N.J. Admin. Code § 11:4-34.12

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:4-34.12 - Requirement for application, enrollment forms and replacement coverage

(a) Application forms shall not include provisions, statements or questions that:

1. Pertain to race, creed, color, national origin or ancestry of the proposed insured;

2. Change the terms of the policy to which it is attached;

3. State that the applicant has not withheld any information or concealed any facts; or

4. Require the applicant to agree that an untrue or false answer material to the risk shall render the policy or certificate void.

(b) If the carrier makes any changes or amendments to the application, signed acceptance by the applicant is required.

(c) Factual-type questions shall be used whenever possible to ascertain the past and present health of a proposed insured. The application shall provide that the answers and statements are to the best of the applicant's knowledge and belief.

(d) Questions concerning alcohol and drug abuse shall be based on specific criteria such as treatment, driving records, work attendance records, etc. Questions such as "Do you use alcohol or drugs to excess" shall not be used.

(e) Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant has another long-term care insurance policy or certificate in force or whether a long-term care policy or certificate is intended to replace any other accident and sickness or long-term care policy or certificate presently in force. A supplementary application or other form to be signed by the applicant and agent, except where the coverage is sold without an agent, containing the questions may be used. With regard to a replacement policy issued to an employer, labor union or trustee group as defined by N.J.S.A. 17B:27-68 and 27, the following questions may be modified only to the extent necessary to elicit information about health or long-term care insurance policies other than the group policy being replaced, provided that the certificate holder has been notified of replacement:

1. Do you have another long-term care insurance policy or certificate in force?

2. Did you have another long-term care insurance policy or certificate in force during the last 12 months?

i. If so, with which carrier?

ii. If that policy or certificate lapsed, when did it lapse?

3. Are you covered by Medicaid?

4. Do you intend to replace any of your medical or health insurance coverage with this policy (certificate)?

(f) Agents shall list any other health insurance policies they have sold to the applicant, including:

1. Policies sold that are still in force; and

2. Policies sold in the past five years that are no longer in force.

(g) Solicitations other than direct response: Upon determining that a sale will involve replacement, a carrier, other than a carrier using direct response solicitation methods, or its agent, shall furnish the applicant, prior to issuance or delivery of the individual long-term care insurance policy, a notice regarding replacement of accident and sickness or long-term care coverage. One copy of the notice shall be retained by the applicant and an additional copy signed by the applicant shall be retained by the carrier. The required notice shall be provided in accordance with subchapter Appendix H, incorporated herein by reference.

(h) Carriers using direct response solicitation methods shall deliver a notice regarding replacement of accident and sickness or long-term care coverage to the applicant upon issuance of the policy or certificate. The required notice shall be provided in accordance with subchapter Appendix I, incorporated herein by reference.

(i) Where replacement is intended, the replacing carrier shall notify, in writing, the existing carrier of the proposed replacement. The existing policy or certificate shall be identified by the carrier, and name of the insured and policy number or address including ZIP code. Notice shall be made within five working days from the date the application is received by the carrier or the date the policy or certificate is issued, whichever is sooner.

(j) Individual life insurance policies that accelerate benefits for long-term care shall comply with this section if the policy being replaced is a long-term care insurance policy. If the policy being replaced is an individual life insurance policy, the carrier shall comply with the replacement requirements of N.J.A.C. 11:4-2. If an individual life insurance policy that accelerates benefits for long-term care is replaced by another such individual policy, the replacing carrier shall comply with both the long-term care and the life insurance replacement requirements.

N.J. Admin. Code § 11:4-34.12