CHAPTER Ins 6200 ANCILLARY HEALTH MINIMUM STANDARDS
Statutory
Authority: RSA 400-A:15, I; RSA 415:6, VII; RSA 415:18, I; RSA 415-A:2; and RSA
415-A:3, I
REVISION NOTE #1:
Document
#12600, effective 8-3-18, adopted Chapter Ins 6200 titled “Ancillary Health
Minimum Standards” containing Part Ins 6201 titled “Ancillary Health Minimum
Standards General Provisions.”
Part
Ins 6201 had been based on the former rules Ins
1901.06(a)(1), (3), (5)-(10), and (14), Ins 1901.07(a)(1)-(3), (5)-(13),
(15)-(18), (23), and (24), Ins 1901.07(b)(1), (2), (4), and (5), and Ins
1901.07(f). The former Ins 1901.06 had been titled “Accident and Health Minimum
Standards for Benefits” and the former
Ins 1901.07 had been titled “Required Disclosure Provisions.” Both the former Ins 1901.06 and the former Ins 1901.07 had expired
4-17-14. Part Ins 6201 replaces
the provisions cited above in the former Ins 1901.06
and former Ins 1901.07.
The
filings affecting the former Ins 1901.06 included the
following documents:
#1900,
effective 1-1-82
#4287,
effective 7-1-87
#4811,
effective 5-4-90
#5656,
effective 7-1-93
#7017,
INTERIM, effective 7-1-99, EXPIRED 10-29-99
#8609,
effective 4-17-06, EXPIRED 4-17-14
The
filings affecting the former Ins 1901.07 included the
following documents:
#1900,
effective 1-1-82
#4287,
effective 7-1-87
#5656,
effective 7-1-93
#7017,
INTERIM, effective 7-1-99, EXPIRED 10-29-99
#8609,
effective 4-17-06, EXPIRED 4-17-14
REVISION NOTE #2:
Document
#12659, effective 11-5-18, adopted Part Ins 6202 titled “Ancillary
Health Minimum Standards for Hospital Confinement Fixed Indemnity and Other
Fixed Indemnity Coverage.”
Part
Ins 6202 had been based on the former rules Ins
1901.05(e), Ins 1901.06(e), and Ins 1901.07(a)(14) and (17). The former Ins
1901.06 and Ins 1901.07 had been titled as noted in Revision Note #1 above, and
had expired 4-17-14. The former Ins 1901.05 had been
titled “Prohibited Policy Provisions” and had also expired 4-17-14. Part Ins 6202 replaces the provisions cited
above in the former Ins 1901.05, Ins 1901.06, and Ins
1901.07.
The
filings affecting the former Ins 1901.06 and Ins
1901.07 included the documents cited in Revision Note #1 above. The filings affecting the former Ins 1901.05 included the following documents:
#1900,
effective 1-1-82
#4287,
effective 7-1-87
#4811,
effective 5-4-90
#5656,
effective 7-1-93
#5943,
effective 1-1-95 (Ins 1901.05(e) EXPIRED 1-1-03)
#7017,
INTERIM, effective 7-1-99, EXPIRED 10-29-99
#8609,
effective 4-17-06, EXPIRED 4-17-14
REVISION NOTE #3:
Document
#12855, effective 8-26-19, adopted Part Ins 6203 titled “Ancillary Health
Minimum Standards for Accident-Only and Specified Accident Coverage.”
Part
Ins 6203 had been based on the former rules Ins
1901.06(i) and Ins 1901.06(k). The former Ins
1901.06 had been titled as noted in Revision Note #1 above, and had expired
4-17-14.
The
filings affecting the former Ins 1901.06 included the
following documents as listed in Revision Note #1:
#1900,
effective 1-1-82
#4287,
effective 7-1-87
#4811,
effective 5-4-90
#5656,
effective 7-1-93
#7017,
INTERIM, effective 7-1-99, EXPIRED 10-29-99
#8609,
effective 4-17-06, EXPIRED 4-17-14
PART
Ins 6201 ANCILLARY HEALTH MINIMUM STANDARDS GENERAL PROVISIONS
Ins
6201.01 Purpose. The purpose of chapter Ins 6200 is to
implement the provisions of RSA 415-A to facilitate public understanding and
comparison of coverage, to eliminate provisions contained in ancillary health
policies subject to RSA 415-A that may be misleading or confusing in connection
with the purchase of the coverages or with the settlement of claims, and to
provide for full disclosure in the marketing and sale of individual ancillary
health insurance policies and group ancillary health insurance policies subject
to RSA 415-A and this chapter.
Source.
(See Revision Note #1 at chapter heading
for Ins 6200) #12600, eff 8-3-18
Ins
6201.02 Applicability and Scope.
(a) Ins 6200 shall apply to all individual
ancillary health policies and group ancillary health policies and certificates,
unless otherwise specified, which provide coverages that are considered limited
benefits, including hospital indemnity and other fixed indemnity, disability
income protection, accident-only, specified disease, specified accident, and
limited benefit health coverages, which are delivered or issued for delivery in
this state on and after the initial effective date of this part, as provided in
RSA 415-A, and that are not specifically exempted from this part.
(b) This part shall not apply to:
(1)
Any policies subject to RSA 420-G;
(2)
Medicare supplement policies subject to RSA 415-F;
(3)
Long-term care insurance policies subject to RSA 415-D; or
(4)
TRICARE formerly known as the Civilian Health and Medical Program of the
Uniformed Services (Chapter 55, title 10, of the
United States Code)(CHAMPUS) supplement insurance policies.
(c) The requirements contained in this part shall
be in addition to any other applicable part previously adopted and still in
effect.
Source. (See Revision
Note #1 at chapter heading for Ins 6200) #12600, eff
8-3-18; ss by #13137, eff 11-24-20
Ins
6201.03 Definitions. Definitions for this part shall be those
outlined in Ins 6001.03 and Ins 6001.04.
Source. (See Revision
Note #1 at chapter heading for Ins 6200) #12600, eff
8-3-18
Ins
6201.04 Ancillary Health Minimum
Standards. The following minimum
standards for benefits shall apply to all ancillary health policies and
certificates which are subject to Ins 6201:
(a) A “noncancellable”, “guaranteed renewable”,
or “noncancellable and guaranteed renewable” individual ancillary health policy
shall not provide for termination of coverage of the spouse solely because of
the occurrence of an event specified for termination of coverage of the
insured, other than nonpayment of premium.
In addition, the policy shall provide that, in the event of the
insured’s death, the spouse of the insured, if covered under the policy, shall
become the insured;
(b)
In an individual ancillary health policy
covering both spouses, the age of the younger spouse shall be used as the basis
for meeting the age and durational requirements of the definitions of
“noncancellable” or “guaranteed renewable.”
However, when the older spouse attains the stated age, the coverage for
that spouse may be terminated, provided that the policy continues in force for
the younger spouse until either that spouse attains the stated age or at the
end of the durational period specified in the policy;
(c) An individual ancillary health policy that
provides for periodic payments, weekly or monthly, for a specified period
during the continuance of disability resulting from accident or sickness may
provide that the insured has the right to continue the policy at least to
Social Security retirement age;
(d) A group ancillary health policy or
certificate that provides for periodic payments, weekly or monthly, for a
specified period during the continuance of disability resulting from accident
or sickness may provide that the insured has the right to continue the policy
at least to Social Security retirement age;
(e) When individual accidental death and
dismemberment coverage is part of the ancillary health insurance coverage
offered under the policy, the insured shall have the option to include all
insureds under the coverage and not just the principal insured;
(f) If a policy or certificate contains a
status-type military service exclusion or a provision that suspends coverage during
military service, the policy shall provide for refund of premiums as applicable
to the person on a pro rata basis within 30 days;
(g) In the event the insurer cancels or refuses
to renew, policies or certificates providing pregnancy benefits shall provide
for an extension of benefits as to pregnancy commencing while the policy or
certificate is in force and for which benefits would have been payable had the
policy or certificate remained in force;
(h) Policies or certificates providing
convalescent or extended care benefits following hospitalization shall not
condition the benefits upon admission to the convalescent or extended care
facility within a period of less than 14 days after discharge from the hospital
and shall not require a minimum hospital stay;
(i) Ancillary health
insurance policies or certificates of coverage shall continue for a dependent
child who is mentally
or physically incapable of earning his or her own living on the date as of
which such dependent's status as a covered family member would otherwise expire
because of age, in accordance with RSA 415:5, I(3-a)(a);
(j)
A policy or certificate providing expense based coverage for the recipient in a
transplant operation shall also provide reimbursement for any medical expenses
of a live donor to the extent that benefits remain and are available under the
recipient’s policy or certificate, after benefits for the recipient’s own
expenses have been paid;
(k)
A policy or certificate may contain a
provision relating to recurrent disabilities, but a provision relating to
recurrent disabilities shall not specify that a recurrent disability be
separated by a period greater than 6 months;
(l)
Termination of the policy or certificate
shall be without prejudice to a continuous loss that commenced while the policy
or certificate was in force, pursuant to Ins 6101. The continuous total disability of the
insured shall be a condition for the extension of benefits beyond the period
the policy was in force, limited to the earlier of either the duration of the
benefit period, if any, or payment of the maximum benefits;
(m)
Policies covering a single specified
disease or combination of specified diseases shall only be sold or offered for
sale as stand-alone specified disease policies;
(n) Policies and certificates shall be delivered
to the policyholder within 45 days of the effective date; and
(o) If there is any reduction of benefits under a
group policy, then the insurer shall issue and deliver updated certificates to
the policyholder.
