N.H. Admin. Code § Ins 6001.05

Current through Register No. 50, December 12, 2024

Section Ins 6001.05 - Prohibited Policy Provisions

(a) Except as provided in Ins 6001.04(l), an ancillary health policy or certificate shall not contain provisions establishing a probationary or waiting period during which no coverage is provided under the policy, except for specified disease coverage. Elimination periods shall be prohibited in accident-only and hospital confinement indemnity coverages, unless otherwise stated herein.

(b) A policy, certificate, or rider for additional coverage may not be issued as a dividend unless an equivalent cash payment is offered as an alternative to the dividend policy, certificate or rider.

(1) A dividend policy, certificate, or rider for additional coverage shall not be issued for an initial term of less than 6 months; and

(2) The initial renewal subsequent to the issuance of a policy, certificate, or rider as a dividend shall clearly disclose that the policyholder or certificate holder is renewing the coverage that was provided as a dividend for the previous term and that the renewal is optional.

(c) In all circumstances in which an insurer does not request information about an applicant's health history or medical treatment in the application process, the policy must cover the loss consistent with RSA 415-A:5(I). Otherwise, a policy or certificate shall not exclude coverage for a loss due to a preexisting condition for a period of greater than 6 months following the issuance of the policy or certificate where the policy or certificate is issued on a guaranteed issue basis, except for disability income protection policies in which coverage may be excluded for 24 months due to a preexisting condition.

(d) A disability income protection policy or certificate may contain a "return of premium" or "cash value benefit" so long as the return of premium or cash value benefit is not reduced by an amount greater than the aggregate of claims paid under the policy and the insurer demonstrates that the reserve basis for the policies is adequate. No other policy or certificate subject to RSA 415-A and this chapter shall provide a return of premium or cash value benefit, except return of unearned premium upon termination or suspension of coverage, retroactive waiver of premium paid during disability, payment of dividends on participating policies or certificates, or experience rating refunds.

(e) Policies or certificates providing hospital confinement indemnity or other fixed indemnity coverage shall not contain provisions excluding coverage because of confinement in a hospital operated by the federal government.

(f) A policy or certificate shall not limit or exclude coverage by type of sickness, accident, treatment, or medical condition, except as follows:

(1) Preexisting conditions or diseases other than congenital anomalies of a covered dependent child;

(2) Mental or emotional disorders and substance use disorders;

(3) Sickness, treatment, or medical condition arising out of:

a.War or act of war (whether declared or undeclared); participation in a felony, riot, or insurrection; service in the armed forces or units auxiliary to it;

b.Suicide, sane or insane, attempted suicide, or intentionally self-inflicted injury;

c.Aviation, except as a fare-paying passenger;

d.Professional sports;

e.Incarceration, with respect to disability income protection policies;

f.The voluntary consumption of drugs that are not prescribed by the insured's physician or are not used in the manner prescribed; and

g.Driving under the influence of drugs or alcohol or any combination thereof;

(4) Cosmetic surgery, except that "cosmetic surgery" shall not include reconstructive surgery when the service is incidental to or follows surgery resulting from trauma, infection, or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child that has resulted in a functional defect;

(5) Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, or symptomatic complaints of the feet;

(6) Care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion, or subluxation in the human body for purposes of removing nerve interference and the effects of it, where the interference is the result of or related to distortion, misalignment of subluxation of, or in the vertebral column;

(7) Treatment provided in a government hospital, benefits provided under Medicare or other governmental program (except Medicaid), a state or federal workers' compensation, employers' liability or occupational disease law services rendered by employees of hospitals, laboratories or other institutions; services performed by a member of the covered person's immediate family; and services for which no charge is normally made in the absence of insurance;

(8) Dental care or treatment;

(9) Eye glasses, hearing aids, and examinations for the prescription or fitting of them;

(10) Rest cures, custodial care, transportation, and routine physical examinations; and

(11) Territorial limitations.

(g) This part shall not impair or limit the use of waivers to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases, physical condition, or extra hazardous activity. Where waivers are required as a condition of issuance, renewal, or reinstatement, signed acceptance by the insured is required unless on initial issuance the full text of the waiver is contained either on the first page or specification page.

(h) Except as specifically provided in other ancillary health administrative rules, coordination of benefits shall be prohibited for the following products:

(1) Hospital confinement and other fixed indemnity;

(2) Accident-only and specified accident;

(3) Specified disease; and

(4) Limited benefit.

(i) Excess insurance shall be prohibited.

(j) Arbitration provisions shall be prohibited.

(k) No policy of health and accident insurance shall be approved that contains a provision that the disability period shall be considered to commence with the date on which written notice is actually received by the company.

(l) Any provision that excludes coverage by use of the terms "chronic disease" or "organic disease" shall be prohibited.

(m) No group accident and health policy shall contain a provision for automatic termination of an individual's coverage upon the occurrence of a loss, except a loss that has exhausted all possible benefits under the policy.

(n) Policy or certificate provisions precluded in this section shall not be construed as a limitation on the authority of the commissioner to disapprove other policy provisions in accordance with RSA 415-A that in the opinion of the commissioner are unjust, unfair, or unfairly discriminatory to the policyholder, beneficiary, or a person insured under the policy or certificate.

N.H. Admin. Code § Ins 6001.05

Derived From Volume XXXVIII Number 10, Filed March 8, 2018, Proposed by #12478, Effective 2/12/2018, Expires 2/12/2028.

Amended by Volume XXXVIII Number 41, Filed October 11, 2018, Proposed by #12629, Effective 9/28/2018, Expires 9/28/2028.

Amended by Volume XL Number 41, Filed October 8, 2020, Proposed by #13113, Effective 9/28/2020, Expires 9/28/2030.