Section 146.101 - Outline of Coverage[CARRIER NAME]
[ADDRESS - CITY & STATE],[TELEPHONE NUMBER]
SPECIFIED DISEASE INSURANCE - OUTLINE OF COVERAGE
Policy Number:
1. This policy is [an individual policy of insurance/a group policy which was issued in (indicate jurisdiction in which group policy was issued)]. THIS IS A LIMITED POLICY. [Except for policies or certificates that are guaranteed issue, the following caution statement, or language substantially similar, must appear as follows in the outline of coverage.]
Caution: The issuance of this specified disease insurance [policy] [certificate] is based upon your responses to the questions on your application. A copy of your [application] [enrollment form] [is enclosed] [was retained by you when you applied]. If your answers are incorrect or untrue as of the date you signed the applications, the carrier has the right to deny benefits or rescind your policy subject to the [Time Limit on Certain Defenses, Incontestable] section of your policy. The best time to clear up any questions is now, before a claim arises! If, for any reason, any of your answers were incorrect, contact the carrier at this address: [insert address]
2.SUMMARY OF POLICY FEATURESThis policy:
1. is not a Medicare Supplement policy.2. [is guaranteed renewable/is noncancelable] for your lifetime.3. [is/is not] subject to automatic premium increases as you get older.4. [may be/is not] subject to across the board premium increases for all policyholders in your class.5. [does/does not] offer an option to purchase inflation protection.6. [does/does not] offer an option to purchase nonforfeiture protection.7. [does/does not] contain special age limitations for purchase.8. [does not cover services due to pre-existing conditions (existing health problems) for a period of __ months from policy issue][does not have a waiting period before pre-existing conditions (existing health problems) are covered].9. [may have/has] a waiting period of __ days before benefits are payable by policy.10. [offers a waiver of premium after __ days of __ benefits][does not offer a waiver of premium].3. PURPOSE OF OUTLINE OF COVERAGE. An outline of coverage provides a very brief description of the important features of the coverage. You should compare this outline of coverage to outlines of coverage for other policies available to you. This is not an insurance contract, but only a summary of coverage. Only the individual or group policy contains actual contractual provisions. This means that your [policy/certificate] sets forth in detail the rights and obligations of both you and the carrier. Therefore, if youpurchase this coverage, or any other coverage, it is important that you READ YOUR [POLICY/CERTIFICATE] CAREFULLY!4. TERMS UNDER WHICH THE [POLICY/CERTIFICATE] MAY BE CONTINUED IN FORCE OR DISCONTINUED.(a) [For specified disease insurance policies or certificates describe one of the following permissible policy renewability provisions: (1) Policies and certificates that are guaranteed renewable must contain the following statement:] RENEWABILITY: THIS [POLICY[/CERTIFICATE] IS GUARANTEED RENEWABLE. This means you have the right, subject to the terms of your policy, to continue this coverage as longas youpayyour premiums on time. [Carrier Name] cannot change any of the terms of your policy on its own, except that, in the future, IT MAY INCREASE THE PREMIUM YOU PAY. OR
(1) Policies and certificates that are noncancelable must contain the following statement:] RENEWABILITY: THIS [POLICY/CERTIFICATE] IS NONCANCELABLE. This means you have the right, subject to the terms of your policy, to continue this coverage as long as you pay your premiums on time. [Carrier Name] cannot change any of the terms of your policy on its own without your agreement, and cannot change the premium you currently pay. However, if your policy contains an inflation protection feature where you choose to increase your benefits, [Carrier Name] may increase your premium at that time for those additional benefits. OR
(1) Policies and certificates that are convertiblefrom a group policy must contain the following statement:] RENEWABILITY: THIS POLICY [CERTIFICATE] IS CONVERTIBLE TO AN INDIVIDUAL POLICY.](For group coverage, specifically describe continuation/conversion provisions applicable to the certificate and group policy:](b) [Describe waiver of premium provisions or state such provisions are not in the policy.](c) [State whether or not the carrier has a right to change premium, and if the right exists, describe clearly and concisely each circumstance under which premium may change, including that it is subject to the commissioner's approval.]5. TERMS UNDER WHICH THE [POLICY/CERTIFICATE] MAYBERETURNED AND PREMIUM REFUNDED.(a) [Provide a brief description of the right to return-the policy's "free look" provision, which must be a minimum of ten days from the date of policy delivery.](b) [Include a statement that the policy either does or does not contain provisions providing for a refund or partial refund of premium upon the death of an insured or surrender of the policy or certificate. If the policy contains such provisions, include a description of them.]6. THIS IS NOT MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare, review the Medicare Supplement Buyer's Guide available from the carrier. (a) [For agents] Neither [insert carrier name] nor its agents represent Medicare, the federal government, or any state government.(b) [For direct response] [insert carrier name] is not representing Medicare, the federal government or any state government.7. BENEFITS PROVIDED BY THIS [POLICY/CERTIFICATE].(a) [Covered services, deductible(s), waiting periods, and maximums.] [A policy that provides for the payment of benefits based on standards described as "usual and customary," "reasonable and customary" or words of similar import must include anexplanationof such terms in this section of the outline of coverage.]
[Any benefit screening must be explained in this section. If these screens differ for different benefits, explanation of the screen should accompany each benefit description.]
8. LIMITATIONS AND EXCLUSIONS[Describe:
(a) Pre-existing conditions(b) Non-eligible levels of care (e.g. unlicensed providers, care by a family member, etc.)(c) Exclusions/exceptions(d) Limitations] [This section should provide a brief specific description of any policy provisions which limit, exclude, restrict, reduce, delay, or in any other manner operate to qualify payment of the benefits described in (6) above.]
9. RELATIONSHIP OF COST OF CARE AND BENEFITS. Because the costsof care services will likely increase over time, you should consider whether and how the benefits of this plan may be adjusted. [As applicable, indicate the following:(a) That the benefit level will not increase over time;(b) Any automatic benefit adjustment provisions;(c) Whether the insured will be guaranteed the option to buy additional benefits and the basis upon which benefits will be increased over time if not by specified amount or percentage;(d) If there is not a guarantee, include whether additional underwritingor healthscreeningwillbe required, the frequency and amounts of the upgrade options, and any significant restrictions or limitations;(e) Describe whether there will be any additional premium charge imposed, and how that is to be calculated.]10. NONFORFEITURE BENEFITS (if applicable). As an accident and sickness policy, this policy does not have a cash value associated with life insurance products. This policy does offer [for an additionalcharge (ifapplicable)] a nonforfeiture benefit that will continue until exhausted even if the policy lapses due to nonpayment of policy premiums. The following represents an example of how this benefit would apply to your policy: [As applicable, indicate the following: [Carriers must include the following information in or with the outline of coverage:
(a) A description of the benefits that would accrue at different periods of policy lapse(b) Whether or not the benefit was chosen by the policyholder.]11. PREMIUM. (a)[ State the total annual premium for the policy;(b) If the premium varies with an applicant's choice of benefit options, indicate the portion of annual premium that corresponds to each benefit option; OR(c) Refer individual to schedule page of the policy. ] COMPLAINTS. If you have a complaint, call your agent. If you are not satisfied, you may call or write the Massachusetts Division of Insurance, Consumer Services Section, One South Station, 5th Floor, Boston, MA 02110-2208.