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§3216
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§3216 . Individual accident and health insurance policy provisions.
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§3216(a)
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(a) In (this §) the term:
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§3216(a)(1)
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(1) "Policy of accident and health insurance" includes any individual policy or contract covering the kind or kinds of insurance described in paragraph §1113(a)(3) of this chapter.
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§3216(a)(2)
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(2) "Indemnity" means benefits promised.
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§3216(a)(3)
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(3) "Family" may include husband, wife, or dependent children, or any other person dependent upon the policyholder.
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§3216(a)(4)
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(4) "Dependent children" (A) shall include any children under a specified age which shall not exceed age 19 except:
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§3216(a)(4)
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(i) Any unmarried dependent child, regardless of age, who is incapable of self-sustaining employment by reason of mental illness, developmental disability, or mental retardation as defined in the mental hygiene law, or physical handicap and who became so incapable prior to the age at which dependent coverage would otherwise terminate, shall be included in coverage subject to any pre-existing conditions limitation applicable to other dependents.
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§3216(a)(4)
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(ii) Any unmarried student at an accredited institution of learning may be considered a dependent child until attaining age 23.
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§3216(a)(4)(B)
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(B) may include, at the option of the insurer, any unmarried child until attaining age 25.
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§3216(b)
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(b) No policy of accident and health insurance, including non-cancellable disability insurance, except as provided in (sub§ (h)) hereof, shall be delivered or issued for delivery in this state until the rate manual showing rates, rules and classifications of risks for use in connection with such accident and health insurance policies or with riders or endorsements thereon, has been filed with the superintendent.
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§3216(c)
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(c) No policy of accident and health insurance shall be delivered or issued for delivery to any person in this state unless:
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§3216(c)(1)
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(1) The entire money and other considerations therefor are expressed therein.
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§3216(c)(2)
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(2) The time at which the insurance takes effect and terminates is expressed therein.
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§3216(c)(3)
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(3) It purports to insure only 1 person, except that a policy may insure, originally or by subsequent amendment, members of a family, as defined herein, upon the application of an adult member of the family who shall be deemed the policyholder.
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§3216(c)(4)
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(4)
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§3216(c)(4)(A)
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(A) Coverage of an unmarried dependent child who is incapable of self-sustaining employment by reason of mental illness, developmental disability, or mental retardation, as defined in the mental hygiene law, or physical handicap and who became so incapable prior to attainment of the age at which dependent coverage would otherwise terminate and who is chiefly dependent upon such policyholder for support and maintenance, shall not terminate while the policy remains in force and the dependent remains in such condition, if the policyholder has within 31 days of such dependent's attainment of the limiting age submitted proof of such dependent's incapacity as described herein.
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§3216(c)(4)(B)
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(B) Coverage of a dependent spouse or named insured which would terminate upon such spouse or named insured attaining the age prescribed in subchapter XVIII of the federal Social Security Act, 42 U. S. C. §§1395 et seq. ("medicare"), as the age of 1st eligibility for the benefits provided by such law shall not so terminate, if such dependent spouse is not then eligible for all of such benefits, for as long as the policy remains in force and such dependent spouse remains ineligible to receive any of such "medicare" benefits, provided proof of such ineligibility is submitted to the insurer within 31 days of the date notice of termination of coverage be sent by 1st class mail by the insurer to the last known address of the policyholder.
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§3216(c)(4)(C)
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(C) Any family coverage shall provide that coverage of newborn infants, including newly born infants adopted by the insured or subscriber if such insured or subscriber takes physical custody of the infant upon such infant's release from the hospital and files a petition pursuant to §100 c the domestic relations law within 30 days of birth; and provided further that no notice of revocation to the adoption has been filed pursuant to §100 b the domestic relations law consent to the adoption has not been revoked, shall be effective from the moment birth for injury or sickness including the necessary care treatment medically diagnosed congenital defects birth abnormalities including premature birth, except that in cases adoption, coverage the initial hospital stay shall not be required where a birth parent has insurance coverage available for the infant's care. In the case individual coverage the insurer must also permit the person to whom the policy is issued to elect such coverage newborn infants from the moment birth. If notification and/or payment an additional premium or contribution is required to make coverage effective for a newborn infant, the coverage may provide that such notice and/or payment be made within no less than 30 days of the day of birth to make coverage effective from the moment of birth. This election shall not be required in the case of student insurance.
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§3216(c)(5)
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(5)
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§3216(c)(5)(A)
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(A) Any family policy providing hospital or surgical expense insurance (but not including such insurance against accidental injury only) shall provide that, in the event such insurance on any person, other than the policyholder, is terminated because the person is no longer within the definition of the family as set forth in the policy but before such person has attained the limiting age, if any, for coverage of adults specified in the policy, such person shall be entitled to have issued to him by the insurer, without evidence of insurability, upon application therefor and payment of the 1st premium, within 31 days after such insurance shall have terminated, an individual conversion policy. The conversion privilege afforded herein shall also be available upon the divorce or annulment of the marriage of the policyholder to the former spouse of such policyholder.
