reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › GENERAL PROVISIONS › Section 88.2 - Applicability and scope

Current through Register Vol. 54, No. 28, July 13, 2024
This chapter applies to, and the term "policy" includes,
					 all individual accident and health insurance policies, nongroup subscriber
					 contracts of health plan corporations and nonprofit health service plans, and
					 certificates issued by fraternal benefit societies delivered or issued for
					 delivery in this Commonwealth on and after the effective date hereof. This
					 chapter does not apply to credit accident and health insurance nor to
					 individual policies or contracts issued pursuant to a conversion privilege
					 under a group policy as required by section
					 621.2 of the act of May 17, 1921
					 (P. L. 682, No. 284) (40 P. S. §
											756.2). The requirements contained in this
					 chapter are in addition to any statutory requirements and any chapters
					 previously adopted, except to the extent that the previous chapters are
					 expressly inconsistent herewith, in which case the terms of this chapter are
					 controlling.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › POLICY PROVISIONS › Section 88.11 - Terms of renewability

Current through Register Vol. 54, No. 28, July 13, 2024
Each policy of accident and health insurance covered by
					 this chapter shall include a renewal, continuation or nonrenewal provision. The
					 language or specifications of the provision must be consistent with the type of
					 contract to be issued such as noncancellable and guaranteed renewable,
					 guaranteed renewable, renewable at the option of the insurer, single term
					 nonrenewable, and the like. Such provision must be appropriately captioned and
					 commence or be referenced on the first page of the policy and on the filing
					 back, if any, and must clearly state the duration, where limited, of
					 renewability and the duration of the term of coverage for which the policy is
					 issued and for which it may be renewed. Policies which allow for a change in
					 premiums shall specify the conditions under which rate changes may be made by
					 insurer.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › POLICY PROVISIONS › Section 88.12 - Noncancellable and guaranteed renewable policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) All such policies must be renewable to at
				  least age 60, subject to the timely payment of premiums, and shall provide that
				  the company cannot cancel the policy and that the company cannot increase the
				  premium.
(b) In a family policy
				  covering both husband and wife the age of the younger spouse must be used as
				  the basis for meeting the age and durational requirements of the definitions of
				  "noncancellable" and "guaranteed renewable." However, this requirement shall
				  not prevent termination of coverage of the older spouse upon attainment of the
				  stated age limit, such as age 60, so long as the policy may be continued in
				  force as to the younger spouse to the age or for the durational period as
				  specified in said definition.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › POLICY PROVISIONS › Section 88.13 - Guaranteed renewable policy

Current through Register Vol. 54, No. 28, July 13, 2024
All such policies must be renewable to at least age 65,
					 subject to the timely payment of premiums, and shall provide that the company
					 cannot cancel the policy. However, the insurer may reserve the right to change
					 the premium on a class basis. Such right shall be clearly expressed within the
					 renewal provision and referenced in the caption of such provision. The insurer
					 may include a policy provision for termination or nonrenewal of disability
					 income policies prior to age 65 when the insured is no longer subject to the
					 risk of loss of income as a result of accident or sickness.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › POLICY PROVISIONS › Section 88.14 - Renewable subject to consent of company and variants thereof

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The renewal
				  provision of a policy characterized as renewable subject to the consent of the
				  company shall be appropriately captioned as one of the following:
(1) "Renewable Subject to Consent of
				  Company."
(2) "Renewable Subject to
				  Company Consent."
(3) "Renewable at
				  Option of Company."
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › POLICY PROVISIONS › Section 88.15 - Qualified right of renewal

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				  renewal provision, other than enumerated in this chapter, may grant to the
				  insured the right of renewal by timely payment of premiums up to a stated age,
				  if any, subject to the reserved right of the insurer to terminate all such
				  policies on a specified basis upon the giving of a specified period of notice,
				  which shall be set forth in the appropriate provision of the policy.
(b) The right of the insured to renew the
				  policy may be conditioned upon the continuation of a specified status, such as
				  an employee of a named employer, member of a named organization, while engaged
				  in a specific occupation associated with such employment of such organization,
				  residence in a given state or geographic area, insured under a given form of
				  insurance having like form number identification.
(c) The rights of the insured and of the
				  insurer shall be clearly set forth in the renewal provision. Such shall include
				  the specified age limit, if any, requirements as to the professional or
				  occupational status, if any, and requirements as to the continuing
				  relationship, if any, of the employe or member.
(d) Continuance of insurance after the
				  insured ceases to be eligible for coverage under the plan may be at the option
				  of the insurer. In the event a different table of premium rates is to be
				  applicable with respect to renewals occurring thereafter, such fact shall be
				  declared in the renewal provision.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › POLICY PROVISIONS › Section 88.16 - Single term nonrenewable policy