Source. (See Revision
Note #1 at chapter heading for Ins 6200) #12600, eff
8-3-18
Ins
6201.05 Required Disclosure
Provisions. The following disclosure
provisions shall apply to all ancillary health policies and certificates which
are subject to Ins 6201:
(a)
All policies and certificates of ancillary health insurance, except for
disability income protection, shall contain the following statement:
“This policy does not provide comprehensive health insurance coverage. It
is not intended to satisfy the individual mandate of the Affordable Care Act
(ACA) or provide the minimum essential coverage required by the ACA (often referred to as “Major
Medical Coverage”). It does not provide
coverage for hospital, medical, surgical, or major medical expenses.”;
(b) All applications for coverages specified in
RSA 415-A:3, I(d), (h), (i), (j), and (k) shall
contain a prominent statement by type, stamp, or other appropriate means in
either contrasting color or in boldface type at least equal to the size type
used for the headings or captions of sections of the application and in close
conjunction with the applicant’s signature block on the application as follows:
“This [policy] [certificate]
provides limited benefits. Review your
[policy] [certificate] carefully.”;
(c) All applications for dental plans shall
contain a prominent statement by type, stamp, or other appropriate means in
either contrasting color or in boldface type at least equal to the size type
used for the headings or captions of sections of the application and in close
conjunction with the applicant’s signature block on the application as follows:
“This [policy] [certificate]
provides dental benefits only. Review
your [policy] [certificate] carefully.”;
(d) All applications for vision plans shall
contain a prominent statement by type, stamp, or other appropriate means in
either contrasting color or in boldface type at least equal to the size type
used for the headings or captions of sections of the application and in close
conjunction with the applicant’s signature block on the application as follows:
“This [policy] [certificate]
provides vision benefits only. Review
your [policy] [certificate] carefully.”;
(e) Except for amendments or riders by which the
insurer effectuates a request made in writing by the policyholder or exercises
a specifically reserved right under the policy, all amendments or riders added
to a policy after the date of issue, or at reinstatement or renewal, that
reduce or eliminate benefits or coverage in the policy shall require signed
acceptance by the policyholder. After
the date of policy issue, any amendment or rider that increases benefits or
coverage with a concomitant increase in premium during the policy term shall be
agreed to in writing signed by the policyholder, unless the increased benefits
or coverage is required by law. The
signature requirements in this paragraph apply to group ancillary health
insurance certificates only where the certificateholder
also pays the insurance premiums;
(f)
Where a separate additional premium is charged for benefits provided in
connection with amendments or riders, the premium charge shall be set forth in
the policy;
(g) A policy or certificate that provides for the
payment of benefits based on standards described as “usual and customary”,
“reasonable and customary”, or words of similar import shall include a
definition of the terms and an explanation of the terms in its accompanying
outline of coverage;
(h) If a policy or certificate contains any
limitations with respect to preexisting conditions, the limitations shall
appear as a separate paragraph of the policy or certificate and be labeled as
“Preexisting Condition Limitations”;
(i) All accident-only
policies and certificates shall contain a prominent statement on the cover page
of the policy or certificate, in either contrasting color or in boldface type
at least equal to the size of type used for headings or captions of sections in
the policy or certificate, a prominent statement as follows:
“Notice to Buyer: This is an accident-only [policy]
[certificate] and it does not pay benefits for loss from sickness. Review your [policy] [certificate] carefully.”;
(j) Accident-only policies and certificates that
provide coverage for hospital or medical care shall contain the following
statement on the cover page, in addition to the Notice to Buyer in (i) above:
“This [policy] [certificate]
provides limited benefits. Benefits
provided are not intended to cover all medical expenses.”;
(k) All policies and certificates, except
single-premium nonrenewable policies and as otherwise provided in this section,
shall have a notice prominently printed on the cover page of the policy or
certificate stating in substance that the policyholder or certificateholder
shall have the right to return the policy or certificate within 30 days of its
delivery and to have the premium refunded if, after examination of the policy
or certificate, the policyholder or certificateholder
is not satisfied for any reason;
(l) If age is to be used as a determining factor
for reducing the maximum aggregate benefits made available in the policy or certificate
as originally issued, that fact shall be prominently set forth in the outline
of coverage;
(m) If a policy or certificate contains a
conversion privilege, it shall comply, in substance, with the following:
(1)
The caption of the provision shall be “Conversion Privilege” or words of
similar import;
(2)
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; and
(3)
The provision shall specify the benefits to be provided on conversion or
shall state that the converted coverage shall be as provided on a policy form
then being used by the insurer for that purpose;
(n) Insurers, except direct response insurers,
shall give a person applying for cancer insurance the National Association of
Insurance Commissioners’ (NAIC) “A Shopper’s Guide to Cancer Insurance” (2006),
available as referenced in Appendix B, at the time of application enrollment
and shall obtain all recipients’ written acknowledgement of the guide’s
delivery. Direct response insurers shall
provide the NAIC’s “A Shopper’s Guide to Cancer Insurance” upon request but not
later than the time that the policy or certificate is delivered;
(o) All specified disease policies and
certificates shall contain on the cover page in either contrasting color or in
boldface type at least equal to the size type used for headings or captions of
sections in the policy or certificate, a prominent statement
as follows:
“Notice to Buyer: This is a specified disease [policy]
[certificate]. This [policy]
[certificate] provides limited benefits.
Benefits provided are supplemental and are not intended to cover all
medical expenses. Read your [policy]
[certificate] carefully with the outline of coverage and the Buyer’s Guide.”;
(p) Hospital confinement indemnity and other
indemnity policies:
(1)
All hospital confinement indemnity policies and certificates shall
display prominently by type, stamp, or other appropriate means on the cover
page of the policy or certificate, in either contrasting color or in boldface
type at least equal to the size type used for headings or captions of sections
in the policy or certificate the following:
“Notice to Buyer: This is a hospital confinement indemnity
[policy] [certificate]. This [policy]
[certificate] provides limited benefits.
Benefits provided are supplemental and are not intended to cover all
medical expenses.”; and
(2)
In addition to the “Notice to Buyer” required by (1) above, all
“hospital confinement indemnity” and “other indemnity” policies sold in the
individual market shall display prominently on the cover page in at least 14 point type the following language:
“THIS IS A SUPPLEMENT TO HEALTH
INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE.”;
(q) Unless a specific disclosure for the coverage
type is provided as described in paragraphs (i), (j),
(o), and (p) above, an ancillary health policy or certificate shall display
prominently by type, stamp, or other appropriate means on the cover page of the
policy or certificate, in either contrasting color or in boldface type at least
equal to the size type used for headings or captions of sections in the policy
or
certificate the following:
“Notice to Buyer: This is an ancillary health [policy]
[certificate]. This [policy]
[certificate] provides limited benefits.
Benefits provided are supplemental and are not intended to cover all
medical expenses.”;
(r) All dental plan policies and certificates
shall display prominently by type, stamp, or other appropriate means on the
cover page of the policy or certificate, in either contrasting color or in
boldface type at least equal to the size type used for headings or captions of
sections in the policy or certificate the following:
“Notice to Buyer: This [policy] [certificate] provides dental
benefits only.”;
(s) All vision plan policies and certificates
shall display prominently by type, stamp, or other appropriate means on the
cover page of the policy or certificate, in either contrasting color or in
boldface type at least equal to the size type used for headings or captions of
sections in the policy or certificate the following:
“Notice to Buyer: This [policy] [certificate] provides vision
benefits only.”; and
(t) Any policy or certificate that contains
exclusions, 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 Benefit Policy – Read it
Carefully” imprinted across the face and filing back, if any, of the policy, in
not less than 18-point outline type of contrasting color, not less than
24-point outline type of non-contrasting color diagonally, or not less than
24-point bold within a black border.
Source. (See Revision
Note #1 at chapter heading for Ins 6200) #12600, eff
8-3-18; ss by #13137, eff 11-24-20
Ins
6201.06 Outline of Coverage
Requirements.
(a) An insurer shall deliver an outline of
coverage to an applicant or enrollee in the sale of individual ancillary health
insurance, group ancillary health insurance, dental plans, and vision plans as
required in RSA 415-A:4
(b) If an outline of coverage was delivered at
the time of application or enrollment and the policy or certificate is issued
on a basis which would require revision of the outline, a revised outline of
coverage properly describing the policy or certificate shall accompany the
policy or certificate when it is delivered and contain the following statement
in no less than 14 point type, immediately above the
company name:
“NOTICE: Read this outline of coverage carefully. It is not identical to the outline of
coverage provided upon [application] [enrollment], and the coverage originally
applied for has not been issued.”
(c) In any case where the prescribed outline of
coverage is inappropriate for the coverage provided by the policy or
certificate, an alternative outline of coverage shall be submitted to the
commissioner prior to use.
(d) Advertisements shall fulfill the requirements
for outlines of coverage if they satisfy the standards specified for outlines
of coverage in RSA 415-A:4 as well as this part.
(e) The outline of coverage shall not refer back to the policy for exclusions and limitations but
shall specify exclusions and limitations in the outline of coverage.
(f) Policies for persons eligible for Medicare:
(1)
Outlines of coverage delivered in connection with policies that provide
hospital confinement indemnity, specified disease, or limited benefit health
coverage to persons eligible for Medicare by reason of age shall contain the
following language, which shall be printed on or attached to the first page of
the outline of coverage:
“This IS NOT A MEDICARE SUPPLEMENT
policy. If you are eligible for
Medicare, review the Guide to Health Insurance for People With
Medicare available from the company.”; and
(2)
An insurer shall deliver to persons eligible for Medicare any notice
required under RSA 415-F:5 and Ins 1905.19(e) Notice
Regarding Policies or Certificates Which Are Not Medicare Supplement Policies.
(g) An outline of coverage, in the format
prescribed in (h) below, shall be issued in connection with policies meeting the
standards of this part.
(h) The items included in the outline of coverage
shall appear in the following sequence:
“[COMPANY NAME]
[TYPE OF ANCILLARY HEALTH COVERAGE]
THIS [POLICY] [CERTIFICATE] PROVIDES
LIMITED BENEFITS
BENEFITS PROVIDED ARE SUPPLEMENTAL
AND ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES
OUTLINE OF COVERAGE
Read Your [Policy] [Certificate]
Carefully—this outline of coverage provides a very brief description of the
important features of coverage. This is
not the insurance contract and only the actual policy provisions will
control. The policy itself sets forth in
detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ
YOUR [POLICY] [CERTIFICATE] CAREFULLY!
[Type of Ancillary Health] coverage
is designed to provide, to persons insured, [brief description of Type of
Ancillary Health coverage], subject to any limitations set forth in the policy
or certificate. Coverage is not provided
for any benefits other than the specific [Type of Ancillary Health] benefits described and any additional benefit described below:
(1)
[A brief specific description of the benefits, including dollar amounts];
(2)
[A description of any policy provisions that exclude, eliminate,
restrict, reduce, limit, delay, or in any other manner operate to qualify
payment of the benefit described in paragraph (1) above]; and
(3)
[A description of policy provisions respecting renewability of
continuation of coverage, including age restrictions or any reservation of
right to change premiums].”
Source. (See Revision
Note #1 at chapter heading for Ins 6200) #12600, eff
8-3-18
Ins
6201.07 Waiver of Rules.
(a) The commissioner, upon the commissioner’s own
initiative or upon request by an insurer, shall waive any requirement of this
chapter if such waiver does not contradict the objective or intent of the rule
and:
(1)
Applying the rule provision would cause confusion or would be misleading
to consumers;
(2)
The rule provision is in whole or in part inapplicable to the given circumstances;
(3)
There are specific circumstances unique to the situation such that
strict compliance with the rule would be onerous without promoting the
objective or intent of the rule
provision; or
(4)
Any other similar extenuating circumstances exist such that application
of an alternative standard or procedure better promotes the objective or intent
of the rule provision.
(b) No requirement prescribed by statute shall be
waived unless expressly authorized by law.
(c) Any person or entity seeking a waiver shall
make a request in writing.
(d) A request for a waiver shall specify the
basis for the waiver and proposed alternative, if any.
Source. (See Revision
Note #1 at chapter heading for Ins 6200) #12600, eff
8-3-18
PART Ins 6202 ANCILLARY HEALTH MINIMUM STANDARDS FOR HOSPITAL
CONFINEMENT FIXED INDEMNITY AND OTHER FIXED INDEMNITY COVERAGE
Statutory Authority: RSA 400-A:15, I; RSA 415:18, I; RSA 415-A:2,
I; RSA 415-A:3, I
Ins
6202.01 Applicability and Scope. Ins 6202 shall apply to all individual and
group ancillary health policies and certificates that provide coverage for
hospital confinement fixed indemnity and other fixed indemnity as applicable
and which are not covered under other rules and are delivered or issued for
delivery in this state on and after the initial effective date of this part.
Source. (See Revision Note #2 at chapter heading for Ins 6200) #12659, eff 11-5-18
Ins 6202.02 Definitions.
(a)
“Benefits waiting period” is the time measured from the effective date
of coverage during which no benefits are provided.
(b)
“Eligibility waiting period” is the period of time that an employee must
be in the employ of an employer or an individual must
be a member of an association before coverage under a group ancillary health
insurance plan becomes effective.
(c)
“Hospital confinement fixed indemnity coverage” means a policy or
certificate of ancillary health insurance offered as an independent,
non-coordinated benefit that provides a fixed dollar amount per day or per
other period for hospital confinement on an indemnity basis, triggered by the
event of an admission to the hospital or other covered facility and regardless
of the amount of expense incurred.
(d)
“Other fixed indemnity coverage” means a policy or certificate of
ancillary health insurance offered as an independent, non-coordinated benefit
that provides a benefit on an indemnity basis in a fixed amount per covered
event or time period regardless of the amount of
expense incurred.
Source. (See Revision
Note #2 at chapter heading for Ins 6200) #12659, eff
11-5-18; ss by #13137, eff 11-24-20
Ins 6202.03 Minimum Standards for Benefits. The following minimum standards for benefits
are prescribed for individual and group ancillary health policies and
certificates that provide coverage for hospital confinement and other fixed
indemnity:
(a)
Hospital confinement coverage shall provide a minimum benefit of $50 per
day per covered person and not less than 31 days during each period of
confinement for each person insured under the policy or certificate;
(b)
A minimum of 1 period of confinement shall be provided per policy year
per covered person;
(c)
Coverage shall not be excluded due to a preexisting condition for a
period greater than
6
months following the effective date of coverage of an insured person;
(d)
Except as provided in RSA 415:6, II(3) regarding other insurance with
the insurer, benefits shall be paid regardless of other coverage;
(e)
The benefit shall be for a specific amount that is event based and shall
not be expense based;
(f) The benefit shall not be
assignable to a health care provider and shall be paid directly to the
subscriber. The policy shall contain a
provision prohibiting assignment of the benefit;
(g)
The policy, the certificate, and the schedule of benefits shall be
written in a manner such that a covered person is able to determine what
coverage is provided;
(h)
Rates for all indemnity health insurance products shall be submitted
pursuant to Ins 4106;
(i) Disclosures shall be provided in accordance
with Ins. 6201.05 and Ins 6202.05; and
(j) Indemnity policies and certificates that do
not comply with this part or that fail to qualify as an excepted benefit under
federal law shall be considered “health coverage” as defined under RSA 420-G
and shall be required to meet the requirements of RSA 420-G and RSA 415
provisions applicable to health insurance.
