N.J. Admin. Code § 11:2-13.5

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:2-13.5 - Extension of benefits

(a) Every group policy or other contract subject to these rules hereafter issued, or under which the level of benefits is hereafter altered, modified or amended, shall provide a reasonable provision for extension of benefits in the event of total disability which exists as of the date of discontinuance of the group policy or contract, as required by (b) through (e) below.

(b) In case of a group life plan which contains a disability benefit extension of any type (for example, premium waiver extension, extended death benefit in event of total disability or payment of income for a specified period during total disability), the discontinuance of the group policy shall not operate to terminate such extension.

(c) In the case of a group plan providing benefits for loss of time from work or specified indemnity during hospital confinement, discontinuance of the policy during a disability shall have no effect on benefits payable for that disability or confinement.

(d) In the case of hospital, medical, dental expense, dental plan organization, dental service corporation or health maintenance organization coverages, a reasonable extension of benefits or accrued liability provision is required. Such a provision shall be considered reasonable if:

1. Under major medical, comprehensive medical and HMO coverages, it provides an extension of at least 12 months.

2. Under other types of hospital, medical or dental expense coverages, other than for maternity, it provides either an extension of at least 90 days or an accrued liability for expenses incurred during a period of disability or during a period of at least 90 days starting with a specific event which occurred while coverage was in force (such as, an accident).

3. Under hospital or medical expense or health maintenance organization coverages related to maternity, any extension of benefits or accrued liability shall be considered reasonable if benefits for expenses incurred or services or supplies are provided in connection with maternity resulting from conception prior to the date of discontinuance of the group policy or contract.

(e) Any applicable extension of benefits or accrued liability shall be described in all policies, contracts, group insurance certificates and evidence of coverages. The benefits payable during any period of extension or accrued liability may be subject to the regular benefit limits of the policy or contract (for example, benefits ceasing at exhaustion of a benefit period or of maximum benefits). No separate premium shall be charged for the coverage provided during the extension of benefits period.

N.J. Admin. Code § 11:2-13.5

As amended, R.1975 d.109, effective 4/24/1975.
See: 7 N.J.R. 114(b), 7 N.J.R. 276(a).
Amended by R.1999 d.134, effective 4/19/1999.
See: 30 N.J.R. 3356(a), 31 N.J.R. 1101(a).
Rewrote (a), (d) and (e).