N.Y. Comp. Codes R. & Regs. tit. 11 § 52.56
To comply with section 52.54 of this Part, policies of individual insurance meeting the standards of section 52.6 of this Part shall use the following statement only, except that appropriate policy identification may be included:
COMPANY NAME
BASIC MEDICAL INSURANCE
REQUIRED DISCLOSURE STATEMENT
This policy meets the minimum standards for basic medical insurance as defined by the New York State Insurance Department and pays [FN*] (________% [FN**]of the doctor's reasonable charges for anesthesia, in-hospital medical and surgical services.) (a maximum of $________for surgery) (anesthesia up to ________% of the surgical coverage) (in-hospital medical service up to $________per day for ________days.) (surgical, anesthetic and in-hospital medical service in full for persons whose income is below $________per year.) (surgical, anesthetic and in-hospital medical services in full.) 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 § 52.56