Source. (See Revision
Note #2 at chapter heading for Ins 6200) #12659, eff
11-5-18; ss by #13137, eff 11-24-20
Ins
6202.04 Prohibited Policy Provisions.
(a) Coordination of benefits shall not be permitted.
(b) Managed care and network requirements shall
not be permitted. The policy shall not
include a provision requiring pre-certification.
(c) Expense based benefits and riders shall not
be permitted.
(d) Group coverage shall not include benefits on
a per service basis, except for coverage that is provided to associations, but
not related to employment, and sold to individuals.
(e) Policies or certificates providing hospital
confinement indemnity or other fixed indemnity coverage shall not contain
provisions excluding coverage because of confinement in a hospital operated by
the federal government.
(f) Benefits for “skilled nursing facility”, as
defined in Ins 6001.04(b), services shall not be contingent
upon a hospital stay.
(g) A benefits waiting
period shall not be permitted.
(h) Any eligibility waiting period shall not
exceed 12 months.
(i) Coverage shall
not be stated on an “up to” basis.
Source. (See Revision
Note #2 at chapter heading for Ins 6200) #12659, eff
11-5-18; ss by #13137, eff 11-24-20
Ins
6202.05 Required Disclosure
Provisions.
(a) All hospital confinement indemnity policies
and certificates shall display prominently by type, stamp
or other appropriate means on the face page of the policy or certificate, in
either contrasting color or in boldface type at least equal to the size type
used for headings or captions of sections in the [policy] [certificate] the
following:
“Notice to Buyer: This is a hospital confinement indemnity
[policy] [certificate]. This [policy]
[certificate] provides limited benefits.
Benefits provided are supplemental and are not intended to cover all
medical expenses.”; and
(b) For all “hospital confinement fixed
indemnity” and “other fixed indemnity” products sold in the individual market,
a notice shall be displayed prominently on the cover page in at least 14 point type that has the following language:
“THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL
COVERAGE.”
Source. (See Revision
Note #2 at chapter heading for Ins 6200) #12659, eff
11-5-18
Ins
6202.06 Outline of Coverage. An outline of coverage, in the format
prescribed below, shall be issued in connection with policies meeting the
standards of this part. The items
included in the outline of coverage shall appear in the following sequence:
(a)
A brief specific description of the benefits shall be provided in the following
order:
(1)
Daily benefit payable during hospital confinement;
(2)
Duration of benefit described in (1); and
(3)
Any benefits provided in addition to the daily hospital benefit;
(b) A description of any policy provisions that
exclude, eliminate, restrict, reduce, limit, delay, or in any other manner
operate to qualify payment of the benefit described in paragraph (a) above
shall be included;
(c) A description of policy provisions with
respect to renewability or continuation of coverage, including age restrictions
or any reservation of right to change premiums shall be included; and
(d) The notice required by paragraphs (a) – (c)
above shall be in substantially the same form as follows:
[COMPANY NAME]
[HOSPITAL CONFINEMENT FIXED
INDEMNITY COVERAGE]
[OTHER FIXED INDEMNITY COVERAGE]
THIS [POLICY] [CERTIFICATE] PROVIDES
LIMITED BENEFITS
BENEFITS PROVIDED ARE NOT INTENDED
TO COVER ALL MEDICAL EXPENSES
OUTLINE OF COVERAGE
Read Your [Policy] [Certificate]
Carefully—this outline of coverage provides a very brief description of the
important features of coverage. This is
not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the
rights and obligations of both you and your insurance company. It is, therefore, important that you READ
YOUR [POLICY] [CERTIFICATE] CAREFULLY!
[Hospital confinement fixed
indemnity coverage is designed to provide, to persons insured, coverage in the
form of a fixed daily benefit during periods of hospitalization resulting from
a covered accident or sickness, subject to any limitations set forth in the
policy or certificate. Coverage is
provided as described below:]
[Other fixed indemnity coverage is
designed to provide, to persons insured, coverage in the form of a fixed dollar
benefit for the covered event resulting from a covered accident or sickness,
subject to any limitations set forth in the policy or certificate. Coverage is provided as described below:]
Source. (See Revision
Note #2 at chapter heading for Ins 6200) #12659, eff
11-5-18
Ins
6202.07 Waiver of Rules.
(a) The commissioner, upon the commissioner’s own
initiative or upon request by an insurer, shall waive any requirement of this
part if such waiver does not contradict the objective or intent of the rule
and:
(1)
Applying the rule provision would cause confusion or would be misleading
to consumers;
(2)
The rule provision is in whole or in part inapplicable to the given circumstances;
(3)
There are specific circumstances unique to the situation such that
strict compliance with the rule would be onerous without promoting the
objective or intent of the rule provision; or
(4)
Any other similar extenuating circumstances exist such that application
of an alternative standard or procedure better promotes the objective or intent
of the rule provision.
(b) No requirement prescribed by statute shall be
waived unless expressly authorized by law.
(c) Any person or entity seeking a waiver shall
make a request in writing.
(d) A request for a waiver shall specify the
basis for the waiver and proposed alternative, if any.
Source. (See Revision
Note #2 at chapter heading for Ins 6200) #12659, eff
11-5-18
PART Ins 6203 ANCILLARY HEALTH MINIMUM STANDARDS FOR
BENEFITS FOR ACCIDENT-ONLY AND SPECIFIED ACCIDENT COVERAGE
Statutory Authority: RSA 400-A:15, I; RSA 415:18, I; RSA 415-A:2;
and RSA 415-A:3, I
Ins
6203.01 Applicability and Scope. Ins 6203 shall apply to all individual and
group ancillary health policies and certificates that provide coverage for
accident-only and all group ancillary health policies that provide coverage for
specified accident, as applicable, and which are not covered under other rules
and are delivered or issued for delivery in this state on and after the initial
effective date of this part.
Source. (See Revision
Note #3 at chapter heading for Ins 6200) #12855, eff
8-26-19
Ins
6203.02 Definitions.
(a) “Accident-only coverage” means a policy or
certificate that provides coverage, singularly or in combination, for death,
dismemberment, disability, or hospital and medical care caused by accident.
(b) “Specified accident coverage” means a group
policy or certificate that provides coverage for death, dismemberment,
disability, or hospital and medical care caused by a specifically identified
kind of accident or accidents for each person covered under the policy, either
singularly or in combination.
Source. (See Revision
Note #3 at chapter heading for Ins 6200) #12855, eff
8-26-19
Ins
6203.03 Minimum Standards for
Benefits.
(a) Accidental death and double dismemberment amounts under the policy shall be at least $5,000 per
covered person. Amounts for a single
dismemberment of a limb, in whole or in part, shall be at least $2,500 per
covered person. Amounts for the
dismemberment of a digit shall be at least $1,000 per digit per covered
person. The benefits shall be paid
without regard to whether benefits are provided under other insurance.
(b) Accidental death and dismemberment benefits
shall be payable if the loss occurs within 90 days from the date of the
accident, irrespective of total disability.
(c) All policies and certificates shall include
a schedule of benefits that clearly sets forth the benefits, including amounts
of coverage.
(d) Rates for all insurance products under this
part shall be submitted for approval pursuant to Ins
4100.
Source. (See Revision
Note #3 at chapter heading for Ins 6200) #12855, eff
8-26-19; ss by #13137, eff 11-24-20
Ins
6203.04 Prohibited Policy Provisions.
(a)
A policy providing coverage for fractures or dislocations shall not provide
benefits only for “full or complete” fractures or dislocations.
(b) Benefits shall not be assignable to a health
care provider but shall be paid directly to the insured. The policy and certificate shall contain a
provision prohibiting assignment of the benefit to a health care provider.
(c) Pre-existing condition exclusions shall be
prohibited.
(d) Coordination of benefits shall be prohibited.
(e) Managed care and network requirements shall
be prohibited. The policy shall not
include a provision requiring pre-certification.
(f) Coverage for sickness, illness, or wellness
shall be prohibited.
(g) Specific dismemberment benefits shall not be
in lieu of other benefits unless the specific benefit equals or exceeds the
other benefits.
(h) Loss of time benefits, if provided, shall not
require the loss to commence less than 30 days after the date of accident nor
shall any policy that the insurer cancels or refuses to renew require that it
be in force at the time the disability commences, if
the accident occurred while the coverage was in force.
Source. (See Revision
Note #3 at chapter heading for Ins 6200) #12855, eff
8-26-19; ss by #13137, eff 11-24-20
Ins
6203.05 Required Disclosure
Provisions.
(a) All accident-only policies and certificates
shall contain a prominent statement on the cover page of the policy or
certificate, in either contrasting color or in boldface type at least equal to
the size of type used for headings or captions of sections in the policy or
certificate, as follows:
“Notice to Buyer: This is an accident-only [policy]
[certificate] and it does not pay benefits for loss from sickness. Review your [policy] [certificate]
carefully”.
(b) Accident-only policies and certificates that
provide coverage for hospital or medical care shall contain the following
statement on the cover page, in addition to the Notice to Buyer in (a) above:
“This [policy] [certificate]
provides limited benefits. Benefits
provided are not intended to cover all medical expenses”.
Source. (See Revision
Note #3 at chapter heading for Ins 6200) #12855, eff
8-26-19; ss by #13137, eff 11-24-20
Ins
6203.06 Outline of Coverage. Items included in the outline of coverage
issued in connection with policies meeting the standards of this part shall
appear in the following sequence:
(a) A brief specific description of the benefits
shall be provided;
(b) A description of any policy provisions that
exclude, eliminate, restrict, reduce, limit, delay, or in any other manner
operate to qualify payment of the benefit described in paragraph (a) above;
(c) A description of policy provisions with
respect to renewability or continuation of coverage, including age restrictions
or any reservation of right to change premiums; and
(d) The outline of coverage required by
paragraphs (a) – (c) above shall be in the same format as follows:
(1) An accident-only or specified accident policy
or certificate providing benefits that vary according to the type of accidental
cause shall be prominently set forth in the outline of coverage; and
(2)
An outline of coverage in the format prescribed below shall be issued in
connection with accident-only or specified accident policies meeting the
standards of this part. The items
included in the outline of coverage shall appear in the following sequence:
“[COMPANY NAME]
[ACCIDENT-ONLY COVERAGE]
[SPECIFIED ACCIDENT COVERAGE]
THIS [POLICY] [CERTIFICATE] PROVIDES
LIMITED BENEFITS
BENEFITS PROVIDED ARE SUPPLEMENTAL
AND NOT INTENDED TO COVER ALL MEDICAL EXPENSES
OUTLINE OF COVERAGE
Read Your [Policy] [Certificate]
Carefully—This outline of coverage provides a very brief description of the
important features of the coverage. This
is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the
rights and obligations of both you and your insurance company. It is, therefore, important that you READ
YOUR [POLICY] [CERTIFICATE] CAREFULLY!
Accident-only coverage is designed
to provide, to persons insured, benefits for injuries resulting from an
accident, subject to any limitations set forth in the policy or
certificate. Coverage is not provided
for any benefits other than the specific accident-only benefits described and
any additional benefit described below:
(1)
[A brief specific description of the benefits.]
(2)
[A description of any policy provisions that exclude, eliminate,
restrict, reduce, limit, delay, or in any other manner operate to qualify
payment of the benefits described in paragraph (1) above.]
(3)
[A description of any policy provisions respecting renewability or
continuation of coverage, including age restriction or any reservations of
right to change premiums.]”.
