N.M. Admin. Code § 13.10.4.7

Current through Register Vol. 35, No. 23, December 10, 2024

Section 13.10.4.7 - DEFINITIONS

The following definitions apply for purposes of this rule:

A."Accident and health insurance policy" means any policy, plan, certificate, contract, agreement, statement of coverage, rider or endorsement which provides accident or health benefits, medical, surgical or hospital expense benefits, or dental or vision benefits, whether on an indemnity, reimbursement, service or prepaid basis, except when issued in connection with another kind of insurance other than life and except disability, waiver of premium, double indemnity or accelerated death benefits included in life insurance and annuity contracts.

B."Advertisement:"

(1) Advertisement means:

(a) printed and published material, audio visual material, and descriptive literature of an insurer used in direct mail, newspapers, magazines, radio scripts, TV scripts, billboards and similar displays;

(b) descriptive literature and sales aids of all kinds issued by an insurer, agent, producer, broker or solicitor for presentation to members of the insurance-buying public, including but not limited to circulars, leaflets, booklets, depictions, illustrations, form letters and lead-generating devices of all kinds as herein defined;

(c) prepared sales talks, presentations and material for use by agents, brokers, producers and solicitors whether prepared by the insurer or the agent, broker, producer or solicitor; and

(d) advertising material included with a policy when the policy is delivered and material used in the solicitation of renewals and reinstatements.

(2) Advertisement does not mean:

(a) material to be used solely for the training and education of an insurer's employees, agents or brokers;

(b) material used in-house by insurers;

(c) communications within an insurer's own organization not intended for dissemination to the public;

(d) individual communications of a personal nature with current policyholders other than material urging the policyholders to increase or expand coverages;

(e) correspondence between a prospective group or blanket policyholder and an insurer in the course of negotiating a group or blanket contract;

(f) court-approved material ordered by a court to be disseminated to policyholders; or

(g) a general announcement from a group or blanket policyholder to eligible individuals on an employment or membership list that a contract or program has been written or arranged; provided, the announcement clearly indicates that it is preliminary to the issuance of a booklet.

C."Certificate" means any certificate issued under a group accident and health insurance policy which has been delivered or issued for delivery in this state.

D."Exception" means any provision in a policy whereby coverage for a specified hazard is entirely eliminated. It is a statement of a risk not assumed under the policy.

E."Institutional advertisement" means an advertisement having as its sole purpose the promotion of the reader's, viewer's or listener's interest in the concept of accident and health insurance, or the promotion of the insurer as a seller of accident and health insurance.

F."Insurer" means any individual, corporation, association, partnership, reciprocal exchange, inter-insurer, Lloyds, fraternal benefit society, health maintenance organization, hospital service corporation, medical service corporation, prepaid health plan and any other legal entity which is defined as an "insurer" in the Insurance Code and is engaged in the advertisement of itself, or an accident and health insurance policy.

G."Invitation to contract" means an advertisement which is neither an invitation to inquire nor an institutional advertisement.

H."Invitation to inquire" means an advertisement having as its objective the creation of a desire to inquire further about accident and health insurance and which is limited to a brief description of coverage, and which shall contain a provision in the following or substantially similar form: "This policy has [exclusions] [limitations] [reduction of benefits] [terms under which the policy may be continued in force or discontinued]. For costs and complete details of the coverage, call [or write] your insurance agent or the company [whichever is applicable]."

I."Lead-generating device" means any communication directed to the public which, regardless of form, content or stated purpose, is intended to result in the compilation or qualification of a list containing names and other personal information to be used to solicit residents of this state for the purchase of accident and health insurance.

J."Limitation" means any provision which restricts coverage under the policy other than an exception or a reduction.

K."Person" means any natural person, association, organization, partnership, trust, group, discretionary group, corporation or any other entity.

L."Reduction" means any provision which reduces the amount of the benefit; a risk of loss is assumed but payment upon the occurrence of the loss is limited to some amount or period less than would be otherwise payable and the reduction has not been used.

N.M. Admin. Code § 13.10.4.7

7/1/97; Recompiled 11/30/01