Current through Register Vol. 54, No. 28, July 13, 2024
A policy characterized as a single term nonrenewable policy
					 shall include a provision appropriately captioned, for example, "this policy is
					 not renewable" or words of similar import. Such provision must identify or
					 reference the proper part of the contract within which the term or duration of
					 the coverage is specified.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › POLICY PROVISIONS › Section 88.17 - Renewable at the option of the insured

Current through Register Vol. 54, No. 28, July 13, 2024
Policies which may not be characterized as noncancellable
					 and guaranteed renewable or guaranteed renewable under existing definitional
					 requirements solely because such policy may not be continuable to age 60 or for
					 a minimum period of five years, may use a renewal provision caption, subject to
					 the approval of the Commissioner, which states that the right of renewal is
					 vested in the insured for a stated period of years, to a stated age, to the
					 occurrence of a stated event or during the continuance of a given status such
					 as employment or membership.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › POLICY PROVISIONS › Section 88.18 - Conditional or limited continuance

Current through Register Vol. 54, No. 28, July 13, 2024
Policies which provide a qualified right of continuance
					 after expiration of the period during which such policy is noncancellable and
					 guaranteed renewable or guaranteed renewable must clearly specify the
					 conditions, such as continued gainful employment, which must be fulfilled to
					 permit continuance of the policy. If premiums are to be based on an attained
					 age or on a step rate basis, such must be declared in the renewal provision.
					 The age limit, if any, to which any policy may be renewed shall be declared in
					 the renewal provision.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › CONDITIONS OF ELIGIBILITY › Section 88.31 - Family members

Current through Register Vol. 54, No. 28, July 13, 2024
A family policy providing hospital, surgical, medical
					 expense, hospital confinement indemnity, or accident only insurance shall
					 include provisions which specify the identity and qualifications applicable to
					 those family members who may become insured under the policy initially or by
					 subsequent addition.
This section cited in 31 Pa. Code §
												88.35 (relating to accidental
						injuries).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › CONDITIONS OF ELIGIBILITY › Section 88.32 - Eligibility

Current through Register Vol. 54, No. 28, July 13, 2024
Eligible family members may include the insured, the
					 insured's spouse, children of the insured, and of the insured's spouse who are
					 under a specified age not to exceed 19, unless a dependency test is specified,
					 and any other person dependent upon the insured. However, newborn children of
					 any insured shall be covered pursuant to act of August 1, 1975 (P.L. 157, No.
					 81) (40 P. S. §§
											771-774).
This section cited in 31 Pa. Code §
												88.35 (relating to accidental
						injuries).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › CONDITIONS OF ELIGIBILITY › Section 88.33 - Subsequent eligibility

Current through Register Vol. 54, No. 28, July 13, 2024
The provisions concerning eligibility shall, for persons
					 who may become insured subsequent to policy issuance, state the condition under
					 which such coverage may become effective. Such conditions may include:
(1) qualifications for automatic coverage and
				  the duration thereof;
(2) required
				  evidence of insurability;
(3) The
				  necessity of application or notice from the insured;
(4) any requirements as to the payment of
				  premiums as to such addition; and
(5) The time within which action is to be
				  taken by the insured.
This section cited in 31 Pa. Code §
												88.35 (relating to accidental
						injuries).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › CONDITIONS OF ELIGIBILITY › Section 88.34 - Time limit on defenses

Current through Register Vol. 54, No. 28, July 13, 2024
In family policies providing for the addition of newly
					 eligible family members, the Time Limit on Certain Defenses provision, section
					 618(A)(2) of the Insurance Company Law (40 P. S. §
											753(A)(2)) may be modified
					 to provide for a new contestable period for each new member so added, but shall
					 not provide for a new contestable period for the policy.
This section cited in 31 Pa. Code §
												88.35 (relating to accidental
						injuries).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › CONDITIONS OF ELIGIBILITY › Section 88.35 - Accidental injuries

