N.Y. Comp. Codes R. & Regs. tit. 11 § 360.5

Current through Register Vol. 46, No. 50, December 11, 2024

Section 360.5 - Prohibited underwriting practices and eligibility rules affecting individual and small group health insurance

(a) In addition to the specific prohibitions set forth in sections 3221(q) and 4305(k) of the Insurance Law, the following underwriting practices are prohibited in regard to an insurer's decision whether to offer or accept health insurance applications:

(1) lists of excluded industries or occupations;

(2) use of medical or laboratory tests;

(3) medical examinations;

(4) questions about avocations, hobbies, or other activities;

(5) attending physician statements, questionnaires or any investigations or reviews regarding health status, health history, family health status or sexual orientation;

(6) medical underwriting information obtained pursuant to other lines of business not subject to chapter 501 of the Laws of 1992 (such as applications for life insurance, disability income insurance, or long term care insurance);

(7) medical underwriting information obtained from other sources (such as agents, brokers, consultants, third-party administrators, trustees, associations, group policyholders or the Medical Information Bureau); and

(8) consideration of the nonprofit status of the small group.

(b) Insurers shall not provide coverage to groups where medical underwriting which affects eligibility for coverage under the policy has been performed by the group or anyone acting on the group's behalf.

(c) Actively at work rules, which delay eligibility of coverage under a group plan until the insured returns to the normal duties of employment for a specified period of time are prohibited.

(d) Applicants for group or individual insurance may not be denied coverage based upon eligibility for coverage under another group or individual plan unless the applicant is actually covered by another plan. However, applicants for an individual health insurance policy may be denied coverage where the individual is eligible for comparable group coverage through an employer.

(e) Notwithstanding any provisions of Part 52 of this Title to the contrary, no application for individual and small group policies of Medicare supplement insurance, as that term is defined in section 52.11 of Part 52 of this Title, shall include questions dealing with the health or health history of applicants.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 360.5