N.Y. Comp. Codes R. & Regs. tit. 11 § 52.54

Current through Register Vol. 46, No. 45, November 2, 2024

Section 52.54 - Disclosure requirements

(a) No individual accident and health insurance policy shall be delivered or issued for delivery in this State, unless the appropriate disclosure form in sections 52.55 through 52.62 of this Part is completed as to such policy and accompanies or is incorporated in such policy when delivered, or unless such appropriate disclosure form is delivered to the applicant at the time application is made and acknowledgment of receipt or certification of delivery of such disclosure form is provided to the insurer. The appropriate disclosure form for policies providing hospital coverage which does not meet the standards of section 52.5 or 52.7 of this Part shall be that statement contained in section 52.59 of this Part. The appropriate disclosure form for policies providing coverage which meets the standards of both sections 52.5 and 52.6 of this Part shall be the statement contained in section 52.57 of this Part. The appropriate disclosure form for policies providing coverage which meets the standards of both sections 52.5 and 52.7 or sections 52.6 and 52.7 or sections 52.5, 52.6 and 52.7 shall be the statement contained in section 52.58 of this Part.

(b) The expected benefit ratio required in the statement contained in sections 52.55 through 52.61, 52.65 and 52.66 of this Part shall be:

(1) a number which is greater than or equal to the applicable minimum loss ratio of section 52.45 of this Part, and is less than or equal to the expected future loss ratio filed for the policy form;

(2) where no expected future loss ratio has been filed with a previously approved policy form, but an anticipated loss ratio has been filed, a number which is greater than or equal to the currently applicable minimum loss ratio and is less than or equal to the anticipated loss ratio filed for the policy form;

(3) where no anticipated loss ratio or expected future loss ratio has been filed with a previously approved policy form, the minimum loss ratio permitted for the policy form as set forth in section 52.45; and

(4) where different loss ratios are expected for different classes within the same form, the limits specified in paragraphs (1) through (3) of this subdivision, based on the expected aggregate premium of all classes under the policy form.

(c) Except certificates providing coverage under sections 52.12, 52.13 and 52.15 of this Part which are subject to the disclosure requirements in sections 52.65 and 52.66 of this Part, no certificate of insurance covering persons resident in this State shall be used in conjunction with a group or blanket accident and health insurance policy delivered or issued for delivery in this State unless incorporated in or accompanied by:

(1) a synopsis of the benefits, exclusions and limitations of the policy; and

(2) the appropriate disclosure statement or statements as follows:

(i) Basic hospital insurance. The insurance evidenced by this certificate meets the minimum standards for basic hospital insurance as defined by the New York State Insurance Department. It does NOT provide basic medical or major medical insurance.

(ii) Basic medical insurance. The insurance evidenced by this certificate meets the minimum standards for basic medical insurance as defined by the New York State Insurance Department. It does NOT provide basic hospital or major medical insurance.

(iii) Major medical insurance. The insurance evidenced by this certificate meets the minimum standards for major medical insurance as defined by the New York State Insurance Department. It does NOT provide basic hospital or basic medical insurance.

(iv) Limited benefits health insurance. The insurance evidenced by this certificate provides limited benefits health insurance only. It does NOT provide basic hospital, basic medical, major medical, Medicare supplement, long term care insurance, nursing home insurance only, home care insurance only, or nursing home and home care insurance as defined by the New York State Insurance Department.

(v) Disability income insurance. The insurance evidenced by this certificate provides disability income insurance only. It does NOT provide basic hospital, basic medical or major medical insurance as defined by the New York State Insurance Department.

(vi) Accident insurance. The insurance evidenced by this certificate provides ACCIDENT insurance only. It does NOT provide basic hospital, basic medical or major medical insurance as defined by the New York State Insurance Department.

IMPORTANT NOTICE - THIS POLICY DOES NOT PROVIDE COVERAGE FOR SICKNESS.

(vii) Dental insurance. The insurance evidenced by this certificate provides DENTAL insurance only.

except that such statements may be made to conform to the actual insurance provided where such insurance complies with more than one of the definitions contained in sections 52.5 through 52.9 of this Part.

(d)

(1) The disclosure requirements in Insurance Law sections 3217-a(a)(1) through (6), (9), (10), (15), (16), (17), (18), (19)(A) and (B), and (20); 3217-a(b)(1), (2), (4), (5), (7), (8) if applicable, (10), (11), (13) and (14); 4324(a)(1) through (6), (9), (10), (15), (16), (17), (19), (20)(A) and (B), and (21); and 4324-a(b)(1), (2), (4), (5), (7), (8) if applicable, (10), (11), (13) and (14) shall apply to stand-alone dental insurance and standalone vision insurance.

(2) In addition to the disclosure requirements in paragraph (1) of this subdivision, the disclosure requirements in Insurance Law section 3217-a(a)(7) and (11) through (13) and Insurance Law section 4324(a)(7) and (11) through (13) shall apply to stand-alone dental insurance and standalone vision insurance that meets the definition of a "managed care product" in Insurance Law section 4801(c).

(3) This subdivision shall apply to any policies issued, renewed, modified, or amended on or after one year after the effective date of this section.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 52.54

Amended New York State Register December 7, 2022/Volume XLIV, Issue 49, eff. 12/7/2022