Current through Register Vol. 54, No. 28, July 13, 2024
A family policy providing benefits for accidental injuries
					 such as accidental death, dismemberment, loss of sight, indemnity for fractures
					 or dislocations, and the like shall provide an option to include all insureds
					 under the contract and not just the principal insured. The level of benefits
					 for covered dependents may be different than the benefits for the principal
					 insured. Provisions decribing eligibility of family members, the adding of
					 family members and the termination of insurance as to such family members will
					 generally follow the pattern specified in §§
										88.31-88.41 (relating to conditions of
					 eligibility and termination of insurance). Generally, causes of termination of
					 coverage of individual family members will be predicated on age, cessation of
					 dependency which would include legal separation, termination of marriage by
					 divorce and similar occurrences.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › PRE-EXISTING CONDITIONS › Section 88.51 - Applicability of conditions

Current through Register Vol. 54, No. 28, July 13, 2024
The policy must clearly disclose the intent of the insurer
					 as to the applicability or nonapplicability of coverage relating to preexisting
					 conditions. If coverage of the policy is not to be applicable to preexisting
					 conditions, the policy shall specify, in substance, that coverage pertains
					 solely to accidental bodily injuries resulting from accidents occurring after
					 the effective date of coverage, and that sickness is limited to that which is
					 diagnosed or treated subsequent to the effective date of coverage or expiration
					 of the probationary period, if any.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › PRE-EXISTING CONDITIONS › Section 88.52 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in these
					 §§
										88.51-88.53, have the following
					 meanings, unless the context clearly indicates otherwise:
Preexisting condition
-A condition for
					 which medical advice or treatment was recommended by a physician or received
					 from a physician within a 5-year period preceding the effective date of the
					 coverage of the insured person.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › PRE-EXISTING CONDITIONS › Section 88.53 - Simplified application form

Current through Register Vol. 54, No. 28, July 13, 2024
Notwithstanding the provisions of section 618 (A)(2) of The
					 Insurance Company Law of 1921 (40 P. S. §
											753(A)(2)), if an insurer
					 elects to use a simplified application form, with or without a question as to
					 the health of the applicant at the time of application, but without any
					 questions concerning the health history or medical treatment history of the
					 insured, the policy must cover any loss occurring after 12 months from the
					 effective date of the insured person's coverage from any preexisting condition
					 not specifically excluded from coverage by terms of the policy, and, except as
					 so provided, the policy or contract shall not include wording that would permit
					 a defense based upon preexisting conditions. Changes to policies or contracts
					 required under this section, including changes to premium rates applicable
					 thereto, shall be permitted by endorsement or rider.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › PROBATIONARY OR WAITING PERIODS › Section 88.61 - Period of time

Current through Register Vol. 54, No. 28, July 13, 2024
Probationary or waiting periods shall relate to that period
					 of time which may be specified in the policy and which must follow the date a
					 person is initially insured under the policy, or following reinstatement of a
					 policy, before the coverage or coverages of the policy shall become effective
					 as to such person. A probationary or waiting period shall not be used with
					 respect to any loss resulting from accidental injuries as defined in the
					 policy. However, as to loss resulting from sickness a policy may specify a
					 probationary or waiting period which shall not exceed 30 days, except as
					 follows:
(1) For normal pregnancy and
				  childbirth, 30 days where the probationary or waiting period is expressed in
				  terms of the inception of the pregnancy.
(2) For elective surgery, not to exceed six
				  months. The following is a list of surgical procedures which may be considered
				  elective surgery:
(i) Cataract
				  operations.
(ii) Strabismus
				  operations.
(iii) Tonsilectomies,
				  adenoidectomies.
(iv)
				  Herniotomies.
(v)
				  Arthrotomies.
(vi)
				  Hemorrhoidectomies.
(vii)
				  Laminectomies.
(viii) Varicose
				  veins.
(ix) Gall bladder.
(x) Appendectomies concurrent with gall
				  bladder operation.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › LIMITATIONS › Section 88.71 - Clarity

Current through Register Vol. 54, No. 28, July 13, 2024
The limitations on the risk undertaken, whether applicable
					 to amounts, duration of benefits, or age or other matters, must be specified
					 with clarity and certainty in the appropriate provision of the
					 contract.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › EXCEPTIONS, EXCLUSIONS AND REDUCTIONS › Section 88.81 - Exception or exclusion