Source. (See Revision
Note #3 at chapter heading for Ins 6200) #12855, eff
8-26-19; ss by #13137, eff 11-24-20
Ins
6203.07 Waiver of Rules.
(a) The commissioner, upon the commissioner’s own
initiative or upon request by an insurer, shall waive any requirement of this
chapter if such waiver does not contradict the objective or intent of the rule
and:
(1)
Applying the rule provision would cause confusion
or would be misleading to consumers;
(2)
The rule provision is in whole or in part inapplicable to the given circumstances;
(3)
There
are specific circumstances unique to the situation such that strict compliance
with the rule would be onerous without promoting the objective or intent of the
rule provision; or
(4)
Any other similar extenuating circumstances exist such that application
of an alternative standard or procedure better
promotes the objective or intent of the rule provision.
(b) No requirement prescribed by statute shall be
waived unless expressly authorized by law.
(c) Any person or entity seeking a waiver shall
make a request in writing.
(d) A request for a waiver shall specify the
basis for the waiver and proposed alternative, if any.
Source. (See Revision
Note #3 at chapter heading for Ins 6200) #12855, eff
8-26-19
PART Ins 6204 ANCILLARY HEALTH MINIMUM STANDARDS
FOR BENEFITS FOR SPECIFIED DISEASE COVERAGE
Statutory
Authority: RSA 400-A: 15, I; RSA 415:6,
VII; RSA 415:18, I; RSA 415-A:2; and
RSA 415-A:3, I(i)
and IV
Ins
6204.01 Applicability and Scope. Ins 6204 shall apply to all individual and
group ancillary health policies and certificates that provide specified disease
coverage which are not
covered under other rules and are delivered or issued for delivery in this
state or renewed on and after the initial effective date of this part.
Source. #13163, eff 1-25-21
Ins
6204.02 Definitions.
(a) “Home health care agency” means an agency
that:
(1)
Is approved under Medicare; or
(2)
Is licensed to provide home health care under applicable state law.
(b) “Hospice care” means a provider licensed,
certified, or registered in accordance with New Hampshire law that provides a
formal program of care that is:
(1)
For terminally ill patients whose life expectancy is 6 months or less;
(2)
Provided on an in-patient, out-patient, or in-home
basis; and
(3)
Directed by a physician.
(c) “Major organ failure” means failure or loss
of one or more organs requiring a surgical transplant of a partial or full
human organ.
(d) “Medical necessity” means “medical necessity”
as defined in RSA 420-J:3, XXV-b.
(e) “Specified disease coverage” means a policy
or certificate of insurance that pays benefits for the diagnosis and treatment
of a specifically named disease or diseases, including critical illnesses and named conditions.
Source. #13163, eff 1-25-21
Ins
6204.03 Minimum Standards for
Benefits.
(a) A specified disease policy or certificate of
insurance shall:
(1)
Cover cancer-only or cancer in conjunction with other conditions or
diseases and meet the standards of paragraph (b) and either (d), (e) or (f)
below; and;
(2)
Cover specified diseases other than cancer and meet the standards of
paragraph (b) and either (c) or (f) below.
(b) Except for cancer coverage provided on an
expense-incurred basis, either as cancer-only coverage or in combination with
one or more other specified diseases, the following rules shall apply to
specified disease coverages in addition to all other rules imposed by this
regulation. In cases of conflict between the following and other rules, the
following shall govern:
(1)
Policies covering a single specified disease or combination of specified
diseases may not be sold or offered for sale other than as specified disease
coverage under this section;
(2)
Any policy or certificate issued pursuant to this part that conditions
payment upon pathological diagnosis of a covered disease shall also provide
that, if the pathological diagnosis is medically inappropriate, a clinical
diagnosis will be accepted instead;
(3)
Specified disease policies or certificates that do not pay on a fixed,
one-time lump sum basis, upon proof of diagnosis, shall provide benefits
to any insured person not only for the specified diseases but also for any
other conditions or diseases directly caused or aggravated by the specified
diseases or the treatment of the specified diseases;
(4)
Individual ancillary health policies or certificates containing
specified disease coverage shall be at least guaranteed renewable;
(5)
An application or enrollment form for specified disease coverage shall
contain a statement above the signature of the applicant or enrollee that a
person to be covered for a specified disease is not also covered by any program
under 42 USC 7, Title XIX, 1396-1396w-5.
The statement may be combined with any other statement for which the
insurer may require the applicant’s or enrollee’s signature;
(6)
Benefits for specified disease coverage shall be paid regardless of
other coverage;
(7)
After the effective date of the coverage, or any applicable waiting
period, benefits shall begin with the first day of care or confinement, when
the care or confinement is for a covered disease, even if the diagnosis is made
at some later date. The retroactive
application of the coverage may not be less than 90 days prior to the diagnosis;
(8)
Payments may be conditioned upon medical necessity;
(9)
Hospice care is an optional benefit.
However, if a specified disease insurance product offers coverage for
hospice care, it shall meet the following minimum standards:
a.
Eligibility for payment of benefits when the attending physician of the
insured provides a written statement that the insured person has a life expectancy
of 6 months or less;
b.
A fixed-sum payment of at least $50 per day;
c.
A lifetime maximum benefit limit of at least $10,000; and
d.
Does not provide coverage for non-terminally ill patients who may be
confined in a:
1.
Convalescent home;
2.
Rest or nursing home;
3.
Skilled nursing facility;
4.
Rehabilitation unit; or
5.
Facility providing treatment for persons suffering from mental diseases
or disorders, substance use disorders, or custodial care; and
(10) Major organ failure coverage is an optional
benefit. However, if offered, it shall meet the following minimum standards:
a. Surgical requirements must be waived if the
insured is too ill to undergo surgery, but surgery or placement on the United Network
of Organ Sharing (UNOS) would otherwise be recommended due to the organ
failure; and
b. Coverage may be limited to a particular organ
but must include coverage for the transplant of a partial or full organ.
(c) The following minimum benefits standards
apply to non-cancer coverages:
(1)
Coverage for each insured person for a specifically named disease or
diseases with a deductible amount not in excess of
$250, an overall aggregate benefit limit of no less than $10,000, and a benefit
period of not less than 2 years for at least the following incurred expenses:
a.
Hospital room and board and any other hospital furnished medical
services or supplies;
b.
Treatment by, or under the direction of, a physician;
c.
Private duty services of a registered nurse (RN);
d.
X-ray, radium, and other therapy procedures used in diagnosis and treatment;
e.
Professional ambulance for local service to or from a local hospital;
f.
Blood transfusions and their administration, including expense incurred
for blood donors;
g.
Drugs and medicines prescribed by a physician;
h.
The rental of respirators or other breathing therapy apparatus;
i.
Braces, crutches, or wheel chairs as prescribed
by provider for the treatment of the
disease;
j.
Emergency transportation if, in the opinion of the attending physician,
it is necessary
to transport the insured to another
locality for treatment of the disease; and
k.
May include coverage of any other expenses necessarily incurred in the
treatment of
the disease; or
(2)
Coverage for each insured person 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.
(d) A policy that provides coverage for each
insured person for cancer-only
coverage, or cancer coverage in combination with one or more other specified
diseases, on an expense-incurred basis for services, supplies, and care and
treatment of cancer, in amounts not in excess of the usual and customary
charges, with a deductible amount not in excess of $250, an overall aggregate
benefit limit of not less than $10,000, and a benefit period of not less than 3
years shall provide at least the following minimum provisions:
(1)
Treatment by, or under the direction of, a physician;
(2)
X-ray, radium chemotherapy, and other therapy procedures used in
diagnosis and treatment;
(3)
Hospital room and board and any other hospital furnished medical
services or supplies;
(4)
Blood transfusions and their administration, including expense incurred
for blood donors;
(5)
Drugs and medicines prescribed by a physician;
(6)
Professional ambulance for local service to or from a local hospital;
(7)
Private duty services of a registered nurse provided in a hospital; and
(8)
May include coverage of any other expenses necessarily incurred in the
treatment of the
disease; however, subparagraphs
(1), (2), (4), (5), and (7) plus at least the following also shall
be included, but may be subject to
copayment by the insured person not to exceed 20 percent
of covered charges when rendered on
an out-patient basis:
a.
Braces, crutches, and wheelchairs deemed necessary by the attending
physician for
the treatment of the disease;
b.
Emergency transportation if, in the opinion of the attending physician,
it is
necessary to transport the insured
to another locality for treatment of the disease; and
c.
Home health care that is necessary care and treatment provided at the
insured person's residence by a home health care agency or by others. The program of treatment shall be prescribed
in writing by the insured person's attending physician, who shall approve the
program prior to its start. The
physician shall certify that hospital confinement would be otherwise required.
Home health care shall include at least:
1.
Part-time or intermittent skilled nursing services provided by a
registered nurse or a licensed practical nurse;
2.
Part-time or intermittent home health aide services that provide support
services in the home under the supervision of a registered nurse or a physical,
speech, or hearing occupational therapist;
3.
Physical, occupational, or speech and hearing therapy; and
4.
Medical supplies, drugs, and medicines prescribed by a physician and any
related pharmaceutical services and laboratory services, to the extent the
charges or costs would have been covered if the insured person had remained in
the hospital;
d.
Physical, speech, hearing, and occupational therapy;
e.
Special equipment, including hospital bed, toilet, pulleys, wheelchairs,
aspirator, chux bed pads, oxygen, surgical dressings,
rubber shields, and colostomy and ileostomy appliances;
f.
Prosthetic devices, including wigs and artificial breasts;
g.
Nursing home care for noncustodial services; and
h.
Reconstructive surgery when deemed necessary by the attending physician.
(e) The following minimum benefits standards
apply to cancer coverages written on a per diem indemnity basis:
(1)
A fixed-sum payment of at least $100 for each day of hospital
confinement for at least
365 days;
(2)
A fixed-sum payment equal to one half the hospital inpatient benefit for
each day of hospital or nonhospital outpatient surgery, chemotherapy, and radiation
therapy for at least 365 days of treatment;
(3)
A fixed-sum payment of at least $50 per day for blood and plasma, which
includes their administration, whether received as an inpatient or outpatient,
for at least 365 days of treatment; and
(4)
Benefits tied to confinement in a skilled nursing home or to receipt of
home health care are optional. If a
policy offers these benefits, they shall equal the following:
a.
A fixed-sum payment equal to one-fourth the hospital inpatient benefit
for each day
of skilled nursing home confinement
for at least 100 days; or
b.
A fixed-sum payment equal to one-fourth the hospital inpatient benefit
for each day
of home health care for at least
100 days; and
c.
Benefit payments shall begin with the first day of care or confinement
after the effective date of coverage, if the care or
confinement is for a covered disease. If the diagnosis of a covered disease is
made at some later date, benefits must provide retroactive coverage of at least
30 days from the date of diagnosis, if the initial care or confinement was for
diagnosis or treatment of the covered disease; and
d.
Any restriction or limitation applied to the benefits in a. and b.,
whether by definition or otherwise, shall be no more restrictive than those
under Medicare.
(f) The following minimum standards apply to lump-sum
indemnity coverage of any specified
disease:
(1)
Coverages shall pay indemnity benefits on behalf of insured persons for
a specifically named disease or diseases;
(2)
Benefits are payable as a fixed, one-time payment for each diagnosis of
a covered disease made within 30 days of submission to the insurer of proof of
diagnosis of the specified disease; and
(3)
Where coverage is advertised or otherwise represented to offer generic
coverage of a disease or diseases, the same dollar amounts shall be payable
regardless of the particular subtype of the disease
with one exception. In the case of
clearly identifiable subtypes with significantly lower treatments costs, lesser
amounts may be payable so long as the policy clearly differentiates that
subtype and its benefits.
Source. #13163, eff 1-25-21
Ins
6204.04 Prohibited Policy Provisions.
(a) Policies or certificates providing expense
benefits shall not use the term “actual charges” when the policy or certificate
only pays up to a limited amount of expenses.
Instead, the term “charge” or substantially similar language shall be
used that does not have the misleading or deceptive effect of the phrase
“actual charges”.
