Sec. 52.59. Required disclosure statement for policies meeting definition of section 52.10 of this Part

(a) To comply with section 52.54 of this Part, policies of individual insurance that are issued to persons who are less than 65 years of age and meet the definition of section 52.10 of this Part shall use the following statement only, except that appropriate policy identification may be included:

COMPANY NAME

LIMITED BENEFITS HEALTH INSURANCE

REQUIRED DISCLOSURE STATEMENT

This policy provides limited benefits health insurance ONLY. This policy does NOT provide basic hospital, basic medical or major medical insurance, as defined by the New York State Department of Financial Services.

(Accurately list benefits, exclusions, reductions and limitations of the policy in a manner that does not encourage misrepresentation of the actual coverage provided.)

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. It is therefore imperative that you READ YOUR POLICY carefully.

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.

(b) To comply with section 52.54 of this Part, policies of individual insurance that are issued to persons who are age 65 or older and meet the definition of section 52.10 of this Part shall use the following statement only, except that appropriate policy identification may be included:

COMPANY NAME

LIMITED BENEFITS HEALTH INSURANCE

REQUIRED DISCLOSURE STATEMENT

This policy provides limited benefits health insurance ONLY. This policy does NOT provide Medicare supplement insurance, long term care insurance, nursing home insurance only, home care insurance only, or nursing home and home care insurance as defined by the New York State Department of Financial Services. For information concerning Medicare supplement insurance contact the New York State Department of Financial Services. You may also contact your local social security office or this company and request a copy of the Medicare supplement buyers' guide.

(Accurately list benefits, exclusions, reductions and limitations of the policy in a manner that does not encourage misrepresentation of the actual coverage provided.)

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. It is therefore imperative that you READ YOUR POLICY carefully.

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.