Current through Register Vol. 54, No. 28, July 13, 2024
An exception or exclusion is any provision in a policy
					 whereby coverage for a specific hazard is entirely eliminated. It is statement
					 of a risk not assumed under the terms and provisions of the
					 contract.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › EXCEPTIONS, EXCLUSIONS AND REDUCTIONS › Section 88.82 - Reduction

Current through Register Vol. 54, No. 28, July 13, 2024
A reduction is a provision which takes away some portion,
					 but not all, of the coverage of the policy under certain specific conditions.
					 Such reduction relates to a risk, which although assumed by the insurer,
					 payment upon the occurrence of such loss is limited to some amount or period
					 less than would be otherwise payable had such reduction clause not been
					 used.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › EXCEPTIONS, EXCLUSIONS AND REDUCTIONS › Section 88.83 - Clear expression

Current through Register Vol. 54, No. 28, July 13, 2024
Exceptions, exclusions, and reductions must be clearly
					 expressed as a part of the benefit provision to which such applies, or if
					 applicable to more than one benefit provision, shall be set forth as a separate
					 provision and appropriately captioned. The use of general policy exclusions and
					 the scope thereof will, of necessity, vary with the type of benefits afforded
					 in a given policy, subject to the requirement that said exclusions are
					 reasonable in light of the nature of benefits afforded.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › EXCEPTIONS, EXCLUSIONS AND REDUCTIONS › Section 88.84 - Listing of exclusions

Current through Register Vol. 54, No. 28, July 13, 2024
The following is a list of the exclusions which shall be
					 permitted in addition to those specified under § 618 of The Insurance
					 Company Law of 1921 (40 P. S. §
											753). The
					 wording of the exclusions is illustrative and is intended to indicate the
					 general intent of the Department. Alternate wording is permissible as long as
					 the meaning preserves the general intent of the exclusions, as follows:
(1) General exclusions shall conform with the
				  following:
(i) Loss sustained or expenses
				  incurred while on active duty as a member of the armed forces of any nation, or
				  losses sustained or expenses incurred as a result of act of war whether
				  declared or undeclared.
(ii)
				  Suicide or intentionally self-inflicted injuries.
(iii) Sickness or injury covered by any
				  Workmen's Compensation Act or Occupational Disease Law or by United States
				  Longshoreman's Harbor Worker's Compensation Act (33 U.S.C.A. §§
												901-950).
(iv) Mental, nervous, or emotional
				  disorders.
(v) Aviation hazards
				  except while flying as a fare-paying passenger on a commercial
				  airline.
(vi) Participation in a
				  riot or insurrection.
(vii)
				  Cosmetic surgery, except when necessitated by covered sickness or
				  injury.
(viii) Named hazardous
				  occupations.
(ix) Named hazardous
				  sports or hobbies.
(x) Normal
				  pregnancy, childbirth, and miscarriage.
(xi) Exclusions which, in the opinion of the
				  Commissioner, are justified by special circumstances or the particular coverage
				  of the policy.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › EXCEPTIONS, EXCLUSIONS AND REDUCTIONS › Section 88.85 - Unusual limitations, reductions, restrictions

Current through Register Vol. 54, No. 28, July 13, 2024
Any policy which contains unusual limitations, reductions,
					 or conditions of such a restrictive nature that the payment of benefits under
					 such policies is limited in frequency or in amounts shall carry the legend
					 "This Is A Limited Policy-Read It Carefully" imprinted in not less than
					 18-point outline type of contrasting color diagonally across the face and
					 filing back, if any, of the policy.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › EXCEPTIONS, EXCLUSIONS AND REDUCTIONS › Section 88.86 - Waivers

Current through Register Vol. 54, No. 28, July 13, 2024
The listing of specified exclusionary subjects set forth in
					 §
										88.84 (relating to listing of
					 exclusions) may not impair or limit the use of waivers to exclude, limit or
					 reduce coverage or benefits for specifically named or described preexisting
					 diseases, physical condition or extra hazardous activity. Where waivers are
					 required as a condition of issuance, renewal or reinstatement, signed
					 acceptance by the insured is required unless on initial issuance the full text
					 of the waiver is contained either on the first page or specification page of
					 the policy or unless notice of the waiver appears on the first page or
					 specification page.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › EXCEPTIONS, EXCLUSIONS AND REDUCTIONS › Section 88.87 - Military service exclusions

