N.H. Admin. Code § Ins 7001.05

Current through Register No. 50, December 12, 2024

Section Ins 7001.05 - Prohibited Policy Provisions

(a) Except as provided in Ins 7001.04(g), an individual non-renewable short term limited duration health insurance policy shall not contain provisions establishing a waiting period during which no coverage is provided under the policy.

(b) 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. Otherwise, a policy or certificate shall not exclude coverage for a loss due to a preexisting condition for a period of greater than 6 months following the issuance of the policy.

(c) A policy shall not limit or exclude coverage by type of sickness, accident, treatment, or medical condition, except as follows:

(1) Preexisting conditions or diseases, other than congenital anomalies of a covered dependent child;

(2) Mental or emotional disorders and substance use disorders;

(3) Sickness, treatment, or medical condition arising out of:

a. War or act of war, whether declared or undeclared, or service in the armed forces or units auxiliary to it;

b. Professional sports;

c. Cosmetic surgery, except that cosmetic surgery shall not include reconstructive surgery when the service is incidental to or follows surgery resulting from trauma, infection, or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child that has resulted in a functional defect;

d. Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, or symptomatic complaints of the feet; or

e. Care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion, or subluxation in the human body for purposes of removing nerve interference and the effects of it, where the interference is the result of or related to distortion, misalignment of subluxation of, or in the vertebral column;

(4) Treatment provided in a government hospital, benefits provided under Medicare or other governmental program, other than Medicaid, state or federal workers' compensation, or an employers' liability or occupational disease law, services performed by a member of the covered person's immediate family, and services for which no charge is normally made in the absence of insurance;

(5) Dental care or treatment;

(6) Routine eye care, including eye glasses and examinations for the prescription or fitting of them;

(7) Rest cures, custodial care, transportation, and routine physical examinations; and

(8) Territorial limitations.

(d) A policy shall not contain arbitration provisions.

(e) Any rider or endorsement that reduces or eliminates coverage under the policy shall be prohibited.

(f) A policy shall not contain any provision that excludes coverage by use of the terms "chronic disease" or "organic disease".

(g) Policy provisions precluded in this section shall not be construed as a limitation on the authority of the commissioner to disapprove other policy provisions in accordance with RSA 415-A that in the opinion of the commissioner are unjust, unfair, or unfairly discriminatory to the policyholder, beneficiary, or a person insured under the policy.

(h) Short term limited duration health insurance shall not be group coverage.

(i) Services that are provided at facilities that are not licensed as hospital emergency facilities shall not be subject to member cost-sharing associated with emergency services.

(j) If a policy provides for a reduction in benefits due to the failure of the insured or the insured's physician to follow required procedures or obtain any necessary authorization, the reduction in benefits or penalty may not be more than 50% of the benefit that would have otherwise been payable, or $1,000.00, whichever is less. With respect to a provision that requires authorization from the insurer prior to a hospital admission, the insurer may, in lieu of a percentage reduction, state that either the benefits payable or eligible charges will be reduced or denied up to a specified dollar amount. In no event shall a policy provision provide for a reduction in benefits or penalty that is greater than $1,000.00.

(k) In the case of an emergency admission, the policy shall not require pre-admission authorization unless the insured is allowed 48 hours following the admission within which to request authorization for the admission, or as soon as reasonably possible, whichever is later.

N.H. Admin. Code § Ins 7001.05

Derived from Volume XXXIX Number 24, Filed June 13, 2019, Proposed by #12798, Effective 6/10/2019, Expires 6/10/2029.