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H02G - Group Accident Only Policies

All Rate and Form Filings submitted to the Bureau of Insurance for review must be accompanied by the completed appropriate transmittal Document as well as the completed appropriate rate/form review checklist. The checklist must be completed by the company submitting the filing and must reference, for each item on the checklist, the location of each specific item in the filing. The transmittal ll Document takes the place of the cover letter requirement. Blank transmittal documents are attached here for your use.

 

REVIEW REQUIREMENTS REFERENCE DESCRIPTION OF REVIEW
STANDARDS REQUIREMENTS		 LOCATION OF
STANDARD IN FILING
Required provisions 24-A M.R.S.A. §2816 - §2828 Application statements, notice of claim, proof of loss, assignment of benefits, etc.  
Accident”, “Accidental Injury”, “Accidental Means” Rule 755, Sec. 4(C) Shall be defined to employ “result” language and shall not include words that establish an accidental means test or use words such as “external, violent, visible wounds” or similar words of description or characterization. The definition shall not be more restrictive than the following: “accident,” “accidental injury,” or “accidental means” means accidental bodily injury sustained by the insured person that is the direct cause of the condition for which benefits are provided and that occurs while the insurance is in force.  
Probationary or Waiting Periods Not Allowed Rule 755, Sec. 5(A) Accident policies shall not contain probationary or waiting periods.  
Limitations and Exclusions Rule 755, Sec. 5(E) A policy shall not limit or exclude coverage except as provided in this subsection.  
Designation of Classification of Coverage Rule 755, Sec. 6 The heading of the cover letter of any form filing subject to this rule shall state the category of coverage set forth in 24-A M.R.S.A. § 2694 that the form is intended to be in.  
General Rules for Minimum Standards Rule 755, Sec. 6(A) The requirements set forth in this section are in addition to any other requirements contained in any other applicable statutes and rules including, but not limited to, 24-A M.R.S.A. Chapters 27, 32, 33, 35, 36 and 56-A and Rules 140, 320, 330, 360, 530, 590, 600, 850 and 940.  
Minimum Standards for “Accident Only Coverage” and “Specified Accident Coverage” Rule 755, Sec. 6(1) “Accident only coverage” is a policy that provides coverage, singly or in combination, for death, dismemberment, disability, or hospital and medical care caused by accident. Accidental death and double dismemberment amounts under the policy shall be at least $2,000 and a single dismemberment amount shall be at least $1,000.  
REQUIRED DISCLOSURE PROVISIONS INCLUDING, BUT NOT LIMITED TO: Rule 755, Sec. 7 Each policy shall contain all appropriate provisions contained in this section including, but not limited to the following:  
Renewal, Continuation, or Nonrenewal Provisions Rule 755, Sec. 7(A)(4) Each policy of individual health insurance and group health insurance shall include a renewal, continuation, or nonrenewal provision. The language or specification of the provision shall be consistent with the type of contract to be issued. The provision shall be appropriately captioned, shall appear on the first page of the policy, and shall clearly state the duration, where limited, of renewability and the duration of the term of coverage for which the policy is issued and for which it may be renewed.  
Required disclosure statements on policies/certificates Rule 755, Sec. 7(A)(9) See this section for required disclosure statements to be placed prominently on the first page of the policy/certificate.  
Conversion Privilege Rule 755, Sec. 7(A)(12) If a policy or certificate contains a conversion privilege, it shall comply, in substance, with the following: The caption of the provision shall be “Conversion Privilege” or words of similar import. The provision shall indicate the persons eligible for conversion, the circumstances applicable to the conversion privilege, including any limitations on the conversion, and the person by whom the conversion privilege may be exercised. The provision shall specify the benefits to be provided on conversion or may state that the converted coverage will be as provided on a policy form then being used by the insurer for that purpose.  
General Outline of Coverage Requirements Rule 755, Sec. 7(B) This subsection contains general requirements and disclosures for Outlines of Coverage.  
Accident-Only Coverage (Outline of Coverage)