Current through Register Vol. 54, No. 28, July 13, 2024
If a policy contains a military service exclusion or a
					 provision suspending coverage during military service, and if the premiums are
					 either reduced or refunded for the period of the military service, the policy
					 shall clearly so state the following:
(1) As to policies other than noncancellable
				  and guaranteed renewable and guaranteed renewable policies, the following
				  provisions apply:
(i) If the policy contains a
				  "status" type of exclusion which excludes all coverages applicable to an
				  insured person while in military service on full time active duty, the policy
				  shall provide, upon receipt of written request, for refund of premiums as
				  applicable to such person on a pro rata basis.
(ii) If the policy contains a "causation"
				  type exclusion, that is loss resulting from military service while an insured
				  person is on full time active duty, refund of premium is not required since the
				  policy would be operative as to any other loss not resulting from military
				  service causes.
(iii) A provision
				  for voluntary suspension of coverage as to an insured person during military
				  service may be used and if an identifiable premium is charged as to such
				  person, then upon written request for suspension a pro rata premium must be
				  refunded.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › ELIMINATION PERIOD › Section 88.91 - Definition

Current through Register Vol. 54, No. 28, July 13, 2024
(a) "Elimination
				  period" means the initial period of time, during the continuance of a condition
				  insured against and specified in respect to a particular benefit, for which the
				  benefit will not be paid.
(b) The
				  periods shall be clearly expressed in the policy schedule or benefits page and
				  referenced in the benefit provision to which the elimination period
				  applies.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › REQUIREMENTS FOR REPLACEMENT › Section 88.101 - Application form

Current through Register Vol. 54, No. 28, July 13, 2024
Application forms shall contain a question to elicit
					 information as to whether the insurance to be issued is to replace any other
					 accident and health insurance presently in force. A supplementary application
					 or other form to be signed by the applicant containing such a question may be
					 used.
This section cited in 31 Pa. Code §
												88.102 (relating to delivery to
						applicant); and 31 Pa. Code §
												90c.3 (relating to replacement
						questions for life insurance).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › REQUIREMENTS FOR REPLACEMENT › Section 88.102 - Delivery to applicant

Current through Register Vol. 54, No. 28, July 13, 2024
Upon determining that a sale will involve replacement, an
					 insurer, other than a direct response insurer or its agent, shall furnish the
					 applicant at the time of completing the application, the notice described in
					 §
										88.103 (relating to notice form).
					 One copy of such notice shall be furnished to the applicant and an additional
					 copy signed by the applicant shall be retained by the insurer. A direct
					 response insurer shall deliver to the applicant upon issuance of the policy the
					 notice described in §
										88.104 (relating to notice form
					 for direct response insurer). In no event, however, will §§
										88.101-88.104 (relating to requirements
					 for replacement) apply to the solicitation of single premium nonrenewable
					 policies and accident only policies.
This section cited in 31 Pa. Code §
												88.103 (relating to notice form);
						and 31 Pa. Code §
												88.104 (relating to notice form
						for direct response insurer).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › REQUIREMENTS FOR REPLACEMENT › Section 88.103 - Notice form

