up to a maximum
				  of at least $600;
(E) anesthetist
				  services for an operation in an amount not less than:
(i) 80% of the usual, customary and
				  reasonable charges; or
(ii) 15% of
				  the surgical charges benefit;
(F) nursing expenses of $24 per shift for not
				  less than one shift per day up to $750;
(G) blood transfusions and plasma up to
				  $500;
(H) prescribed drugs and
				  medicine up to $250. If an overall aggregate limit on all benefits is used, it
				  shall be not less than $10,000 per person.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3079 - Minimum Standards for Limited Benefit Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) Limited benefit coverage is a policy of
				  accident and sickness insurance providing the types of coverage set forth in
				  §
										3.3071
				  of this title (relating to Minimum Standards for Basic Hospital Expense
				  Coverage), §
										3.3072
				  of this title (relating to Minimum Standards for Basic Medical-Surgical Expense
				  Coverage), and §
										3.3075
				  of this title (relating to Minimum Standards for Disability Income Protection
				  Coverage), but the types and/or amounts of benefits are less than those
				  prescribed in such sections. Such policies delivered or issued for delivery in
				  this state in addition to meeting all other applicable requirements of these
				  sections must prominently display at the top of the outline of coverage and on
				  the face page of the policy in no less than 14 point type the notice set out in
				  §
										3.3091
				  of this title (relating to Notice Requirements for Outline of Coverage of
				  Limited Benefit, Supplemental and Nonconventional Coverages).
(b) Any limited benefit basic hospital
				  expense coverage or limited benefit basic medical-surgical expense coverage
				  offered pursuant to this section must be guaranteed renewable in accordance
				  with §
										3.3020
				  of this title (relating to Policy Definition of Guaranteed Renewable and
				  Limited Guarantee of Renewability) and §
										3.3038
				  of this title (relating to Mandatory Guaranteed Renewability Provisions for
				  Individual Hospital, Medical or Surgical Coverage; Exceptions) of this
				  subchapter, unless such insurance constitutes short-term limited duration
				  coverage, as defined in §
										3.3002(b)(18)
				  of this title (relating to Definitions).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3080 - Supplemental Coverage

Current through Reg. 49, No. 28; July 12, 2024
Supplemental coverage is a policy of accident and sickness
					 insurance which may be issued only to supplement in-force policies of
					 individual and group accident and sickness insurance, employee benefit plans,
					 hospital, medical, and dental service organization subscriber contracts, any
					 state or federally sponsored coverages and health maintenance organization
					 contracts.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3081 - Nonconventional Coverage

Current through Reg. 49, No. 28; July 12, 2024
The commissioner may authorize approval of a policy that
					 does not correspond with one of the categories as described in
					 §§3.3071-3.3077 and 3.3079-3.3080 of this title (relating to Minimum
					 Standards and Benefits and Readability for Accident and Health Insurance
					 Policies) if such policy is determined to be a type of coverage that is
					 experimental in nature or a type of coverage that will in the opinion of the
					 commissioner fulfill a reasonable public need and is appropriately and
					 prominently described in the outline of coverage. Unless such coverage falls
					 within the definition of excepted benefits set forth in §
										3.3002(b)(6)
					 of this title (relating to Definitions), the coverage must be guaranteed
					 renewable in accordance with §
										3.3020
					 of this title (relating to Policy Definition of Guaranteed Renewable and
					 Limited Guarantee of Renewability) and §
										3.3038
					 of this title (relating to Mandatory Guaranteed Renewability Provisions for
					 Individual Hospital, Medical or Surgical Coverage; Exceptions) of this
					 subchapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3090 - Outline of Coverage Generally

Current through Reg. 49, No. 28; July 12, 2024
(a) In
				  order to facilitate public understanding of coverages and to provide full and
				  fair disclosure in the sale of individual accident and sickness insurance
				  policies, no such policy may be delivered or issued for delivery in this state
				  unless an appropriate outline of coverage, as prescribed in these sections is
				  delivered.
(1) in the case of a direct
				  response insurance product, the outline of coverage shall be delivered with the
				  policy; and
(2) in all other cases,
				  the outline of coverage shall be delivered to the applicant at the time
				  application is made and acknowledgment of receipt or certificate of delivery of
				  such outline of coverage is provided to the insurer. The insurer may secure
				  acknowledgment of delivery of the outline of coverage by an acknowledgment
				  receipt attached to or made a part of the application; or by a certificate of
				  delivery signed by the insured.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3091 - Notice Requirements for Outline of Coverage of Limited Benefit, Supplemental and Non-Conventional Coverages

Current through Reg. 49, No. 28; July 12, 2024
(a) The outline of coverage for policies that
				  are approved under §
										3.3079
				  of this title (relating to Minimum Standards for Limited Benefit Coverage)
				  shall prominently display in no less than 14-point type that the policy is
				  "limited benefit basic hospital expense coverage," "limited benefit basic
				  medical-surgical expense coverage," or "limited benefit disability income
				  protection coverage." The outline of coverage shall further state at the top of
				  the page in capital letters the following: "THE POLICY DESCRIBED IN THIS
				  OUTLINE PROVIDES LIMITED BENEFITS ONLY WHICH ARE LESS THAN THE MINIMUM STANDARD
				  FOR BENEFITS FOR (STATE CATEGORY OF COVERAGE) AS PRESCRIBED BY THE INSURANCE
				  REGULATORY AUTHORITY OF YOUR STATE."
(b) The outline of coverage for policies
				  approved under §
										3.3080 of
				  this title (relating to Supplemental Coverage) shall prominently display at the
				  top of the page in no less than 14-point type, in capital letters, the
				  following: "THE POLICY DESCRIBED IN THIS OUTLINE PROVIDES SUPPLEMENTAL COVERAGE
				  ISSUED ONLY TO SUPPLEMENT INSURANCE ALREADY IN FORCE."
(c) The outline of coverage for policies
				  approved under §
										3.3081
				  of this title (relating to Non-conventional Coverage) shall prominently display
				  at the top of the page in no less that 14-point type, in capital letters, the
				  following: "THE POLICY DESCRIBED IN THIS OUTLINE DOES NOT MEET THE MINIMUM
				  STANDARDS FOR BENEFITS ESTABLISHED FOR BASIC CATEGORIES OF COVERAGE REQUIRED BY
				  THE INSURANCE REGULATORY AUTHORITY OF YOUR STATE."
(d) When no prescribed outline of coverage is
				  appropriate for the coverage provided by the policy, an outline of coverage
				  most appropriate to the categories of coverage offered shall be used.