Sec. 52.58. Required disclosure statement for policies meeting standards of section 52.7 of this Part

To comply with section 52.54 of this Part, policies of individual insurance meeting the standards of section 52.7 of this Part shall use the following statement only, except that appropriate policy identification may be included:

COMPANY NAME

MAJOR MEDICAL INSURANCE

REQUIRED DISCLOSURE STATEMENT

This policy meets the minimum standards for major medical insurance as defined by the New York State Department of Financial Services and pays for hospital and medical care subject to a copayment by you of __%^* and a deductible^** (equal to the benefits paid under other insurance or $__, whichever is greater) (equal to the benefits paid under other insurance plus $__) (of $ __per person) (of $__per family) (of $__per illness) (of $__per benefit period) (of $ __per year) and a total maximum limit of $ __(This policy defines “covered charges,”^***which has the effect of reducing the amount of the actual charges that otherwise would be covered.) (Covered charges are limited to a maximum of $__per day for hospital room and board,) ($ __ for miscellaneous hospital charges) (and $ __for surgery.) 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 period (for up to _days).

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

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

8. (does not cover) (covers) drugs and medicines.

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 and drugs and medicines 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 basic hospital or basic 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

*

Fill in blanks with appropriate material.

**

Use alternate parenthetical material where appropriate.

***

Insert appropriate reference if words such as “eligible expenses”, “compensable expenses”, etc., are used in the policy.

****

This sentence may be appropriately modified if policy also meets the definition for basic hospital or basic medical or deleted if policy meets the definition of both.