Chapter Ins 3

Ins 3.27(10) (10) Exceptions, reductions and limitations.

Ins 3.27(10)(a) (a) When an advertisement refers to any dollar amount of benefits payable, period of time for which any benefit is payable, cost of policy, specific policy benefit or the loss for which such benefit is payable, it shall also disclose those exceptions, reductions and limitations (including waiting, elimination, probationary or similar periods and pre-existing condition exceptions) affecting the basic provisions of the policy without which the advertisement would have the capacity and tendency to mislead or deceive subject to the following.

Ins 3.27(10)(b) (b) An invitation to apply shall be subject to the disclosure requirements of this subsection.

Ins 3.27(10)(c) (c) An invitation to inquire shall not be subject to the disclosure requirements of this subsection unless:

Ins 3.27(10)(c)1. 1. Such an advertisement mentions benefits, benefit periods or premiums for the purpose of doing more than identifying the policy or

Ins 3.27(10)(c)2. 2. Such an advertisement makes any reference to the policy’s exceptions, reductions and limitations.

Ins 3.27(10)(d) (d) A booklet, summary or explanation of coverage issued to insured persons shall be subject to the disclosure requirements of this subsection.

Ins 3.27(10)(e) (e) An institutional advertisement shall not be subject to the disclosure requirements of this subsection.

Ins 3.27(10)(f) (f) If the policy advertised does not provide immediate coverage for pre-existing conditions, an application or enrollment form contained in or included with an advertisement to be completed by the applicant and returned to the insurer shall contain a question or statement immediately preceding the applicant’s signature line which summarizes the pre-existing condition provisions of the policy. The following are a suggested question and statement; however, an insurer shall use wording which is appropriate to the actual pre-existing condition provisions of the policy advertised: “Do you understand that the policy applied for will not pay benefits during the first - - - - - year(s) after the issue date for a disease or physical condition which you now have or have had in the past? Yes - - - - - -” or “I understand that the policy applied for will not pay benefits during the first - - - - - year(s) after the issue date for a disease or physical condition which I now have or have had in the past.”

Ins 3.27(10)(g) (g) An advertisement which is subject to the disclosure requirements of this subsection shall in negative terms disclose the extent to which any loss is not covered if the cause of the loss is a condition which exists prior to the effective date of the policy. The expression “pre-existing conditions” shall not be used unless appropriately defined.

Ins 3.27(10)(h) (h) If a medical examination is required for a policy, an invitation to apply advertisement of such policy shall disclose such requirement.

Ins 3.27(10)(i) (i) The exceptions, reductions and limitations referred to in this subsection shall include:

Ins 3.27(10)(i)1. 1. Those which are set out in the policy under captions referring to exceptions, reductions, limitations or exclusions or are otherwise designated as such, and

Ins 3.27(10)(i)2. 2. Those which are not so captioned or designated contained in other portions of the policy such as a benefit provision, definition or uniform provision.

Ins 3.27(10)(j) (j) The following are examples of exceptions, reductions and limitations which generally do affect the basic policy provisions to such an extent that their absence would cause the advertisement to have the capacity and tendency to mislead or deceive.

Ins 3.27(10)(j)1. 1. War or act of war.

Ins 3.27(10)(j)2. 2. While in armed services.

Ins 3.27(10)(j)3. 3. Territorial restriction or coverage within United States and Canada.

Ins 3.27(10)(j)4. 4. Complete aviation exclusion.

Ins 3.27(10)(j)5. 5. Self-inflicted injury.

Ins 3.27(10)(j)6. 6. Injury inflicted by another person.

Ins 3.27(10)(j)7. 7. Time limitation on death, dismemberment or commencement of disability or medical treatment following an accident.

Ins 3.27(10)(j)8. 8. Pre-existing sickness or disease or other bodily infirmity.

Ins 3.27(10)(j)9. 9. Exclusion or reduction for loss due to specific diseases, classes of diseases or types of injuries.

Ins 3.27(10)(j)10. 10. Confinement restrictions in disability policies such as house confinement, bed confinement and confinement to the premises.

Ins 3.27(10)(j)11. 11. Waiting, elimination, probationary or similar periods.

Ins 3.27(10)(j)12. 12. Reduction in benefits because of age.

Ins 3.27(10)(j)13. 13. Any reduction in benefit during a period of disability.

Ins 3.27(10)(j)14. 14. Workers’ compensation or employers’ liability law exclusion.

Ins 3.27(10)(j)15. 15. Occupational exclusion.

Ins 3.27(10)(j)16. 16. Violation of law.

Ins 3.27(10)(j)17. 17. Automatic benefit in lieu of another benefit.

Ins 3.27(10)(j)18. 18. Confinement in government hospital.

Ins 3.27(10)(j)19. 19. Pregnancy.

Ins 3.27(10)(j)20. 20. Miscarriage in sickness or accident and sickness policy.

Ins 3.27(10)(j)21. 21. Restrictions relating to organs not common to both sexes.

Ins 3.27(10)(j)22. 22. Restrictions on number of hospital hours before benefit accrues.