Specified Accident Coverage

 Rule 755, Sec. 7(J) This subsection describes the required provisions and disclosures for the Outline of Coverage for Accident-Only coverage.  
Notification prior to cancellation 24-A M.R.S.A. §2847-C,
Rule 580		 10 days prior notice, reinstatement required if insured has an organic brain disorder  
Limits on priority liens 24-A M.R.S.A
§2836		 A policy may contain a provision that allows such payments, if that provision is approved by the superintendent, and if that provision requires the prior written approval of the insured and allows such payments only on a just and equitable basis and not on the basis of a priority lien. A just and equitable basis shall mean that any factors that diminish the potential value of the insured's claim shall likewise reduce the share in the claim for those claiming payment for services or reimbursement.  
Renewal provision 24-A M.R.S.A
§2820		 Policy must contain the terms under which the policy can or cannot be renewed  
Child coverage 24-A M.R.S.A
§2833		 Defined as under 19 years of age and are children, stepchildren or adopted children of, or children placed for adoption with the policyholder, member or spouse of the policyholder or member, no financial dependency requirement, court ordered coverage  
Penalty for failure to notify of hospitalization 24-A M.R.S.A
§2847-A		 No penalty for hospitalization for emergency treatment  
Notice Regarding Policies or Certificates Which are Not Medicare Supplement Policies 24-A M.R.S.A. §5013,
Rule 275, Sec. 17(D)		 There must be a notice predominantly displayed on the first page of the policy that states: "THIS [POLICY OR CERTIFICATE] IS NOT A MEDICARE SUPPLEMENT [POLICY OR CONTRACT]. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company."  
Coordination of benefits 24-A M.R.S.A
§2844		 Medicaid is always secondary  
Extension of Benefits 24-A M.R.S.A.
§ 2849-A		 Must provide an extension of benefits of at least 6 months for a person who is totally disabled on the date the group or subgroup policy is discontinued. For a policy providing specific indemnity during hospital confinement, "extension of benefits" means that discontinuance of the policy during a disability has no effect on benefits payable for that confinement.  
Statements in Application 24-A M.R.S.A.
§ 2828		 There shall be a provision that all statements contained in any such application for insurance shall be deemed representations and not warranties.  
Extension of coverage for dependent children with mental or physical illness 24-A M.R.S.A. §2833-A Requires health insurance policies to continue coverage for dependent children up to 24 years of age who are unable to maintain enrollment in college due to mental or physical illness if they would otherwise terminate coverage due to a requirement that dependent children of a specified age be enrolled in college to maintain eligibility.  
Coverage for Dental Hygienists 24-A M.R.S.A
§2847-Q		 Coverage must be provided for dental services performed by a licensed independent practice dental hygienist when those services are covered services under the contract and when they are within the lawful scope of practice of the independent practice dental hygienist.  
Calculation of health benefits based on actual cost 24-A M.R.S.A. §2185 Policies must comply with the requirements of 24-A §2185 which requires calculation of health benefits based on actual cost. All health insurance policies, health maintenance organization plans and subscriber contracts or certificates of nonprofit hospital or medical service organizations with respect to which the insurer or organization has negotiated discounts with providers must provide for the calculation of all covered health benefits, including without limitation all coinsurance, deductibles and lifetime maximum benefits, on the basis of the net negotiated cost and must fully reflect any discounts or differentials from charges otherwise applicable to the services provided. With respect to policies or plans involving risk-sharing compensation arrangements, net negotiated costs may be calculated at the time services are rendered on the basis of reasonably anticipated compensation levels and are not subject to retrospective adjustment at the time a cost settlement between a provider and the insurer or organization is finalized.  
Explanations Regarding Deductibles 24-A M.R.S.A. §2413

All policies must include clear explanations of all of the following regarding deductibles:

  1. Whether it is a calendar or policy year deductible.
  2. Clearly advise whether non-covered expenses apply to the deductible.
  3. Clearly advise whether it is a per person or family deductible or both.
  
Explanations for any Exclusion of Coverage for work related sicknesses or injuries 24-A M.R.S.A. §2413 If the policy excludes coverage for work related sicknesses or injuries, clearly explain whether the coverage is excluded if the enrollee is exempt from requirements from state workers compensation requirements or has filed an exemption from the workers compensation laws.  

Last Updated: December 8, 2011