N.Y. Comp. Codes R. & Regs. tit. 11 § 52.58
To comply with section 52.54 of this Part, policies of individual insurance meeting the standards of section 52.7 of this Part shall use the following statement only, except that appropriate policy identification may be included:
COMPANY NAME
MAJOR MEDICAL INSURANCE
REQUIRED DISCLOSURE STATEMENT
This policy meets the minimum standards for major medical insurance as defined by the New York State Insurance Department and pays for hospital and medical care subject to a copayment by you of ________% [FN*] and a deductible [FN**] (equal to the benefits paid under other insurance or $________, whichever is greater) (equal to the benefits paid under other insurance plus $________) (of $ ________per person) (of $________per family) (of $________per illness) (of $________per benefit period) (of $ ________per year) and a total maximum limit of $ ________(This policy defines "covered charges"[FN***]which has the effect of reducing the amount of the actual charges which otherwise would be covered.) (Covered charges are limited to a maximum of $________per day for hospital room and board,) ($ ________ for miscellaneous hospital charges) (and $ ________for surgery.) 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, private duty nursing and drugs and medicines 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 basic medical insurance. [FN****]
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*] Fill in blanks with appropriate material.
[FN**] Use alternate parenthetical material where appropriate.
[FN***] Insert appropriate reference if words such as "eligible expenses", "compensable expenses", etc., are used in the policy.
[FN****] This sentence may be appropriately modified if policy also meets the definition for basic hospital or basic medical or deleted if policy meets the definition of both.
N.Y. Comp. Codes R. & Regs. Tit. 11 § 52.58