Ins 3.27(10)(j)23. 23. Insanity, mental diseases or disorders or nervous disorder.

Ins 3.27(10)(j)24. 24. Dental treatment, surgery or procedures.

Ins 3.27(10)(j)25. 25. Cosmetic surgery.

Ins 3.27(10)(j)26. 26. While intoxicated or under the influence of narcotics, or other language not substantially the same as the uniform individual policy provision regarding the use of intoxicants and narcotics.

Ins 3.27(10)(j)27. 27. Unemployed persons.

Ins 3.27(10)(j)28. 28. Retired persons.

Ins 3.27(10)(j)29. 29. While handling explosives or chemical compounds.

Ins 3.27(10)(j)30. 30. While or as a result of participating in speed contests.

Ins 3.27(10)(j)31. 31. While or as a result of riding a motorcycle or motorcycle attachment.

Ins 3.27(10)(j)32. 32. While or as a result of participating in professional athletics.

Ins 3.27(10)(j)33. 33. While or as a result of participating in certain specified sports.

Ins 3.27(10)(j)34. 34. While or as a result of serving as a volunteer firefighter or in other hazardous occupations.

Ins 3.27(10)(j)35. 35. Riot or while participating in a riot.

Ins 3.27(10)(j)36. 36. Ptomaine poisoning.

Ins 3.27(10)(j)37. 37. Gas or poisonous vapor.

Ins 3.27(10)(j)38. 38. Sunstroke or heat prostration.

Ins 3.27(10)(j)39. 39. Freezing.

Ins 3.27(10)(j)40. 40. Poison ivy or fungus infection.

Ins 3.27(10)(j)41. 41. Requirement of permanent disability.

Ins 3.27(10)(j)42. 42. Reduction because of other insurance.

Ins 3.27(10)(j)43. 43. Limitations on the choice of providers or geographical area served.

Ins 3.27(10)(k) (k) The following are examples of exceptions, reductions and limitations which generally do not affect the basic policy provisions to such an extent that their absence would cause the advertisement to have the capacity and tendency to mislead or deceive.

Ins 3.27(10)(k)1. 1. Suicide or attempted suicide, while sane or insane.

Ins 3.27(10)(k)2. 2. Intentional self-inflicted injury.

Ins 3.27(10)(k)3. 3. Territorial restriction with no limitation of coverage while in United States and Canada.

Ins 3.27(10)(k)4. 4. Aviation exclusion under which passage on commercial airlines is covered.

Ins 3.27(10)(k)5. 5. Felony or illegal occupation.

Ins 3.27(10)(k)6. 6. All uniform individual policy provisions, both required and optional, other than those relating to other insurance.

Ins 3.27(10)(k)7. 7. Requirement for regular care by a physician.

Ins 3.27(10)(k)8. 8. Definition of total disability.

Ins 3.27(10)(k)9. 9. Definition of partial disability.

Ins 3.27(10)(k)10. 10. Definition of hospital.

Ins 3.27(10)(k)11. 11. Definition of specific total loss.

Ins 3.27(10)(k)12. 12. Definition of injury.

Ins 3.27(10)(k)13. 13. Definition of physician or surgeon.

Ins 3.27(10)(k)14. 14. Definition of nurse.

Ins 3.27(10)(k)15. 15. Definition of recurrent disability.

Ins 3.27(10)(k)16. 16. Definition of commercial air travel.

Ins 3.27(10)(k)17. 17. Provision that hernia will be considered a sickness.

Ins 3.27(10)(k)18. 18. Rest cure.

Ins 3.27(10)(k)19. 19. Diagnosis.

Ins 3.27(10)(k)20. 20. Prosthetics.

Ins 3.27(10)(k)21. 21. Cosmetic surgery exclusion under which such surgery which results from injury is covered.

Ins 3.27(10)(k)22. 22. Dental treatment, surgery or procedures exclusion under which such treatment which results from injury to sound natural teeth is covered.

Ins 3.27(10)(k)23. 23. Bacterial infection exclusion under which pyogenic infection which results from injury is covered.

Ins 3.27(10)(k)24. 24. Eye examination for fitting of glasses.

Ins 3.27(10)(k)25. 25. Hearing aid.

Ins 3.27(10)(k)26. 26. Exclusion of sickness or disease in a policy providing only accident coverage.

Ins 3.27(10)(k)27. 27. Exclusion for miscarriage in policy providing only accident coverage.

Ins 3.27(11) (11) Renewability, cancelability and termination. An advertisement shall disclose, as required below, the provisions relating to renewability, cancelability and termination and any modification of benefits, losses covered or premiums because of age or for other reasons, in a manner which shall not minimize or render obscure the qualifying conditions.

Ins 3.27(11)(a) (a) Any advertisement which refers to renewability, cancelability or termination of a policy shall be subject to the disclosure requirements of this subsection.

Ins 3.27(11)(b) (b) An advertisement which refers to a policy benefit and which is an invitation to apply shall be subject to the disclosure requirements of this subsection.