N.Y. Comp. Codes R. & Regs. tit. 11 § 52.55
To comply with section 52.54 of this Part, policies of individual insurance meeting the standards of section 52.5 of this Part shall use the following statement only, except that appropriate policy identification may be included:
COMPANY NAME
BASIC HOSPITAL INSURANCE
REQUIRED DISCLOSURE STATEMENT
This policy meets the minimum standards for basic hospital insurance as defined by the New York State Insurance Department and pays [FN*] (, subject to ________[FN**] deductible,) (the semi-private room and board and miscellaneous hospital charges) (the semi-private room and board charges up to a maximum of $________ per day and miscellaneous hospital charges up to a maximum of $________) ( ________% of the semi-private room and board charges) ($________ per day for room and board charges and miscellaneous hospital charges up to a maximum of $________) for not more than. ________days for each continuous hospital confinement, and outpatient hospital services for surgery and for accidental injury when performed within ________hours following accidental injury (up to a maximum of $________) This policy:
This disclosure statement is a very brief summary of your policy.
The policy itself sets forth the rights and obligations of both you and the insurance company.
Policies frequently have special limits for pregnancy, mental illness, X-ray and laboratory tests when covered by the policy. All policies contain exclusions which are not listed above. It is therefore important that you READ YOUR POLICY carefully.
This policy does NOT provide basic hospital or major medical insurance.
The expected benefit ratio for this policy is ________%. This ratio is the portion of future premiums which the company expects to return as benefits, when averaged over all people with this policy.
[FN*] Use alternate parenthetical material where appropriate.
[FN**] Fill in blanks with appropriate material.
N.Y. Comp. Codes R. & Regs. Tit. 11 § 52.55