11 N.C. Admin. Code 12.0551

Current through Register Vol. 38, No. 24, June 17, 2024

Section 12 .0551 - CANCER INSURANCE REQUIREMENTS

Cancer policy requirements. Cancer policies approved in this State shall comply with the following:

(1) The policy shall have a pre-existing conditions sticker that complies with 11 NCAC 12 .0543 and reads as follows: NO RECOVERY FOR PRE-EXISTING DIAGNOSED CANCER - READ CAREFULLY No benefits will be provided during the first 12 months of the policy for cancer diagnosed before the 30th day after the effective date shown in the policy schedule.

(2) In the definition of cancer, clinical diagnosis of cancer shall be accepted as evidence that cancer exists in an insured when a pathological diagnosis cannot be made, provided the medical evidence substantially documents the diagnosis of cancer and the insured received definitive treatment for cancer. If the requisite pathological clinical diagnosis can only be made postmortem, liability shall be assumed retroactively beginning with the date of the terminal admission to the hospital for not less than 45 days before the date of death.

(3) A cancer policy shall not have a waiting period any longer than 30 days after the effective date.

(4) Benefits shall be provided for unrelated cancers diagnosed after the effective date of the policy.

(5) Under the benefits provisions of the policy, provided the contract offers these benefits, the minimum standards are as follows:

(a) Benefits for blood and plasma shall cover actual charges incurred, including fees for administering the blood.

(b) The term "In-patient" shall precede the words "drugs" and "medicines" if the policy is an in-hospital indemnity contract or does not provide out-patient benefits.

(c) Ambulance benefits shall include transportation from one medical facility to another.

(d) First diagnosed or first occurrence cancer benefits shall be no less favorable than other generally offered cancer benefits and shall be offered in addition to core benefits.

(6) Cancer coverage may include other diseases or conditions; provided, however, it shall be properly labeled -- CANCER AND SPECIFIED DISEASE(S).

(7) Cancer and dread disease policies are defined as "Medical Expense" policies for the purposes of loss ratio requirements as set forth in the NAIC guidelines.

11 N.C. Admin. Code 12 .0551

Authority G.S. 58-2-40; 58-51-1; 58-51-95;
Eff. July 1, 1986;
Amended Eff. April 1, 1997; April 1, 1989;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 1, 2018.

Authority G.S. 58-2-40; 58-51-1; 58-51-95;
Eff. July 1, 1986;
Amended Eff. April 1, 1997; April 1, 1989.