Current through Register Vol. 54, No. 28, July 13, 2024
The notice required by §
										88.102 of this title (relating to
					 delivery to applicant) for an insurer, other than a direct response insurer,
					 shall provide, in substantially the following form:
NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND
					 SICKNESS INSURANCE
According to (your application) (information you have
					 furnished), you intend to lapse or otherwise terminate existing accident and
					 sickness insurance and replace it with a policy to be issued by (COMPANY NAME)
					 Insurance Company. Your new policy provides 10 days after receipt of the policy
					 within which you may decide whether you desire to keep the policy. For your own
					 information and protection you should be aware of and seriously consider
					 certain factors which may affect the insurance protection available to you
					 under the new policy.
(1) Health
				  conditions which you may presently have, (pre-existing conditions) may not be
				  immediately or fully covered under the new policy. This could result in denial
				  or delay of a claim for benefits under the new policy, whereas a similar claim
				  might have been payable under your present policy.
(This subsection may be modified if pre-existing conditions
					 are covered under the new policy).
(2) Even though some of your present health
				  conditions may be covered under the new policy, these conditions may be subject
				  to certain waiting periods under the new policy before coverage is
				  effective.
(3) You may wish to
				  secure the advice of your present insurer or its agent regarding the proposed
				  replacement of your present policy. This is not only your right, but is also in
				  your best interests to make sure you understand all the relevant factors
				  involved in replacing your present coverage.
(4) If, after due consideration, you still
				  wish to terminate your present policy and replace it with new coverage, be
				  certain to truthfully and completely answer all questions on the application
				  concerning your medical/health history. Failure to include all material medical
				  information on an application may provide a basis for the company to deny any
				  future claims and to refund your premium as though your policy had never been
				  in force.
After the application has been completed and before you
					 sign it, re-read it carefully to be certain that all information has been
					 properly recorded.
above Notice to Applicant' was delivered to me on:
_________________________
(Date)
_________________________
(Applicant's Signature)
This section cited in 31 Pa. Code §
												88.102 (relating to delivery to
						applicant).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › REQUIREMENTS FOR REPLACEMENT › Section 88.104 - Notice form for direct response insurer

Current through Register Vol. 54, No. 28, July 13, 2024
The notice required by §
										88.102 (relating to delivery to
					 applicant) for a direct response insurer shall provide, in substantially the
					 following form:
NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND
					 SICKNESS INSURANCE
According to (your application) (information you have
					 furnished) you intend to lapse or otherwise terminate existing accident and
					 sickness insurance and replace it with the policy delivered herewith issued by
					 (Company Name) Insurance Company. Your new policy provides 10 days within which
					 you may decide without cost whether you desire to keep the policy. For your own
					 information and protection you should be aware of and seriously consider
					 certain factors which may affect the insurance protection available to you
					 under the new policy.
(1) Health
				  conditions which you may presently have, (pre-existing conditions) may not be
				  immediately or fully covered under the new policy. This could result in denial
				  or delay of a claim for benefits under the new policy, whereas a similar claim
				  might have been payable under your present policy.
(This section may be modified if pre-existing conditions
					 are covered under the new policy.)
(2) Even though some of your present health
				  conditions may be covered under the new policy, these conditions may be subject
				  to certain waiting periods under the new policy before coverage is
				  effective.
(3) You may wish to
				  secure the advice of your present insurer or its agent regarding the proposed
				  replacement of your present policy. This is not only your right, but it is also
				  in your best interests to make sure you understand all the relevant factors
				  involved in replacing your present coverage.
(4) (To be included only if the application
				  is attached to the policy.) If, after due consideration, you still wish to
				  terminate your present policy and replace it with new coverage read the copy of
				  the application attached to your new policy and be sure that all questions are
				  answered fully and correctly. Omissions or misstatements in the application
				  could cause an otherwise valid claim to be denied. Carefully check the
				  application and write to (Company Name and Address) within 10 days if any
				  information is not correct and complete, or if any past medical history has
				  been left out of the application.
_________________________
(Company Name)
This section cited in 31 Pa. Code §
												88.104 (relating to delivery to
						applicant).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › RECURRENT CONDITIONS › Section 88.111 - Confinements or disabilities

Current through Register Vol. 54, No. 28, July 13, 2024
A policy may contain provisions relating to recurrent
					 confinements or recurrent disabilities; provided however, a recurrent
					 confinement or recurrent disability provision may not specify that such
					 confinement or such disabilities be separated by a period greater than 6
					 months.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › GENERAL RULES › Section 88.121 - Applications

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Opinion-type
				  questions regarding the past or present health of the applicant should provide
				  that the applicant is to answer to the best of his knowledge and
				  belief.
(b) No provision shall be
				  permitted in an application which changes the terms of the policy to which it
				  is attached.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › GENERAL RULES › Section 88.122 - Assessable policy

Current through Register Vol. 54, No. 28, July 13, 2024
The words "This Is An Assessable Policy" shall be printed
					 prominently on the policy face and filing back, if any, of each assessable
					 policy in at least 16-point type.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › GENERAL RULES › Section 88.123 - Use of certain words and terms