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§3216(c)(5)(B)
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(B) Written notice of entitlement to a conversion policy shall be given by the insurer to the policyholder at least 15 and not more than 60 days prior to the termination of coverage due to the initial limiting age of the covered dependent. Such notice shall include an explanation of the rights of the dependent with respect to his being enrolled in an accredited institution of learning or his incapacity for self-sustaining employment by reason of mental illness, developmental disability or mental retardation as defined in the mental hygiene law or physical handicap.
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§3216(c)(5)(C)
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(C) Such individual conversion policy shall be subject to the following terms and conditions:
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§3216(c)(5)(C)(i)
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(i) The premium shall be that applicable to the class of risk to which such person belongs, to the age of such person and to the form and amount of insurance therefor.
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§3216(c)(5)(C)(ii)
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(ii) Such policy shall provide, on a basis specified in the family policy, the same or substantially the same benefits as those provided in the family policy or such benefits as are provided in a policy specifically approved as an individual conversion policy by the superintendent.
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§3216(c)(5)(C)(iii)
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(iii) The benefits provided under such policy shall become effective upon the date that such person was no longer eligible under the family policy.
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§3216(c)(5)(C)(iv)
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(iv) The policy may exclude any condition excluded by the family policy for such person at the time of the termination of his insurance thereunder. The policy shall not exclude any other pre-existing conditions, but the benefits paid under such policy may be reduced by the amount of any such benefits payable under the family policy after the termination of such person's insurance thereunder and, during the 1st policy year of the conversion policy, the benefits payable under the policy may be reduced so that they are not in excess of those that would have been payable had such person's insurance under the family policy remained in force and effect.
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§3216(c)(5)(C)(v)
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(v) No insurer shall be required to issue a conversion policy if it appears that the person applying for such policy shall have at that time in force another insurance policy or hospital service or medical expense indemnity contract providing similar benefits or is covered by or is eligible for coverage by a group insurance policy or contract providing similar benefits or shall be covered by similar benefits required by any statute or provided by any welfare plan or program, which together with the conversion policy would result in overinsurance or duplication of benefits according to standards on file with the superintendent relating to individual policies.
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§3216(c)(5)(C)(vi)
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(vi) The policy may include a provision whereby the insurer may request information at any premium due date of the policy of the person covered thereunder as to whether he is then covered by another policy or hospital service or medical expense indemnity corporation subscriber contract providing similar benefits or is then covered by a group contract or policy providing similar benefits or is then provided with similar benefits required by any statute or provided by any welfare plan or program. If any such person is so covered or so provided and fails to furnish the details of such coverage when requested, the benefits payable under the conversion policy may be based on the hospital surgical or medical expenses actually incurred after excluding expenses to the extent they are payable under such other coverage or provided under such statute, plan, or program.
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§3216(c)(6)
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(6) The style, arrangement and overall appearance of the policy give no undue prominence to any portion of the text, and unless every printed portion of the text of the policy and of any endorsements or attached papers is plainly printed in light-faced type of a style in general use, the size of which shall be uniform and not less than 10- point with a lower-case unspaced alphabet length not less than 100 point (the "text" shall include all printed matter except the name address the insurer, name or title the policy, the brief description, if any, captions subcaptions).
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§3216(c)(7)
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(7) The exceptions and reductions of indemnity are set forth in the policy and, except those which are set forth in subsection (this §)(d) ,are printed, at the insurer's option, either included with the benefit provision to which they apply, or under an appropriate caption such as "EXCEPTIONS", or "EXCEPTIONS AND REDUCTIONS", provided that if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of such exception or reduction shall be included with the benefit provision to which it applies.
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§3216(c)(8)
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(8) Each such form, including riders and endorsements, shall be identified by a form number in the lower left-hand corner of the 1st page thereof.
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§3216(c)(9)
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(9) It contains no provision purporting to make any portion of the charter, rules, constitution, or by-laws of the insurer a part of the policy unless such portion is set forth in full in the policy, except in the case of the incorporation of, or reference to, a statement of rates or classification of risks, or short-rate table filed with the superintendent.
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§3216(c)(10)
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(10) There is prominently printed on the 1st page thereof or there is attached thereto a notice to the effect that during a specified period of time, which shall not be less than 10 days nor more than 20 days from the date the policy is delivered to the policyholder, it may be surrendered to the insurer together with a written request for cancellation of the policy and in such event the insurer will refund any premium paid therefor including any policy fees or other charges, provided, however, that (this ¶) shall not apply to single premium nonrenewable policies insuring against accidents only or accidental bodily injuries only; provided, however, that a contract or certificate sold by mail order and a contract or certificate providing medicare supplemental insurance or long-term care insurance must contain a provision permitting the contract or certificate holder a 30 day period for such surrender.
