Sec. 52.66. Required disclosure statement for policies and certificates meeting definition of section 52.15 of this Part

(a) To comply with section 52.15 of this Part, policies of individual insurance and certificates and policies of group or blanket insurance meeting the definition of section 52.15 of this Part that are issued to persons who are less than 65 years of age shall use the following statement only, except that appropriate policy and certificate identification may be included:

COMPANY NAME

SPECIFIED DISEASE COVERAGE ONLY

REQUIRED DISCLOSURE STATEMENT

This policy or certificate is (an individual policy of insurance) (a group or blanket policy or certificate). This policy or certificate provides specified disease coverage ONLY. This policy or certificate 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 or certificate in a manner that does not encourage misrepresentation of the actual coverage provided.)

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

The policy or certificate itself sets forth the rights and obligations of both you and the insurance company. It is therefore imperative that you READ YOUR POLICY OR CERTIFICATE carefully.

The expected benefit ratio for this policy or certificate 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 or certificate.

(b) To comply with section 52.15 of this Part, policies of individual insurance and certificates and policies of group or blanket insurance meeting the definition of section 52.15 of this Part that are issued to persons who are age 65 or older shall use the following statement only, except that appropriate policy and certificate identification may be included:

COMPANY NAME

SPECIFIED DISEASE COVERAGE ONLY

REQUIRED DISCLOSURE STATEMENT

This policy or certificate is (an individual policy of insurance) (a group or blanket policy or certificate). This policy or certificate provides specified disease coverage ONLY. This policy or certificate 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. You may also contact your local social security office or this company and obtain a copy of the Guide to Health Insurance for People with Medicare.

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

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

The policy or certificate itself sets forth the rights and obligations of both you and the insurance company. It is therefore imperative that you READ YOUR POLICY OR CERTIFICATE carefully.

The expected benefit ratio for this policy or certificate 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 or certificate.