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				  policy containing, as part of its title, words such as "special" or "preferred"
				  which are used in a misleading fashion, or words such as "Union," "Labor,"
				  "Miner," and the like in its title which could associate it with a particular
				  organization, association, or business will not be approved.
(b) Policies which are to be issued to
				  supplement Medicare shall not have policy titles or headings which could in any
				  way confuse them with the Federal Medicare Program.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › GENERAL RULES › Section 88.124 - Suspension and termination

Current through Register Vol. 54, No. 28, July 13, 2024
No policy shall contain a provision for its automatic
					 termination upon the happening of any loss, except a loss which has exhausted
					 all possible benefits under the policy.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › GENERAL RULES › Section 88.125 - Multiple benefits

Current through Register Vol. 54, No. 28, July 13, 2024
Policies which contain multiple benefit provisions shall
					 not limit the payment of a specific benefit based on the fact that another
					 benefit is paid under the same policy.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › GENERAL RULES › Section 88.126 - Miscellaneous policy provisions

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  If the policy provides for any reduction in benefits because of the attainment
				  of a specified age limit, reference thereto shall be set forth on the first or
				  specifications page. For this purpose, a reduction in a benefit period is a
				  reduction in benefits requiring such reference.
(b) No reduction of benefits by reason of a
				  change in employment status or change in income of the insured shall be
				  permitted, unless clearly set forth in the policy under an appropriate
				  caption.
(c) Dependency status may
				  not be defined by sex.
(d) Any
				  policy providing coverage for hospital, surgical, or medical expense for the
				  recipient in a transplant operation shall also provide for the reimbursement of
				  any medical expenses of a live donor to the extent that benefits remain and are
				  available under the policy of the recipient after the benefits for the
				  recipient's own expenses have been paid.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › DEFINITION OF TERMS › Section 88.131 - Hospital

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The term may be
				  defined in relation to its status, facilities, and available services or to
				  reflect its accreditation by the Joint Commission on Accreditation of Hospitals
				  or the American Osteopathic Association. No definition of the term "hospital"
				  shall be more restrictive than one requiring that the hospital:
(1) Be an institution operated pursuant to
				  law which is licensed or approved as a hospital by the responsible state
				  agency.
(2) Be primarily engaged in
				  providing medical care and treatment of sick or injured persons on an
				  in-patient basis for which a charge is made.
(3) Provide 24 hour nursing service by or
				  under supervision of registered graduate professional nurses
				  (R.N.'s).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › DEFINITION OF TERMS › Section 88.132 - Convalescent nursing home, extended care facility or skilled nursing facility

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  terms "convalescent nursing home," "extended care facility" or "skilled nursing
				  facility" may be defined in relation to their status, facilities and available
				  services. No definition of the home or facility shall be more restrictive than
				  one requiring that it:
(1) Be operated
				  pursuant to law.
(2) Be approved
				  for payment of Medicare benefits or be qualified to receive such approval, if
				  so requested.
(3) Be primarily
				  engaged in providing, in addition to room and board accommodations, skilled
				  nursing care under the supervision of a duly licensed physician.
(4) Provide continuous 24 hours a day nursing
				  service by or under the supervision of a registered graduate professional nurse
				  (R.N.).
(5) Maintain a daily
				  medical record of each patient.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › DEFINITION OF TERMS › Section 88.133 - Accident, accidental injury

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  The definition of accident, accidental injury shall 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 characterization.
(b) No definition shall be more restrictive
				  than the following: Injury or injuries, for which benefits are provided, means
				  accidental bodily injuries sustained by the insured person which are the direct
				  and independent cause of the loss and occur while the insurance is in force.
				  The definition may provide that injuries shall not include injuries for which
				  benefits are provided under any workmen's compensation, employer's liability or
				  similar law.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › DEFINITION OF TERMS › Section 88.134 - Sickness

Current through Register Vol. 54, No. 28, July 13, 2024
No definition of "sickness" shall be more restrictive than
					 the following: "sickness" shall mean sickness or disease of an insured person
					 which is diagnosed or treated after the effective date of insurance and while
					 the insurance is in force. Such definition may provide for a probationary
					 period which shall not exceed 30 days. However, the definition shall clearly
					 state that illnesses diagnosed or treated during the probationary period shall
					 be covered subject to the Time Limit on Certain Defenses. The definition may be
					 further modified to exclude sickness or disease for which benefits are provided
					 under any workmen's compensation, occupational disease, employer's liability,
					 or similar law.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › DEFINITION OF TERMS › Section 88.135 - Physician