(b) No policy or certificate issued pursuant to
this section shall contain a waiting or probationary period greater than 30
days. A specified disease policy or
certificate may contain a waiting or probationary period following the issue or
reinstatement date of the policy or certificate in respect to a particular
insured person.
(c) Coverage for specified diseases shall not be
excluded due to a preexisting condition for a period greater than 6 months
following the effective date of coverage of an insured person unless the
preexisting condition is specifically excluded.
(d) Benefits shall not be assignable to a health care
provider but shall be paid directly to the insured. The policy and
certificate shall contain a provision prohibiting assignment of the benefit to
a health care provider.
Source. #13163, eff 1-25-21
Ins
6204.05 Required Disclosure
Provisions.
(a) Insurers, except direct response insurers,
shall give a person applying for cancer coverage the National Association of
Insurance Commissioners’ (NAIC’s) “A Shopper’s Guide to Cancer Insurance”,
available as referenced in Appendix B, at the time of application enrollment
and shall obtain all recipients’ written acknowledgement of the guide’s
delivery. Direct response insurers shall provide the NAIC’s “A Shopper’s
Guide to Cancer Insurance” upon request but not later than the time that the
policy or certificate is delivered.
(b) All specified disease policies and
certificates shall contain on the cover page, in either contrasting color or in
boldface type at least equal to the size type used for headings or captions of
sections in the [policy] [certificate], a prominent statement as follows:
“Notice to Buyer: This is a specified disease [policy]
[certificate]. This [policy]
[certificate] provides limited benefits.
Benefits provided are supplemental and are not intended to cover all
medical expenses. Read your [policy]
[certificate] carefully with the outline of coverage and the Shopper’s Guide.”
Source. #13163, eff 1-25-21
Ins
6204.06 Outline of Coverage. An outline of coverage, in the format
prescribed below, shall be issued in connection with policies meeting the
standards of this part. The items
included in the outline of coverage shall appear in the following sequence:
[COMPANY NAME]
[SPECIFIED DISEASE COVERAGE]
THIS [POLICY] [CERTIFICATE] PROVIDES
LIMITED BENEFITS
BENEFITS PROVIDED ARE SUPPLEMENTAL
AND ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES
OUTLINE OF COVERAGE
This coverage is designed only as a
supplement to a comprehensive health insurance policy and should not be
purchased unless you have this underlying coverage. Persons covered under Medicaid should not
purchase it. Read the NAIC’s Shopper’s
Guide to Cancer Insurance to review the possible limits on benefits in this
type of coverage.
Read Your [Policy] [Certificate]
Carefully—this outline of coverage provides a very brief description of the
important features of coverage. This is
not the insurance contract and only the actual policy provisions will
control. The policy itself sets forth in
detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ
YOUR [POLICY] [CERTIFICATE] CAREFULLY!
[Specified disease] coverage is
designed to provide, to persons insured, restricted coverage paying benefits
ONLY when certain losses occur as a result of
[specified diseases]. Coverage is not
provided for basic hospital, basic medical-surgical, or major medical expenses.
[A brief specific description of the
benefits, including dollar amounts and any exclusions.]
Source. #13163, eff 1-25-21
Ins
6204.07 Waiver of Rules.
(a) The commissioner, upon the commissioner’s own
initiative or upon request by an insurer, shall waive any requirement of this
part if such waiver does not contradict the objective or intent of the rule
and:
(1)
Applying the rule provision would cause confusion or would be misleading
to consumers;
(2)
The rule provision is in whole or in part inapplicable to the given circumstances;
(3)
There are specific circumstances unique to the situation such that
strict compliance with the rule would be onerous without promoting the
objective or intent of the rule provision; or
(4)
Any other similar extenuating circumstances exist such that application
of an alternative standard or procedure better promotes the objective or intent
of the rule provision.
(b) No requirement prescribed by statute shall be
waived unless expressly authorized by law.
(c) Any person or entity seeking a waiver shall
make a request in writing.
(d) A request for a waiver shall specify the
basis for the waiver and proposed alternative, if any.
Source. #13163, eff 1-25-21
PART
Ins 6205 ANCILLARY HEALTH MINIMUM
STANDARDS FOR BENEFITS FOR DISABILITY INCOME PROTECTION COVERAGE
Statutory
Authority: RSA 400-A:15, I; RSA 415-A:2
and 3; 29 CFR 2560.503
Ins 6205.01 Applicability and Scope. Ins 6205 shall apply to all individual and
group ancillary health policies and certificates that provide coverage for
disability income protection which are not covered under other rules and are
delivered or issued for delivery in this state on and after the initial
effective date of this part.
Source. #13297, eff 11-24-21
Ins 6205.02 Definitions.
(a)
“Activities of daily living (ADL)” means activities related to personal
care, such as bathing or showering, dressing, getting in and out of bed or a chair,
walking, using the toilet, continence, and eating.
(b)
“Adverse benefit determination” means a denial, reduction, termination of, or a failure to provide or
make payment, in whole or in part, for a benefit, including any such denial,
reduction, termination of, or failure to provide or make payment that is based
on a determination of a participant's or claimant's eligibility to participate
in a plan and including a denial, reduction, or termination of, or a failure to
provide or make payment, in whole or in part, for a benefit resulting from the
application of any utilization review, as well as a failure to cover an item or
service for which benefits are otherwise provided because it is determined to
be experimental or investigational or not medically necessary or appropriate.
(c)
“Bathing” means washing oneself by sponge bath or in either a tub or
shower, including the task of getting into or out of the tub or shower.
(d)
“Beneficiary” means the person or persons designated as such in the application.
(e)
“Benefit period” means the length of time for which a disabled insured
receives periodic income benefit amounts under the policy.
(f)
“Catastrophic disability benefit” means a supplemental benefit in
addition to any other disability benefit amounts. The benefit shall be
triggered by an inability of the insured to perform, due to injury or sickness,
a maximum of 2 ADLs. The benefit shall also be triggered by the cognitive
impairment of the insured.
(g)
“Cognitive impairment” means a deficiency in the insured’s short or
long-term memory, orientation as to person, place, and time, deductive or
abstract reasoning, or judgment as it relates to safety awareness.
(h)
“Concurrent disability” means one continuous period of disability that
is caused or is continued by more than one injury or sickness.
(i) “Conditionally renewable” means that renewal
of the policy is based on certain conditions.
(j)
“Contagious disease(s)” means a condition that the Division of
Communicable Disease Control of the Centers for Disease Control and Prevention
works to promptly identify, prevent, and control. This includes infectious
diseases that pose a threat to public health, including emerging and reemerging
infectious diseases, vaccine preventable agents, bacterial toxins,
bioterrorism, and pandemics.
(k) “Continence” means the ability to maintain
control of bowel and bladder function or, when unable to maintain control of
bowel or bladder function, the ability to perform associated personal hygiene,
including caring for catheter or colostomy bag.
(l)
“Cost of living index” means an index used to measure the rate of change
over time of the cost of living, such as the Consumer Price Index for Urban
Wage Earners and Clerical Workers published by the United States Department of
Labor.
(m)
“Death benefits” means the benefit to be paid due to the death of the
insured resulting from an injury or sickness.
(n)
“Disability” means that due to injury or sickness, the insured meets the
definition of partial disability, residual disability, or total disability, or
the insured meets other disability benefit triggers specified in the policy or
certificate.
(o) “Disability income protection coverage” means
a policy or certificate that provides for periodic payments, weekly or monthly,
for a specified period during the continuance of disability resulting from
either sickness or injury.
(p)
“Dressing” means putting on and taking off all items of clothing and any
necessary braces, fasteners, or artificial limbs.
(q)
“Earnings” means the amount of income received by an insured.
(r)
“Eating” means feeding oneself by getting food into the body from a
receptacle, such as a plate, cup, table, or by a feeding tube or intravenously.
(s)
“Elimination period” means the length of time an insured shall wait from
the commencement of disability for the insured as defined in the policy
before periodic income benefit amounts are paid under the policy.
(t)
“Hands-on assistance” means physical assistance without which an insured
or spouse, as applicable, would not be able to perform an ADL.
(u) “Integration” means income from
other sources, as permitted under these rules, that is factored into the
calculation of income to determine the amount of disability benefits paid under
the policy or certificate. Integration does not mean coordination of benefits.
(v)
“Occupation” means a position or professional calling for which a person
receives or is eligible to receive remuneration.
(w)
“Partial disability” means that due to an injury or sickness, the
insured is unable to perform one or more, but not all, of the substantial and
material duties of an occupation for which he or she is qualified by reason of
education, training, or experience or the inability to perform all of the
substantial and material duties of an occupation for which he or she is
qualified by reason of education, training, or experience for as long as
usually required. The term shall also include residual disability.
(x)
“Presumptive disability” means total and permanent loss of any one of
the following 6 body functions which shall be sufficient to trigger any
benefits based upon presumptive disability:
(1) Speech;
(2) Hearing in both ears;
(3) Sight in both eyes;
(4) Use of both arms;
(5) Use of both legs; or
(6) Use of one arm and one leg.
(y)
“Pre-disability earnings” means the measurement of earnings of an
insured just before disability began in order to
provide an accurate and fair measure of earnings of an insured just before
disability began.
(z) “Recurrent disability” means a disability
that occurs within a specified period of time
immediately following a prior period of disability and which is due to the same
or related cause applicable to the prior period of disability.
(aa)
“Rehabilitation” means a program of receiving services that is geared
toward aiding an insured to better perform his or her occupation or any
occupation for which he or she is qualified by reason of education, training,
or experience.
(ab) “Relevant to a
claimant's claim” means, when used in reference to a
document, record, or other information, that the document, record, or other
information:
(1) Was relied upon in
making the benefit determination;
(2) Was submitted, considered, or generated in the
course of making the benefit determination, without regard to whether such
document, record, or other information was relied upon in making the benefit determination;
(3) Demonstrates compliance
with the administrative processes and safeguards required in making the benefit
determination; or
(4) Constitutes a statement
of policy or guidance with respect to the carrier's policy concerning the
denied treatment option or benefit for the claimant's diagnosis, without regard
to whether such advice or statement was relied upon in making the benefit
determination.
(ac)
“Substantial and material duties” means the important tasks, functions,
and operations generally required for an occupation that cannot be reasonably
omitted or modified. This term shall be
permitted to include an insured’s ability to work on a regular work schedule
for a specified number of hours.
(ad)
“Substantial assistance” means assistance or stand-by help required to
perform ADLs.
(ae)
“Toileting” means getting to and from the toilet, getting on and off the
toilet, and performing associated personal hygiene.
(af) “Total disability”:
(1) A
general definition of total disability shall not be more restrictive than one
requiring that the individual who is totally disabled not be engaged in any
employment or occupation for which he or she is or becomes qualified by reason
of education, training, or experience, and is not in fact engaged in any
employment or occupation for wage or profit;
(2) Total
disability shall be permitted to be defined in relation to the inability of the
person to perform duties but shall not be based solely upon an individual’s
inability to:
a. Perform “any occupation whatsoever”, “any
occupational duty”, “any and every duty of his or her occupation”, or other
phrases of similar import;
b. Engage in a training or rehabilitation
program; or
c. Perform activities of
daily living (ADLs);
(3) An
insurer shall be permitted to require the complete inability of the person to
perform all of the substantial and material duties of
his or her regular occupation or words of similar import; and
(4) An
insurer shall be permitted to require care by a physician other than the
insured or a member of the insured’s immediate family.
(ag)
“Transferring” means moving into or out of a bed, chair, or wheelchair.
Source. #13297, eff 11-24-21
Ins 6205.03 Minimum Standards for Benefits for All
Disability Income Policies.
(a)
A disability income policy shall provide a benefit for at least total
disability. Disability income policies
providing benefits only for partial, residual, catastrophic, or any
disabilities less than total disability shall not be permitted. At the company’s option, a disability income
policy shall be permitted to provide coverage for disabilities in addition to a
required benefit for total disability.
