Sec. 52.57. Required disclosure statement for policies meeting standards of both sections 52.5 and 52.6 of this Part

To comply with section 52.54 of this Part, policies of individual insurance meeting the standards of both sections 52.5 and 52.6 of this Part shall use the following statement only, except that appropriate policy identification may be included:

COMPANY NAME

BASIC HOSPITAL AND MEDICAL INSURANCE

REQUIRED DISCLOSURE STATEMENT

This policy meets the minimum standards for basic hospital insurance and basic medical insurance as defined by the New York State Department of Financial Services and pays^* (, subject to a $_^**deductible,) (the semi-private room and board and miscellaneous hospital charges) (the semi-private room and board charges up to a maximum of $__per day and miscellaneous hospital charges up to a maximum of $__) ( __% of the semi-private room and board charge) ($__per day for room and board charges and miscellaneous hospital charges up to a maximum of $__) for not more than _days for each continuous hospital confinement, and outpatient hospital services for surgery and for accidental injury when performed within_hours following accidental injury (up to a maximum of $__) and ( __% of the doctor's reasonable charges for anesthesia, in-hospital medical and surgical services.) (a maximum of $__for surgery) (anesthesia up to __% of the surgical coverage) (in-hospital medical service up to $__per day for__days.) (surgical, anesthetic and in-hospital medical service in full for persons whose insurance is below $ __per year.) (surgical, anesthetic and in-hospital medical services in full.) This policy:

1. (is) (is not) renewable to eligibility for Medicare by reason of age.

2. (does not contain) (contains) special age limitations for coverage.

3. (is) (is not) subject to increases in premium.

4. (does not limit) (limits) coverage for preexisting conditions.

5. (does not contain) (contains) probationary periods (for up to_days).

6. (does not cover) (covers) hospital charges for mental illness.

7. (does not cover) (covers) medical charges for mental illness.

8. (does not provide) (provides) in-hospital medical services for mental illness.

9. (does not cover) (covers) private duty nursing.

10. (does not cover) (covers) X-ray and laboratory tests as admitted hospital outpatient.

11. (does not cover) (covers) X-ray and laboratory tests outside of a hospital.

This disclosure statement is a very brief summary of your policy.

The policy itself sets forth the rights and obligations of both you and the insurance company.

Policies frequently have special limits for pregnancy, mental illness, private duty nursing, outpatient care, X-ray and laboratory tests when covered by the policy. All policies contain exclusions, which are not listed above. It is therefore important that you READ YOUR POLICY carefully.

This policy does NOT provide major medical insurance.

The expected benefit ratio for this policy is ___%. This ratio is the portion of future premiums that the company expects to return as benefits, when averaged over all people with this policy.

Notation

*

Use alternate parenthetical material where appropriate.

**

Fill in blanks with appropriate material.