In order to provide reasonable simplification of terms and coverages of individual health insurance policies, to facilitate public understanding and comparison, to eliminate provisions that may be misleading or unreasonably confusing in connection with either the purchase of such coverage or with the settlement of claims and to provide for full disclosure in the sale of such coverages:

Terms Used In Connecticut General Statutes 38a-505

  • Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
  • Commissioner: means the Insurance Commissioner. See Connecticut General Statutes 38a-1
  • Contract: A legal written agreement that becomes binding when signed.
  • Insurance: means any agreement to pay a sum of money, provide services or any other thing of value on the happening of a particular event or contingency or to provide indemnity for loss in respect to a specified subject by specified perils in return for a consideration. See Connecticut General Statutes 38a-1
  • Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy. See Connecticut General Statutes 38a-1
  • Person: means an individual, a corporation, a partnership, a limited liability company, an association, a joint stock company, a business trust, an unincorporated organization or other legal entity. See Connecticut General Statutes 38a-1
  • Policy: means any document, including attached endorsements and riders, purporting to be an enforceable contract, which memorializes in writing some or all of the terms of an insurance contract. See Connecticut General Statutes 38a-1
  • Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
  • State: means any state, district, or territory of the United States. See Connecticut General Statutes 38a-1
  • Statute: A law passed by a legislature.

(1) The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, to establish specific standards for policy provisions used in individual health insurance policies, that shall be in addition to and in accordance with sections 38a-80, 38a-321 to 38a-324, inclusive, 38a-326, 38a-329, 38a-334 to 38a-336a, inclusive, 38a-338 to 38a-358, inclusive, 38a-470 to 38a-472, inclusive, 38a-475, 38a-480 to 38a-503, inclusive, 38a-507, 38a-514, 38a-519, 38a-523, 38a-531, 38a-577 to 38a-590, inclusive, and 38a-802 to 38a-810, inclusive, and other applicable laws of this state that may cover the terms of renewability, initial and subsequent conditions of eligibility, nonduplication of coverage provisions, coverage of dependents, termination of insurance, probationary periods, limitations, exceptions, reductions, elimination periods, requirements for replacements, recurrent conditions, preexisting conditions, and the definition of the terms hospital, accident, sickness, injury, physician, accidental means, total disability, permanent disability, partial disability, nervous disorders, guaranteed renewable and noncancellable.

(2) The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, that specify prohibited policy provisions not otherwise specifically authorized by statute that in the opinion of the commissioner are unjust, unfair or unfairly discriminatory to the policyholder, any person insured under the policy or any beneficiary.

(3) The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, to establish minimum standards for benefits under each of the following categories of coverage in individual policies: Basic hospital expense coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income protection coverage, accident only coverage, specified accident coverage and specified disease coverage.

(4) Nothing in this section shall preclude the issuance of any policy that combines two or more of the categories of coverage enumerated in subdivision (3) of this section, except that specified accident coverage shall not be combined with any other category of coverage. The commissioner shall prescribe the method of identification of policies based upon coverage provided.

(5) No policy shall be delivered or issued for delivery in this state that does not meet the prescribed minimum standards for the categories of coverage listed in subdivision (3) of this section, provided nothing in this section shall preclude the delivery or issuance of any policy that does not meet such prescribed minimum standards of coverage so long as such policy is clearly identified as not meeting such prescribed standards.

(6) No such policy shall be delivered in this state unless: (A) An outline of coverage described herein accompanies the policy or (B) the outline of coverage described in this section is delivered to the applicant at the time application is made and acknowledgment of receipt of certificate of delivery of such outline is provided the carrier with the application. In the event the policy is issued on a basis other than that applied for, the outline of coverage properly describing the policy shall accompany the policy when it is delivered. The outline of coverage shall include: (i) A statement identifying the applicable category or categories of coverage provided by the policy in accordance with this section; (ii) a description of the principal benefits and coverage provided in the policy; (iii) a statement of the exceptions, reductions and limitations contained in the policy or contract; (iv) a statement of the renewal provisions including any reservation by the carrier of a right to change premiums; and (v) a statement that the outline is a summary of the policy issued or applied for and that the policy should be consulted to determine governing contractual provisions.

(7) Regulations promulgated pursuant to this section shall specify an effective date applicable to policy and benefit riders delivered or issued for delivery in this state on and after such effective date that shall not be less than one hundred eighty days after the date of adoption or promulgation.

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