(b)
The benefits for total or partial disability income policies shall be
permitted to be triggered by any of the following:
(1) The insured is terminally ill with a life
expectancy of 12 months or less, as certified by a physician;
(2) The insured is unable to perform a specified
number of ADLs. The insurance company shall not require the
inability to perform more than two ADLs to trigger benefits;
(3) The insured is cognitively impaired,
suffering significant and irreversible deterioration or loss of intellectual
capacity, as measured by clinical evidence and standardized tests commonly accepted for
use in the medical community;
(4) The insured is confined as an inpatient in a
skilled nursing home or rehabilitation facility where a daily room
and board charge is made;
(5) The insured is receiving home health care or
hospice care; or
(6) The insured is a risk for transmitting a
contagious disease, and the ability to perform the substantial and
material duties of the insured’s occupation is restricted by a state
licensing board or by another appropriate government authority
because of the risk of transmission of a contagious disease to
others with whom the insured may be in contact.
(c)
For a contagious disease trigger, if all contagious diseases are not
covered in a disability income policy, the policy shall specify which
contagious diseases are covered.
(d)
The trigger for the start of any elimination period shall be the
commencement of disability for the insured as defined in the policy.
(e) A policy that is guaranteed renewable or
conditionally renewable shall describe the
conditions for renewability in the policy.
For conditionally renewable policies, a company shall be permitted to
decline to renew on the basis of class, geographic
area, or for stated reasons other than the deterioration of the insured’s
health.
(f)
All policies shall contain a provision on earnings which
identifies the various income sources or components that are
considered earnings and those that are not. The provision on earnings
shall exclude benefits such as formal sick pay plans, individual and group disability
income insurance plans, and retirement plans.
(g)
In the calculation of pre-disability earnings:
(1) Earnings just before disability began shall
be permitted to be considered on a periodic basis so long as the periodic basis
is consistent with the treatment of other terms referring to an insured’s
earnings used in the policy and used to arrive at certain disability policy
benefit payment amounts for a claim;
(2) For earnings of an insured which occurred in
excess of one year but no more than 5 years just prior to the disability for
which the claim is made, the provision shall include policy language which
allows for use of the highest level of earnings during a calendar year or
consecutive 12-month basis of an insured occurring during the period in excess of
one year but no more than 5 years just prior to the disability for which claim
is made; and
(3) The company shall not consider earnings of an
insured which occurred in excess of 5 years just prior
to the disability for which claim is made in determining prior earnings.
(h)
A policy shall be permitted to exclude coverage due to sickness,
treatment, or medical condition arising out of incarceration.
(i) A
policy shall be permitted to exclude disability that results from normal
pregnancy or childbirth. Such limitation or exclusion shall not apply to
complications of pregnancy as diagnosed by a physician.
(j)
A policy shall be permitted to contain a “return of premium” or “cash
value benefit” so long as the return of premium or cash value benefit is not
reduced by an amount greater than the aggregate of claims paid under the policy
and the insurer demonstrates that the reserve basis for the policies is
adequate.
(k)
A policy shall be permitted to contain a provision relating to recurrent
disabilities, but a provision relating to recurrent disabilities shall not
specify that a recurrent disability be separated by a period greater than 6
months, for a policy with a benefit period of 5 years or
less, or up to one year, for a policy with a benefit period greater
than 5 years.
(l)
If a policy provides for catastrophic disability:
(1) Benefits shall:
a. Pay a monthly periodic income benefit amount
in addition to any other disability benefit amounts, and:
1. The minimum benefit shall be one year of
monthly periodic income and shall exclude any time devoted to satisfaction of
elimination periods; or
2. Instead of a monthly periodic benefit, a
single lump sum benefit of no less than $1,000 shall be permitted;
b. Only be directly related to income losses of
the insured on account of catastrophic disability due to injury or sickness;
and
c. Not directly or indirectly provide any
coverage for long-term care services and shall contain a prominent disclosure
of this fact;
(2)
Elimination periods for catastrophic
disability coverage shall not be longer than one year if the insured meets
the benefit triggers for 2 or more types of disability, one of which
is catastrophic disability; and
(3) Required benefit triggers include:
a. Inability of the insured to perform, due to
injury or sickness, a maximum of 2 ADLs; or
b. The cognitive impairment of the insured;
and
(4) Other triggers shall be permitted, such as
the loss of 2 arms or 2 legs, as long as they are
described in the policy.
(m)
If a policy provides for concurrent disability, benefits shall be paid
as if the concurrent disability was caused by one injury or one sickness. In no event shall an insured be considered to
have more than one continuous period of disability at the same time.
(n)
If a policy provides for partial disability:
(1)
The benefit trigger shall be permitted
to be described in terms of a reasonable reduction in the insured’s time worked
expressed as hours per week or otherwise due to disability as follows:
a. In order to trigger benefits, an insured
shall be working at least 20 percent but no more than 80 percent of the time
worked just before a disability began;
b. The benefit shall be permitted to be stated
in terms of paying a stated percentage of the total disability periodic income
benefit amount, and the stated percentage of the total disability periodic
income benefit amount shall be no less than 20 percent and no greater than 80 percent;
c. An insured working greater than 80 percent of
time worked just before a disability began shall be permitted to be deemed
ineligible for partial disability benefits; or
d. An insured working less than 20 percent of
time worked just before a disability began or earning less than 20 percent of
prior earnings shall be considered working 0 percent or a 100 percent reduction
in average prior earnings for the claim time period,
subject to satisfaction of all policy terms and conditions by the insured; or
(2) Alternatively, the benefit trigger shall be
permitted to be described in terms of a reasonable reduction in the insured’s
earnings due to disability as follows:
a. An insured shall be earning at least 20
percent but no more than 80 percent of prior earnings, and:
1. The benefit shall be permitted to be stated
in terms of paying a stated percentage of the total disability periodic income
benefit amounts, and the stated percentage of the total disability periodic
income benefit amount shall be no less than 20 percent and no greater than 80 percent;
2. If the reduction in earnings of an insured
for a claim time period equals or exceeds 80 percent
of average prior earnings, calculated for a comparable time period, then the
insured’s reduction of average prior earnings shall be considered a 100 percent
reduction in average prior earnings for the claim time period subject to
satisfaction of all policy terms and conditions by the insured; or
3. If the reduction in earnings of an insured
for a claim time period is less than 20 percent of
average prior earnings, calculated for a comparable time period, it shall be
permitted to result in no benefits being paid; or
b. The reduction in earnings of an insured shall
be measured by comparing earnings for
a
claim time period to average prior earnings,
calculated for a comparable time period, and:
1. The percentage of the total disability
periodic income benefit amounts paid shall be calculated by subtracting current
earnings for a claim time period from average prior
earnings, calculated for a comparable period of time, and placing this
difference as the numerator over average prior earnings, calculated for a
comparable time period, as the denominator. This fraction shall be converted to
a percentage, and the percentage multiplied by the total disability periodic
income benefit amounts to arrive at the partial or residual disability benefit
paid for a claim time period; or
2. Alternatively, this shall be permitted to be
expressed as a formula, such as the difference between prior earnings and
current earnings divided by prior earnings, multiplied by the total disability
periodic income benefit amounts; and
(3) Partial or residual disability benefits shall
be permitted to be predicated upon a qualification period during which the
insured shall be totally disabled before partial or residual disability
benefits are paid, and:
a. The qualification period shall be permitted
to be in lieu of the elimination period or in addition to the elimination
period, but the combined elimination period and qualification period, if any,
for partial or residual disability benefits shall not exceed that for total
disability; and
b. An
insurer shall be permitted to require care by a physician other than the
insured or a member of the insured’s immediate family.
(o)
If a policy provides for both total disability benefits and partial
disability benefits, only one elimination period shall be required.
(p)
If a policy provides for presumptive disability:
(1) Benefits shall consist of any one of the
following:
a. Payment
of additional monthly periodic income benefits or lump sum benefit amounts
related to income losses of the insured, always
additional to other disability benefits paid under the policy, subject to
satisfaction of all policy terms and conditions by the insured;
b. Waiver
of any elimination period under the policy;
c. Waiver
of any requirement of care by a physician under the policy;
d. Waiver
of any time periods to access waiver of premium benefits under the policy; or
e. Waiver
of usual benefit triggers to access benefits for total disability, partial
disability,
or
residual disability under the policy; and
(2) A policy shall be permitted to provide more
than one of the 5 benefits listed in (1) above based upon the presumptive
disability of the insured, so long as the other benefits:
a. Are
in addition to all other disability benefits of the policy;
b. Do not replace other disability benefits of
the policy; and
c. Are always
more favorable to an insured than just providing other disability benefits
under the policy.
(q)
If a policy provides benefits for which a beneficiary may be designated,
the policy shall contain a beneficiary provision. The provision shall
state that, unless the owner designates an irrevocable beneficiary, the
right to change the beneficiary is reserved to the owner, and the consent of
the beneficiary shall not be required to:
(1) Terminate or assign the policy;
(2) Change the beneficiary; or
(3) Make any other changes in the policy.
(r)
If a cost of living index is included in a
policy, the index shall be specified, and the company shall notify the insured
in advance of any changes, such as discontinuance, substantial changes to the
index, or a substitute index. If the index is temporarily delayed, the company
shall be permitted to compute the value of any benefits due during the period
the index is unavailable using any method that takes into consideration the
most recently available information with respect to the index. Once the index
becomes available, the company shall adjust any future benefits payable to
reflect any benefit overpayments or underpayments made while the index was
unavailable.
(s)
In all circumstances in which an insurer does not request information
about an applicant’s health history or medical treatment in the application
process, the policy shall cover the loss consistent with RSA 415-A:5(I). A disability income protection policy or
certificate shall be permitted to exclude coverage for a loss due to a
preexisting condition for a period up to 24 months following the issuance of
the policy or certificate, where the policy or certificate is issued on a
guaranteed issue basis.
(t)
Termination of the policy or certificate shall be without prejudice to a
continuous loss that commenced while the policy or certificate was in force,
pursuant to Ins 6101.
The continuous total disability of the insured shall be a condition for
the extension of benefits beyond the period the policy was in force, limited to
the earlier of either the duration of the benefit period, if any, or payment of
the maximum benefits.
Source. #13297, eff 11-24-21
Ins
6205.04 Additional Minimum Standards
for Benefits for Individual Policies.
(a)
In individual policies issued with benefit periods of less than 6
months, the application of an elimination period alone or in conjunction with a
qualification period shall not result in the postponement of payment of
periodic income benefit amounts to a disabled insured in
excess of 45 days from the commencement of a disability.
(b)
In individual policies issued with benefit periods of 6 months
to one year, the application of an elimination period alone or in conjunction
with a qualification period shall not result in the postponement of
payment of periodic income benefit amounts to a disabled insured in excess of 90 days from the commencement of a
disability.
(c)
Individual policies shall provide for at least 3 consecutive months of
periodic income benefits.
(d)
Individual policies shall include a relation of earnings to insurance
provision that complies with RSA 415:6, II(6).
(e) Individual policies shall be
permitted to include a provision regarding the integration of its benefits with
social insurance benefits including Federal Social Security
or any similar federal, state, or local government law, workers’ compensation,
occupational disease laws, and state disability benefit plans, subject to the
following:
(1) If the policy includes such integration, the
policy shall describe which other social insurance benefits shall be subject to
the integration and how the integration shall be administered;
(2) The policy shall state that a minimum
disability benefit shall be paid under the policy, regardless of the benefits
received from social insurance benefits, and the minimum monthly amount shall
not be less than required under RSA 415:6, II(6); and
(3) The policy shall not offset, or in any other
manner reduce, any benefit under the policy by the amount of, or in proportion
to, any cost of living increase in social insurance
benefits received by the insured.
(f)
Individual policies shall include a description of the process for
appealing and resolving benefit determinations which shall comply with Ins 1001.
Source. #13297, eff 11-24-21
Ins 6205.05 Additional Minimum Standards for Benefits
for Group Coverage.
(a)
In group certificates, the elimination period shall be
specified in the certificate, and:
(1) The elimination period for a long-term
disability benefits plan shall be permitted to be integrated with the benefit
period of the short term disability benefits plan;
(2) The elimination period shall be permitted to
be integrated with the period of paid time off, including salary continuation
or sick leave available to the covered person, but shall not require use of
accumulated vacation leave;
(3) The length of time required to satisfy the
elimination period shall be permitted to consist of consecutive units of time;
and
(4) The certificate shall be permitted to specify
a separate elimination period for injury and a separate elimination period for
sickness.
