Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-50 - Washington disability insurance regulations › MINIMUM STANDARDS FOR INDIVIDUAL POLICIES › Section 284-50-440 - Standard disclosure form for individual policies - 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 individual 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
				all applicants at the time of solicitation and completion of the application
				form for coverage. Every insurer must have a mechanism in place to verify
				delivery of the disclosure to the applicant.
(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 document provides a very brief description of
				  the important features of the coverage you are considering. 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 you 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), before you purchase this policy you should check with your tax advisor
								to be sure that you will continue to be eligible to contribute to the HSA if
								you purchase this coverage.
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), §
											284-50-440, filed 10/15/07,
					 effective 11/15/07.