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§3216(c)(11)
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(11) The age limit or date or period, if any, after which the coverage provided by the policy will not be effective or the age limit, date or period after which the policy may not be renewed is stated in a renewal provision set forth on the 1st page of the policy or as a separate provision bearing an appropriate caption on the 1st page of the policy or in a brief description in not less than 14- point bold face type set forth on the 1st page of the policy. Nothing herein contained shall limit or restrict the right of the insurer to continue the policy after the age or period so stated.
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§3216(c)(12)
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(12) Any policy, other than 1 issued in fulfillment of the continuing care responsibilities of an operator of a continuing care retirement community in accordance with article 46 of the public health law, made available because of residence in a particular facility, housing development, or community shall contain the following notice in 12 point type in bold face on the 1st page: "NOTICE-THIS POLICY DOES NOT MEET THE REQUIREMENTS of A CONTINUING CARE RETIREMENT CONTRACT. AVAILABILITY of THIS COVERAGE WILL NOT QUALIFY A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT COMMUNITY. "
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§3216(c)(13)
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(13) Any persons covered by the policy who are also members of a reserve component of the armed forces of the United States, including the National Guard, shall be entitled, upon written request, to have their coverage suspended during a period of active duty as described herein. The policy shall provide that the insurer will refund any unearned premiums for the period of such suspension. Persons covered by the policy shall be entitled to resumption of coverage, upon written application and payment of the required premium within 60 days after the date of termination of the period of active duty, with no limitations or conditions imposed as a result of such period of active duty except as set forth in (sub¶ (A)) and (sub¶ (B)) herein. Coverage shall be retroactive to the date of termination of the period of active duty. Such right of resumption provided for herein shall be in addition to other existing rights granted pursuant to state and federal laws and regulations and shall not be deemed to qualify or limit such rights in any way. No exclusion or waiting period may be imposed in connection with coverage of a health or physical condition of a person entitled to such right of resumption, or a health or physical condition of any other person who is covered by the policy unless:
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§3216(c)(13)(A)
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(A) the condition arose during the period of active duty and the condition has been determined by the secretary of veterans affairs to be a condition incurred in the line of duty; or
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§3216(c)(13)(B)
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(B) a waiting period was imposed and had not been completed prior to the period of suspension; in no event, however, shall the sum of the waiting periods imposed prior to and subsequent to the period of suspension exceed the length of the waiting period originally imposed.
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§3216(c)(14)
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(14) To be entitled to the right defined in paragraph (this sub§)(13) a person must be a member of a component of the armed forces of the United States, including the National Guard, who either:
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§3216(c)(14)(A)
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(A) voluntarily or involuntarily enters upon active duty (other than for the purpose of determining his or her physical fitness and other than for training), or
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§3216(c)(14)(B)
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(B) has his or her active duty voluntarily or involuntarily extended during a period when the president is authorized to order units of the ready reserve or members of a reserve component to active duty, provided that such additional active duty is at the request and for the convenience of the federal government, and
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§3216(c)(14)(C)
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(C) serves no more than 4 years of active duty.
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§3216(d)
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(d) Each policy of accident and health insurance delivered or issued for delivery to any person in this state shall contain the provisions specified herein in the words in which the same appear in (this sub§) ,except that the insurer may, at its option, substitute for 1 or more of such provisions corresponding provisions of different wording approved by the superintendent which are not less favorable in any respect to the insured or the beneficiary. Each provision contained in the policy shall be preceded by the applicable caption herein or, at the insurer's option, by such appropriate captions or subcaptions as the superintendent may approve.
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§3216(d)(1)
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(1) Each policy shall, except with respect to designation by numbers or letters as used below, contain the following provisions:
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§3216(d)(1)(A)
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(A) ENTIRE CONTRACT; CHANGES: This policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the insurer and unless such approval be endorsed hereon or attached hereto. No agent or broker has authority to change this policy or to waive any of its provisions.
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§3216(d)(1)(B)
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(B) TIME LIMIT ON CERTAIN DEFENSES:
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§3216(d)(1)(B)(i)
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(i) After 2 years from the date of issue of this 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 (as defined in the policy) commencing after the expiration of such 2 year period.
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(The foregoing policy provision shall not be so construed as to affect any legal requirement for avoidance of a policy or denial of a claim during such initial 2 year period, nor to limit the application of subparagraphs A through E ,inclusive, of (this ¶) in the event of misstatement with respect to age or occupation or other insurance. )
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