431:10-108

Flesch reading ease score; lower score

[§431:10H-108] Preexisting conditions–group and individual policies. (a) No long-term care insurance policy or certificate other than a policy or certificate thereunder issued to a group as defined in paragraph (1) of the definition of “group long-term care insurance” in section 431:10H-104 shall use a definition of “preexisting condition” which is more restrictive than the following: “Preexisting condition” means a condition for which medical advice or treatment was recommended by, or received from a provider of health care services within six months preceding the effective date of coverage of an insured person.

(b) No long-term care insurance policy or certificate other than a policy or certificate thereunder issued to a group as defined in paragraph (1) of the definition of “group long-term care insurance” in section 431:10H-104 may exclude coverage for a loss or confinement which is the result of a preexisting condition unless the loss or confinement begins within six months following the effective date of coverage of an insured person.

© The commissioner may extend the limitation periods in subsections (a) and (b) as to specific age group categories in specific policy forms upon findings that the extension is in the best interest of the public.

(d) The definition of “preexisting condition” does not prohibit an insurer from using an application form designed to elicit the complete health history of an applicant, and, on the basis of the answers on that application, from underwriting in accordance with that insurer’s established underwriting standards. Unless otherwise provided in the policy or certificate, a preexisting condition, regardless of whether it is disclosed on the application, need not be covered until the waiting period described in subsection (b) expires. No long-term care insurance policy or certificate may exclude or use waivers or riders of any kind to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions beyond the waiting period described in subsection (b). [L 1999, c 93, pt of §2]eans.

(e) An insurer may specify conditions pertaining to subsections (a), (b) and © which in the commissioner’s opinion are more favorable to the policyholder. [L 1987, c 347, pt of §2] average loss experience used to determine the prima facie rates if the commissioner determines the use of the higher rates will result in a ratio of claims incurred to premiums earned that is not less than sixty per cent. Except where the deviated rate exceeds the prima facie rate for reducing term credit life insurance and its actuarial equivalent for other forms of credit life insurance, a reasonable variance from the sixty per cent loss ratio standard may be required. The deviation may be limited to the debtors or creditors whose experience was the statistical basis for the filing.

(e) Whenever the commissioner determines it to be prudent, the commissioner may require insurers to file information as the commissioner deems necessary to determine whether the approved deviation from prima facie rates is still justified. If the commissioner determines the insurer’s loss experience no longer justifies a deviation from the prima facie rates, then, upon giving notice as required in subsection (g), the commissioner shall disapprove the deviation and any form including the rate set forth therein.

(f) Credit life insurance policies for which premium rates vary by individual ages or by age brackets shall be filed as provided in this section. The commissioner shall approve or disapprove the filings in accordance with the sixty per cent loss ratio standard and the other applicable provisions of law.

(g) If the commissioner notifies the insurer that the form or premium rate is disapproved, it shall be unlawful thereafter for the insurer to issue or use the form or premium rate. In the notice, the commissioner shall specify the reason for the commissioner’s disapproval and state that a hearing will be granted within twenty days after request in writing by the insurer. No policy, certificate of insurance, or notice of proposed insurance, nor any application, endorsement, or rider, or premium rate, shall be issued or used until the expiration of forty-five days after it has been so filed, unless the commissioner gives the commissioner’s prior written approval.

(h) The commissioner at any time after hearing held not less than twenty days after written notice to the insurer, may withdraw the commissioner’s approval of a form or premium rate on any ground set forth in subsection (b). The written notice of the hearing shall state the reason for the proposed withdrawal.

(i) It shall be unlawful for the insurer to issue or use forms or premium rates after the effective date of their withdrawal.

(j) If a group policy of credit life insurance or credit disability insurance:

(1) Has been delivered in this State before July 1, 1969, or

(2) Has been or is delivered in another state before or after July 1, 1969, the insurer shall be required to file only the group certificate and notice of proposed insurance delivered or issued for delivery in this State as specified in subsections (b) and (e) of section 431:10B-107. The forms shall be approved by the commissioner if:

(i) They conform with the requirements specified in those subsections;

(ii) They are accompanied by a certification in a form satisfactory to the commissioner that the substance of the forms are in substantial conformity with the master policy; and

(iii) The schedules of premium rates applicable to the insurance evidenced by the certificate or notice are not in excess of the insurer’s schedules of premium rates filed with and approved by the commissioner;

provided the premium rate in effect on existing group policies may be continued until the first policy anniversary date following July 1, 1969.

(k) Any order or final determination of the commissioner under this section shall be subject to chapter 91. [L 1987, c 347, pt of §2 as superseded by c 348, §16; am L 1988, c 363, §3; am L 1989, c 207, §12; am L 2000, c 182, §10; am L 2004, c 122, §38]