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 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 |
| Child coverage |
24-A
M.R.S.A. §2742 |
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 |
|
| Grace Period |
24-A
M.R.S.A
§2707 |
30 days |
|
| Notification prior to cancellation |
24-A
M.R.S.A. §2707-A, Rule
580 |
10 days prior notice, reinstatement required if insured has an
organic brain disorder
|
|
| Renewal provision |
24-A
M.R.S.A
§2738 |
Policy must contain the terms under which the policy can or cannot
be renewed |
|
| Notice of claim |
24-A
M.R.S.A.
§2709 |
There shall be a provision that written notice of sickness or of
injury must be given to the insurer within 20 days after the date
when such sickness or injury occurred. Failure to give notice within
such time shall not invalidate nor reduce any claim, if it shall be
shown not to have been reasonably possible to give such notice and
that notice was given as soon as was reasonably possible. |
|
| Claim forms |
24-A
M.R.S.A.
§2710 |
The insurer will furnish claim forms to the claimant. If such forms
are not furnished within 15 days after the giving of such notice the
claimant shall be deemed to have complied with the requirements of
this policy for filing of claim forms. |
|
| Free look period |
24-A
M.R.S.A.
§2717 |
10 day free look except nonrenewable accident policies |
|
| Definition of "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 Exclustions |
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) and Sec. 7(A)(10) |
See this section for required disclosure statements to be placed
prominently on the first page of the policy/certificate. |
|
| 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) |
Rule
755, Sec. 7(J) |
This subsection describes the required provisions and disclosures
for the Outline of Coverage for Accident-Only coverage. |
|
| Notice Regarding Policies or Certificates Which are
Not Medicare Supplement Policies |
24-A
M.R.S.A. §5013, and 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. If you have a Medicare supplement policy
or major medical policy, this coverage may be more than you need.
For information call the Bureau of Insurance at 1-800-300-5000."
|
|
| Misstatement of age |
24-A
M.R.S.A.
§2720 |
Misstatement of age: If the age of the insured has been misstated,
all amounts payable under this policy shall be such as the premium
paid would have purchased at the correct age |
|
| Limits on priority liens |
24-A
M.R.S.A.
§2729-A |
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. |
|
| Assignment of benefits |
24-A
M.R.S.A.
§2755 |
All policies providing benefits for medical or dental care on an
expense-incurred basis must contain a provision permitting the insured
to assign benefits for such care to the provider of the care. An assignment
of benefits under this section does not affect or limit the payment
of benefits otherwise payable under the policy. |
|
| Time limit on defenses |
24-A
M.R.S.A.
§2706 |
After 3 years from the date of issue of policy no misstatements,
except fraudulent misstatements, made by the applicant in the application
for such policy shall be used to void the policy or to deny a claim
for loss incurred or disability, commencing after the expiration of
such 3-year period. |
|
| Legal actions |
24-A
M.R.S.A.
§2715 |
No action can be brought to recover on the policy prior to the
expiration of sixty days after written proof of loss has been furnished
in accordance with the requirements of the policy. No such action
shall be brought after the expiration of 3 years after the time written
proof of loss is required to be furnished. |
|
| Grievance procedure |
24-A
M.R.S.A.
§2747 |
The policy must contain the procedure to follow if an insured wishes
to file a grievance regarding policy provisions or denial of benefits
|
|
| Emergency services |
24-A
M.R.S.A.
§2749-A |
No prior authorization can be required for emergency services |
|
| Claim Payment |
24-A
M.R.S.A.
§2436 |
Payment of claim within 30 days of receipt of proof of loss |
|
| Extension of coverage for dependent children with mental
or physical illness |
24-A
M.R.S.A. §2742-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. |
|