Current through Register Vol. 54, No. 28, July 13, 2024
The insurer may define "physician" or the policy may
					 include words such as qualified physician" or "duly licensed physician." The
					 use of such words requires an insurer to recognize and to accept, to the extent
					 of its obligation under the contract, all providers of medical care and
					 treatment when such services are within the scope of the provider's licensed
					 authority and are provided pursuant to applicable laws.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › DEFINITION OF TERMS › Section 88.136 - Nurses

Current through Register Vol. 54, No. 28, July 13, 2024
The definition or description of "nurse" may be restricted
					 to a type of nurse, such as registered graduate professional nurse (R.N.), a
					 licensed practical nurse (L.P.N.), or a licensed vocational nurse (L.V.N.). If
					 the words "nurse," "trained nurse," or "registered nurse" are used without a
					 specific definition, then the use of such terms requires the insurer to
					 recognize the services of any individual who qualifies under such terminology
					 in accordance with the applicable statutes or administrative rules of the
					 licensing or registry board of the state.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › DEFINITION OF TERMS › Section 88.137 - Total disability

Current through Register Vol. 54, No. 28, July 13, 2024
(a) For the
				  first 24 months after the commencement of a loss, "total disability" shall be
				  defined as the inability of the insured to perform all the substantial and
				  material duties of his regular occupation. After 24 months of continuous
				  disability, total disability may be defined as the inability of the insured to
				  perform all of the substantial and material duties of any occupation for which
				  he is reasonably suited by reason of education, training, or experience. The
				  definition may require that the insured not in fact be engaged in any
				  occupation for wage or profit.
(b)
				  Total disability may be defined in relation to the inability of the person to
				  perform duties but such inability may not be based solely upon the ability of
				  an individual to:
(1) Perform "any occupation
				  whatsoever" or "any occupational duty."
(2) Engage in any training or rehabilitation
				  program.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › DEFINITION OF TERMS › Section 88.138 - Partial disability

Current through Register Vol. 54, No. 28, July 13, 2024
Partial disability may be defined in relation to one's
					 inability to perform one or more but not all of the "major," "important," or
					 "essential" duties of his employment or occupation or may be related to a
					 "percentage" of time worked or to a "specified number of hours" or to
					 "compensation." Where a policy provides total disability benefits and partial
					 disability benefits, only one elimination period may be
					 required.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › DEFINITION OF TERMS › Section 88.139 - Residual disability

Current through Register Vol. 54, No. 28, July 13, 2024
Residual disability shall be defined in relation to the
					 individual's reduction in earnings and may be related either to the inability
					 to perform some part of the "major," "important," or "essential duties" of
					 employment or occupation, or to the inability to perform all usual business
					 duties for as long as is usually required. A policy which provides for residual
					 disability benefits may require a qualification period, during which the
					 insured must be continuously totally disabled before residual disability
					 benefits are payable. The qualification period for residual benefits may be
					 longer than the elimination period for total disability. In lieu of the term
					 "residual disability," the insurer may use "proportionate disability" or other
					 term of similar import which in the opinion of the Commissioner adequately and
					 fairly describes the benefit.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › DEFINITION OF TERMS › Section 88.140 - Medicare

Current through Register Vol. 54, No. 28, July 13, 2024
A hospital, surgical, or medical expenses policy which
					 relates its coverage to eligibility for Medicare or Medicare benefits shall
					 include a definition of Medicare. Such may be substantially defined as "The
					 Health Insurance for the Aged Act, Title XVIII of the Social Security
					 Amendments of 1965 as then Constituted or Later Amended," or "Title I, Part I
					 of Public Laws 89-97as enacted by the Eighty-Ninth Congress of the United
					 States of America and popularly known as the Health Insurance for the Aged Act,
					 as then constituted and any later amendments or substitutes thereof," or words
					 of similar import.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 88 - INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS › DEFINITION OF TERMS › Section 88.141 - Mental or nervous disorders

Current through Register Vol. 54, No. 28, July 13, 2024
Mental, nervous, or emotional disorder means a neurosis,
					 psychoneurosis, psychopathy, or psychosis. The definition may include mental,
					 nervous or emotional disorders without demonstrable organic
					 origin.