(b)
Group coverage shall provide for at least 4 weeks of periodic income
benefits, for coverage with short term benefit periods up to one year, and 12
months of periodic income benefits, for coverage with long-term benefit periods
in excess of one year.
(c)
Group disability benefits payable under the certificate shall be permitted
to be reduced:
(1)
Only by the following other
benefits or income sources from:
a. Federal Social Security, Canada Pension Plan,
the Quebec Pension Plan disability and retirement benefits, and the Railroad
Retirement Act, including benefits that a spouse or child receives as a result of the covered person's disability. If disability begins after the start of a
retirement benefit, benefits shall be permitted to be reduced on account of
such retirement benefit;
b. Any benefits under a workers' compensation
act, except for medical or death benefits, any federal or state occupational disease
or injury law, and income received under the Admiralty and Maritime Law; the
Maritime Doctrine of Maintenance, Wages, and Cure; the Doctrine of
Unseaworthiness; and the Jones Act;
c. Disability benefits under state disability plans;
d. Disability and retirement benefits under a
government plan, including state and municipal public employee plans and state
teachers plans;
e. Disability and retirement benefits under
plans provided by the covered person's policyholder, employer, or collective
bargaining unit, as applicable. Such
reduction shall be permitted to be limited to employer contributions and some
types of retirement plans shall be permitted to be excluded;
f. Another group disability income policy or
plan to the extent that such policy or plan covers the same pre-disability income;
g. Lost income benefits through no-fault vehicle
insurance;
h. Employer salary continuation plan, sick pay,
accumulated sick leave, vacation pay, severance, or other similar paid time off
plans;
i.
Secondary employment. However, if
disability begins after an increase in secondary employment income, the
disability benefit shall be permitted to be reduced on account of such increase;
j. Unemployment compensation;
k. Individual insurance disability plans to the
extent that cumulative benefits payable would exceed pre-disability earnings;
l. Earnings from any work performed. Such reduction shall be permitted to be calculated differently
for the specified months of a return to work period to
encourage return to work;
m. Amounts received by a covered person from a
third party, minus legal fees, in connection with lost income due to a
disability which the covered person suffers because of an act of omission of
the third party, and:
1. If the amount received from the third party
does not specify the lost income amount, the company shall estimate the amount
using a percentage of the settlement amount based on the covered person’s
pre-disability earnings, prorated to cover the period for which the settlement
or judgment was made;
2. If the certificate includes both this right
to reduce benefits or income on account of a third party settlement and a
subrogation right, the certificate shall state that, with regard to any
specific claim, if the insurance company elects to reduce a disability benefit
on account of other benefits or incomes for amounts received, minus legal fees,
for lost income due to a disability because of an act of omission of the third
party, the insurance company shall not be permitted to elect subrogation for
that same claim; and
3. Amounts received from compromises as a result
of a claim for any one of the sources referenced in (1)a. – m. above;
(2) The certificate shall specify which
reductions shall be dollar for dollar and which shall be based on a formula
specified in the certificate;
(3) The certificate shall be permitted to state that if a
covered person is eligible for other benefits or income, the insurance company
reserves the right to reduce the disability benefit available under the
certificate as if the covered person is receiving such benefits or income and
to estimate the amount, and:
a. Estimated reductions based on the benefits or
income specified in Ins 6205.04(e)(1) shall not be
permissible if the covered person provides evidence of application for benefits
and agrees in writing to repay any overpayment; and
b. Benefits or income from a retirement plan and
lost income benefits from no-fault vehicle insurance or third-party settlements
shall not be subject to estimation; and
(4) The certificate shall be permitted to state
that reductions specified in (3) above shall not result in a disability benefit
payment for less than a specified minimum amount in the
certificate.
Source. #13297, eff 11-24-21
Ins 6205.06 Prohibited Policy Provisions.
(a)
Disability income benefits shall not require the loss to commence less
than 30 days after the date of accident nor shall any policy that the insurer
cancels or refuses to renew require that it be in force at the time the
disability commences, if the accident occurred while
the coverage was in force.
(b)
Policies providing disability income protection shall not in any way
condition benefit payments for
total disability on “continuous confinement within doors” or language of
similar import.
(c)
No policy of health and accident insurance shall contain a provision
that the disability period shall be considered to commence with the date on
which written notice is actually received by the
company.
(d)
Disability income benefits shall not be reduced
because of an increase in benefits paid under the Social Security Act as
prohibited under RSA 415:6, I(13) and RSA 415:18, I(o).
Source. #13297, eff 11-24-21
Ins 6205.07 Required Disclosure Provisions. Disclosure provisions shall be provided in
accordance with Ins 6201.05. In addition, individual policies shall
provide the following brief descriptions on the cover page:
(a)
A statement whether the policy is conditionally renewable, guaranteed
renewable, or non-cancellable;
(b)
A conspicuous statement indicating preexisting condition limitations or
exclusions may apply;
(c)
For a policy with a benefit period of less than 6 months, a conspicuous
statement indicating that the policy provides a limited duration of benefits
and specify the duration;
(d)
A statement as to any benefit limits or reductions due to attainment of
certain ages; and
(e)
Whether the policy is participating or non-participating.
Source. #13297, eff 11-24-21
Ins 6205.08 Outline of Coverage. An outline of coverage, in the form
prescribed below, shall be issued in connection with policies meeting the
standards of Ins 6205. The items included in the
outline of coverage shall appear in the sequence prescribed:
[COMPANY
NAME]
DISABILITY
INCOME PROTECTION COVERAGE
OUTLINE
OF COVERAGE
(1) Read Your Policy Carefully—This outline of
coverage provides a very brief description of the important features of your
policy. This is not the insurance contract and only the actual policy
provisions will control. The policy itself sets forth in detail the rights and
obligations of both you and your insurance company. It is, therefore, important
that you READ YOUR POLICY CAREFULLY!
(2) Disability income protection coverage is
designed to provide, to persons insured, coverage for disabilities resulting
from a covered accident or sickness, subject to any limitations set forth in
the policy. Coverage is not provided for basic hospital, basic
medical-surgical, or major medical expenses.
(3) [A brief specific description of the
benefits contained in this policy.]
(4) [A description of any policy provisions that
exclude, eliminate, restrict, reduce, limit, delay, or in any other manner
operate to qualify payment of the benefits described in paragraph (3) above.]
(5) [A description of policy provisions respecting
renewability or continuation of coverage, including age restrictions or any
reservation of right to change premiums.]
Source. #13297, eff 11-24-21
Ins
6205.09
Group Disability Insurance Claim Processing Standards.
(a)
Health carriers that offer disability benefits shall establish and
maintain reasonable procedures governing the filing of benefit claims,
notification of benefit determinations, and appeal of adverse benefit
determinations, hereinafter collectively referred to as claims
procedures. The claims procedures shall be deemed by the department
to be reasonable only if:
(1) They contain a description of all procedures,
including any procedures for obtaining prior approval as a prerequisite for
obtaining a benefit, such as preauthorization procedures or utilization review
procedures and the applicable time frames as part of a summary plan description;
(2) They do not contain any provision, and are
not administered in a way, that unduly inhibits or hampers the initiation or
processing of claims for benefits.A provision or
practice that requires payment of a fee or costs as a condition to making a
claim or to appealing an adverse benefit determination would be considered by
the department to unduly inhibit the initiation and processing of claims for
benefits, as would the denial of a claim for failure to obtain a prior approval
under circumstances that would make obtaining such prior approval impossible or
where application of the prior approval process could seriously jeopardize the
life or health of the claimant;
(3) They do not preclude an authorized
representative of a claimant from acting on behalf of such claimant in pursuing
a benefit claim or appeal of an adverse benefit determination. Nevertheless, a
plan shall be permitted to establish reasonable procedures for determining
whether an individual has been authorized to act on behalf of a claimant; and
(4) They contain administrative processes and
safeguards designed to ensure and to verify that benefit claim determinations
are made in accordance with governing policy documents and that, where
appropriate, the provisions in the policy have been applied consistently with
respect to similarly situated claimants.
(b)
The claims procedures of group disability coverage for appealing adverse
benefit determinations shall be deemed by the department to be reasonable only
if:
(1) They do not contain any provision, and are
not administered in a way, that requires a claimant to file more than two
appeals of an adverse benefit determination prior to bringing a civil
action;
(2) To the extent that a carrier offers voluntary
levels of appeal, including voluntary arbitration or any other form of dispute
resolution, the procedures provide that:
a. The carrier waives any right to assert that a
claimant has failed to exhaust administrative remedies because the claimant did
not elect to submit a benefit dispute to any such voluntary level of appeal
provided by the carrier;
b. The carrier agrees that any statute of
limitations or other defense based on timeliness is tolled during the time that
any such voluntary appeal is pending;
c. The claims procedures provide that a claimant
shall be permitted to elect to submit a benefit dispute to such voluntary level
of appeal only after exhaustion of the appeals permitted by this rule;
d. The carrier provides to any claimant, upon
request, sufficient information relating to the voluntary level of appeal to
enable the claimant to make an informed judgment about whether to submit a
benefit dispute to the voluntary level of appeal, including a statement that
the decision of a claimant as to whether or not to submit a benefit dispute to
the voluntary level of appeal shall have no effect on the claimant's rights to
any other benefits under the plan and information about the applicable rules,
the claimant's right to representation, the process for selecting the
decision-maker, and the circumstances, if any, that may affect the impartiality
of the decision-maker, such as any financial or personal interests in the
result or any past or present relationship with any party to the review
process; and
e. No fees or costs are imposed on the claimant
as part of the voluntary level of appeal; and
(3) The claims procedures do not contain any
provision for the mandatory arbitration of adverse benefit determinations,
except to the extent that the plan or procedures provide that:
a. The arbitration is conducted as one of the 2
appeals referenced in paragraph (b)(1) of this section; and
b. The claimant is not precluded from
challenging the decision under any applicable law.
(c)
The claims procedures of group disability coverage for notifying a
claimant of a benefit determination shall be deemed reasonable by
the department only if:
(1) When a claim is wholly or partially denied,
the carrier's procedures require it to notify the claimant of the carrier's
adverse benefit determination within a reasonable period of
time, but not later than 45 days after the carrier's receipt of the
claim, and:
a. This period shall be permitted to be extended
for up to 30 days, provided that the carrier both determines that such an
extension is necessary due to matters beyond its control and notifies the
claimant, prior to the expiration of the initial 45-day
period, of the circumstances requiring the extension of time and the
date by which the carrier expects to render a decision;
b. If, prior to the end of the first 30-day
extension period, the carrier determines that, due to matters beyond the
control of the carrier, a decision shall not be rendered within that extension
period, the period for making the determination shall be permitted to be
extended for up to an additional 30 days, provided that the carrier notifies
the claimant, prior to the expiration of the first 30-day extension period, of
the circumstances requiring the extension and the date as of which the carrier
expects to render a decision; and
c. In the case of any extension, the notice of
extension shall specifically explain the standards on which entitlement to a
benefit is based, the unresolved issues that prevent a decision on the claim, and
the additional information needed to resolve those issues, and the claimant
shall be afforded at least 45 days within which to provide the specified
information; and
(2) In calculating time periods for benefit
determinations:
a. The period of time
within which a benefit determination is required to be made shall begin at the
time a claim is filed in accordance with the reasonable procedures of a
carrier, without regard to whether all the information necessary to make a
benefit determination accompanies the filing; and
b. In the event that a
period of time is extended due to a claimant's failure to submit information
necessary to decide a claim, the period for making the benefit determination
shall be tolled from the date on which the notification of the extension is
sent to the claimant until the date on which the claimant responds to the
request for additional information.
