Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-96 - Group and blanket disability insurance › Section 284-96-550 - Standard disclosure form for group coverage - Illness-triggered fixed payment insurance, hospital confinement fixed payment insurance, or other fixed payment insurance

Current through Register Vol. 24-14, July 15, 2024
(1) All
			 disability insurers offering group policies that provide benefits in the form
			 of illness-triggered fixed payments, hospital confinement fixed payments or
			 other fixed payment insurance, must issue a disclosure form in substantially
			 the format and content outlined below. The disclosure form must be provided to
			 the master policyholder at the time of solicitation and completion of the
			 application form and to all enrollees at the time of enrollment. Every insurer
			 must have a mechanism in place to verify delivery of the disclosure to the
			 master policyholder and to every enrollee.
(2) The type size and font of the disclosure
			 form must be easily read and be no smaller than 10 point.
(3) The insurer's disclosure form must be
			 filed
for approval
with the commissioner prior to use.
(4) The standard disclosure form replaces any
			 outline of coverage that would otherwise be required for fixed payment policies
			 and must include, at a minimum, the following information:
(Insurer's name and address)
IMPORTANT INFORMATION ABOUT THE
COVERAGE YOU ARE BEING OFFERED
Save this statement! It may be important to you in the future.
				The Washington State Insurance Commissioner requires that we give you the
				following information about fixed payment benefits.
This coverage is not comprehensive health care
							 insurance and will not cover the cost of most hospital and other medical
							 services.
This disclosure provides a very brief description of the
				important features of the coverage being considered. It is not an insurance
				contract and only the actual policy provisions will control. The policy itself
				will include in detail the rights and obligations of both the master
				policyholder and (insurer's name).
This coverage is designed to pay you a fixed dollar amount
				regardless of the amount that the provider charges. Payments are not based on a
				percentage of the provider's charge and are paid in addition to any other
				health plan coverage you may have.
CAUTION: If you are also covered under a High
							 Deductible Health Plan (HDHP) and are contributing to a Health Savings Account
							 (HSA), you should check with your tax advisor or benefit advisor prior to
							 purchasing this coverage to be sure that you will continue to be eligible to
							 contribute to the HSA if this coverage is purchased.
The benefits under this policy are summarized below.
Type of coverage:
Benefit amount:
Benefit trigger (identify any periods of no coverage such as
				eligibility or waiting periods):
Duration of coverage:
Renewability of coverage:
Policy provisions that exclude, eliminate, restrict, reduce,
				limit, delay, or in any other manner operate to qualify payment of the benefits
				described above include the following:
(List all exclusions including those that relate to limitations
				for preexisting conditions.)
Statutory Authority:
				  RCW
				  48.02.060,
				  48.20.550, and
				  48.21.370. 07-21-073 (Matter No. R
				  2007-05), §
										284-96-550, filed 10/15/07,
				  effective 11/15/07.