(d)
The carrier shall provide a claimant with written or, if requested by
the claimant, electronic notification of any adverse benefit
determination. The notification shall set forth, in a manner
calculated to be understood by the claimant:
(1) The specific reason or reasons for the
adverse determination;
(2) Reference to the specific policy provisions
on which the determination is based;
(3) A description of any additional material or
information necessary for the claimant to perfect the claim and an explanation
of why such material or information is necessary;
(4)
A description of the carrier's review procedures and the time limits applicable
to such procedures, including a statement of the claimant's right to bring a
civil action following an adverse benefit determination on review;
(5) If an internal rule, guideline, protocol, or
other similar criterion was relied upon in making the adverse determination,
the carrier shall either provide a copy of the specific rule, guideline,
protocol, or other similar criterion, or explain when the rule, guideline,
protocol, or other similar criterion that was relied upon in making the adverse
determination shall be provided; and
(6) If the adverse benefit determination is based
on a medical necessity or experimental treatment or similar exclusion or limit,
the carrier shall either provide an explanation of the scientific or clinical
judgment for the determination, applying the terms of the plan to the
claimant's medical circumstances, or state that such explanation shall be
provided free of charge upon request.
(e)
Every carrier that offers group disability insurance shall establish and
maintain a procedure by which a claimant shall have a reasonable opportunity to
appeal an adverse benefit determination to an appropriate named fiduciary of
the carrier and under which there shall be a full and fair review of the claim
and the adverse benefit determination. The claims procedures of a
group disability policy shall not be deemed by the department to provide a
claimant with a reasonable opportunity for a full and fair review of a claim and
adverse benefit determination unless the claims procedures:
(1) Provide a claimant with at least 180 days
following receipt of a notification of an adverse benefit determination within
which to appeal the determination;
(2) Provide for a review that does not afford
deference to the initial adverse benefit determination and that is conducted by
an appropriate named fiduciary of the carrier who is neither the individual who
made the adverse benefit determination that is the subject of the appeal nor
the subordinate of such individual;
(3) Provide that, in deciding an appeal of any
adverse benefit determination that is based in whole or in part on a medical
judgment, including determinations with regard to whether a particular
treatment, drug, or other item is experimental, investigational, or not
medically necessary or appropriate, the appropriate named fiduciary shall
consult with a health care professional who has appropriate training and
experience in the field of medicine involved in the medical judgment;
(4) Provide for the identification of medical or
vocational experts whose advice was obtained on behalf of the carrier in
connection with a claimant's adverse benefit determination, without regard to
whether the advice was relied upon in making the benefit determination;
(5) Provide that the health care professional
engaged for purposes of a consultation shall be an individual who is neither an
individual who was consulted in connection with the adverse benefit
determination that is the subject of the appeal, nor the subordinate of any
such individual;
(6) Provide claimants with the opportunity to
submit written comments, documents, records, and other information relating to
the claim for benefits;
(7) Provide that a claimant shall be provided,
upon request and free of charge, reasonable access to, and copies of, all
documents, records, and other information relevant to the claimant's claim for
benefits, to include specific information relating to any denial of benefits;
and
(8) Provide for a review that takes
into account all comments, documents, records, and other information
submitted by the claimant relating to the claim, without regard to whether such
information was submitted or considered in the initial benefit determination.
(f)
The carrier shall notify a claimant of the outcome of the
review conducted under paragraph (e) above within a reasonable period of time,
but not later than 45 days after receipt of the claimant's request for review
by the carrier, unless the carrier determines that special circumstances, such
as the need to hold a hearing, if the carrier's procedures provide for a
hearing, require an extension of time for processing the claim, and:
(1) If the carrier determines that an extension
of time for processing is required, written notice of the extension shall be
furnished to the claimant prior to the termination of the initial 45-day period;
(2) In
no event shall such extension exceed a period of 45 days from the end of the
initial period; and
(3) The extension notice shall indicate
the special circumstances requiring an extension of time and the date by which
the carrier expects to render the determination on review.
(g)
The period of time within which a benefit
determination on review is required to be made shall begin at the time an
appeal is filed, in accordance with the procedures the carrier has established
pursuant to paragraph (a) of this section, without regard to whether all the
information necessary to make a benefit determination on review accompanies the
filing. In the event
that a period of time is extended due to a claimant's failure to submit
information necessary to decide a claim, the period for making the benefit
determination on review shall be tolled from the date on which the notification
of the extension is sent to the claimant until the date on which the claimant
responds to the request for additional information.
(h)
The carrier shall provide a claimant with written or, if requested by
the claimant, electronic notification of its benefit determination on review. The notification shall set forth, in a manner
calculated to be understood by the claimant:
(1) The specific reason or reasons for the
adverse determination;
(2) Reference to the specific policy provisions
on which the benefit determination is based;
(3) A statement that the claimant is entitled to
receive, upon request and free of charge, reasonable access to, and copies of,
all documents, records, and other information relevant to the claimant's claim
for benefits;
(4) A statement describing any voluntary appeal
procedures offered by the plan and the claimant's right to obtain the
information about such procedures and a statement of the claimant's right to
bring a legal action;
(5) If an internal rule, guideline, protocol, or
other similar criterion was relied upon in making the adverse determination,
the carrier shall provide the claimant with either the specific rule,
guideline, protocol, or other similar criterion or a statement that such rule,
guideline, protocol, or other similar criterion was relied upon in making the
adverse determination and shall agree to provide a copy of the rule, guideline,
protocol, or other similar criterion free of charge to the claimant upon
request;
(6) If the adverse benefit determination is based
on a medical necessity or experimental treatment or similar exclusion or limit,
the carrier shall provide either an explanation of the scientific or clinical
judgment for the determination, applying the terms of the plan to the claimant's
medical circumstances, or a statement that such explanation shall be provided
free of charge upon request; and
(7) The carrier shall include in the notice of
adverse benefit determination the statement “You and your plan may have other voluntary
alternative dispute resolution options, such as mediation. One way to find out
what may be available is to contact your local US department of labor
office or the New Hampshire insurance department.”
Source. #13297, eff 11-24-21
Ins 6205.10 Failure to Establish and Follow Reasonable
Claims Procedures. In the case of
the failure of a carrier to establish or follow its claims and appeals
procedures, a claimant shall be deemed by the department to have exhausted the
administrative remedies available under the plan and shall be entitled to
pursue any available legal remedies on the basis that the carrier has failed to
provide a reasonable claims procedure that would yield a decision on the merits
of the claim.
Source. #13297, eff 11-24-21
Ins 6205.11 Waiver of Rules.
(a)
The commissioner, upon the commissioner’s own initiative or upon request
by an insurer, shall waive any requirement of this part if such waiver does not
contradict the objective or intent of the rule and:
(1) Applying the rule provision would cause
confusion or would be misleading to consumers;
(2) The rule provision is in whole or in part
inapplicable to the given circumstances;
(3) There are specific circumstances unique to
the situation such that strict compliance with the rule would be onerous
without promoting the objective or intent of the rule provision; or
(4) Any other similar extenuating circumstances
exist such that application of an alternative standard or procedure better
promotes the objective or intent of the rule provision.
(b)
No requirement prescribed by statute shall be waived unless expressly
authorized by law.
(c)
Any person or entity seeking a waiver shall make a request in writing.
(d)
A request for a waiver shall specify the basis for the waiver and proposed
alternative, if any.
Source. #13297, eff 11-24-21
APPENDIX
A
Rule |
Specific State Sta
Specific Statute the Rule Implements |
Ins 6201.01 |
RSA 400-A:15, I; RSA 415-A:2 and
3 |
Ins
6201.02 |
RSA
400-A:15, I; RSA 415-A:2 and 3 |
Ins 6201.03 |
RSA 400-A:15, I; RSA 415-A:2,
I(n) |
Ins 6201.04 |
RSA 400-A:15, I; RSA 402:81, RSA
415:5, I(3-a); RSA 415-A:3 |
Ins
6201.05 |
RSA
400-A:15, I; RSA 415-A:2; RSA 415-F:2 and 3 |
Ins 6201.06 |
RSA 400-A:15, I; RSA 415-A:4 |
Ins 6201.07 |
RSA 400-A:15, I; RSA 541-A:22, IV |
|
|
Ins 6202.01 |
RSA 400-A:15, I; RSA 415:6, VII;
RSA 415:18; RSA 415-A:2, I |
Ins 6202.02 |
RSA 400-A:15, I; RSA 415:18; RSA
415-A:2, I |
Ins
6202.02 |
RSA
400-A:15, I; RSA 415:18; RSA 415-A:2, I |
Ins
6202.03 |
RSA
400-A:15, I; RSA 415:18; RSA 415-A:3, I; RSA 415:6, II(3) |
Ins
6202.04 |
RSA
400-A:15, I; RSA 415:18; RSA 415-A:2, II |
Ins 6202.06 |
RSA 400-A:15, I; RSA 415:18; RSA
415-A:4 |
Ins 6202.07 |
RSA 400-A:15, I; RSA 541-A:22, IV |
|
|
Ins 6203.01 |
RSA 400-A:15, I; RSA 415:1; RSA
415:6, VII; RSA 415:18; RSA 415-A:2, I |
Ins 6203.02 |
RSA 400-A:15, I; RSA 415-A:2, I(n) |
Ins 6203.03 |
RSA 400-A:15, I; RSA 415:1; RSA
415:6; RSA 415:18; RSA 415-A:2; RSA 415-A:3 |
Ins 6203.03 |
RSA 400-A:15, I; RSA 415:1; RSA
415:6; RSA 415:18; RSA 415-A:2; RSA 415-A:3 |
Ins 6203.04 |
RSA 400-A:15, I; RSA 415-A:2, II |
Ins 6203.05 |
RSA 400-A:15, I; RSA 415-A:2, I |
Ins 6203.07 |
RSA 400-A:15, I; RSA 541-A:22, IV |
Ins 6204.01 |
RSA 400-A:15, I; RSA 415:6, VII;
RSA 415-A:3, I(i) |
Ins 6204.02 |
RSA 400-A:15, I; RSA 415-A:2,
I(n); RSA 420-J:3, XXV-b |
Ins 6204.03 |
RSA 400-A:15, I; RSA 415-A:2, I;
RSA 415-A:3, I(i) |
Ins 6204.04 |
RSA 400-A:15, I; RSA 415:18; RSA
415-A:2, II |
Ins 6204.05 |
RSA 400-A:15, I; RSA 415-A:2, I |
Ins 6204.06 |
RSA 400-A:15, I; RSA 415-A:4 |
Ins 6204.07 |
RSA 400-A:15, I; RSA 541-A:22, IV |
Ins 6205.01 |
RSA 400-A:15, I; RSA 415-A:2 and
3 |
Ins 6205.02 |
RSA 400-A:15, I; RSA 415-A:2 and
3 |
Ins 6205.03 |
RSA 400-A:15, I; RSA 415-A:2 and
3 |
Ins 6205.04 |
RSA 400-A:15, I; RSA 415:6, II(6);
RSA 415-A:2 and 3 |
Ins 6205.05 |
RSA 400-A:15, I; RSA 415-A:2 and
3 |
Ins 6205.06 |
RSA 400-A:15, I; RSA
415:6, I(13); RSA 415:18, I(o); RSA 415-A:2 and 3 |
Ins 6205.07 |
RSA 400-A:15, I; RSA 415-A:2 and
3 |
Ins 6205.08 |
RSA 400-A:15, I; RSA 415-A:2 and
3 |
Ins 6205.09 |
RSA 400-A:15, I; RSA 415-A:6, II;
29 CFR 2560.503 |
Ins 6204.10 |
RSA 400-A:15, I; RSA 415-A:6, II;
29 CFR 2560.503 |
Ins 6205.11 |
RSA 400-A:15, I; RSA 541-A:22,
IV |
APPENDIX
B – INCORPORATION BY REFERENCE
Rule |
Title of Material |
Cost and How to
Obtain |
Ins 6201.05(n) |
“Shopper’s Guide to Cancer Insurance”
(2006) by the National Association of Insurance Commissioners (NAIC) |
Available for no cost on-line at: http://www.naic.org/documents/prod_serv consumer_guide_cancer.pdf |
Ins 6204.05(a) |
“Shopper’s Guide to Cancer
Insurance” (2007) by the National Association of Insurance Commissioners
(NAIC) |
Available for no cost on-line at: http://www.naic.org/documents/prod_serv_ consumer_guide_cancer.pdf |