N.J.A.C. 11:4 — ACTUARIAL SERVICES (Subchapter 1 to 62)

(a) In recommending the purchase or replacement of any Medicare supplement policy or certificate, an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement. (b) Any sale of Medicare supplement coverage which will provide an i…

(a) This subchapter shall apply to:1. All Medicare supplement policies, as defined by this subchapter, delivered or issued for delivery in this State; 2. All certificates, as defined by this subchapter, issued under group Medicare supplement policies, which certificates have been…

(a) Every carrier shall report annually, on or before March 1, to the Commissioner, the policy and certificate number and date of issuance of each policy or certificate, grouped by individual insureds for every individual resident of this State for which the carrier has in force …

(a) All forms, rates, loss ratio reporting and advertisements submitted for filing with or by the Commissioner shall be submitted to the Office of Life and Health Actuarial Services, New Jersey Department of Insurance, PO Box 470, Trenton, New Jersey 08625-0470. (b) Annual report…

Failure to comply with the terms of this subchapter may result in the assessment of any and all penalties available in accordance with the laws of this State. Notes N.J. Admin. Code § 11:4-23.22 Recodified from N.J.A.C. 11:4-23.21 by R.1999 d.38, effective 12/28/1998 (to expire F…

If any provision of this subchapter or the application thereof to any person or circumstance is held to be invalid for any reason, the remainder of the subchapter and the application of such provision to other persons or circumstances shall not be affected thereby. Notes N.J. Adm…

(a) For all policies with policy years beginning on or after May 21, 2009, the following provisions concerning the use of genetic information and requests for genetic testing shall apply: 1. An issuer of a Medicare supplement policy or certificate shall not deny or condition the …

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise. "Aggregate loss ratio" means the ratio of the accumulated value of past benefits (from the original effective date of the form to the dat…

(a) No policy or certificate may be advertised, solicited or issued for delivery in this State as a Medicare supplement policy or certificate unless such policy or certificate contains definitions or terms which conform to the requirements of this section. 1. "Accident," "acciden…

(a) No policy or certificate shall be advertised, solicited, delivered or issued for delivery in this State as a Medicare supplement policy if the policy or certificate contains limitations or exclusions that are more restrictive than those of Medicare, except with respect to pre…

(a) No policy or certificate shall be advertised, solicited, or issued for delivery in this State as a Medicare supplement policy if it does not meet the minimum standards contained in this section. (b) The following general standards apply to Medicare supplement policies and cer…

(a) All policies delivered or issued for delivery in this State prior to January 4, 1993, and all certificates delivered or issued for delivery in this State on or after July 15, 1991 but prior to January 4, 1993 as a Medicare supplement policy or certificate, shall meet the mini…

(a) No policy or certificate shall be advertised, solicited, delivered or issued for delivery in this State as a Medicare supplement policy on or after January 4, 1993 and with an effective date for coverage prior to June 1, 2010 unless it complies with the standards of N.J.A.C. …

(a) No policy or certificate shall be advertised, solicited, delivered or issued for delivery in this State as a Medicare supplement policy or certificate with an effective date for coverage on or after June 1, 2010 unless it complies with the standards of N.J.A.C. 11:4-23.6 and …

(a) Carriers shall not deny or condition the effectiveness or issuance, nor discriminate in the pricing, of Medicare supplement policies or certificates based on the health status, claims experience, receipt of health care by, or medical condition of an applicant if the applicati…

The purpose of this subchapter is to authorize the use of mortality tables adopted after September 11, 1981 by the National Association of Insurance Commissioners in determining minimum nonforfeiture standards and minimum valuation standards. Notes N.J. Admin. Code § 11:4-24.1…

The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise. "1980 CSO Table" means that mortality table, consisting of separate rates of mortality for male and female lives, prescribed by N.J.S.A. 17B:19…

(a) In determining minimum cash surrender values, minimum amounts and minimum periods of nonforfeiture benefits for any policy of insurance delivered or issued for delivery in this State after the operative date of N.J.S.A. 17B:25-19h(xi) for that policy form and before January 1…

(a) Because the smoker and nonsmoker mortality tables do not extend below age 15, the Department shall permit the following uses of the composite and smoker and nonsmoker mortality tables for juvenile insureds, as hereafter provided: 1. Insurers may use the composite mortality ta…

If any provision of this subchapter or the application thereof to any person or circumstances is for any reason held to be invalid, the remainder of the subchapter and the application of such provision to other persons or circumstances shall not be affected thereby. Notes N.J. Ad…

(a) The purpose of this subchapter is to establish rules for the filing and review of funeral insurance policies pursuant to N.J.S.A. 17B:17-5.1. (b) This subchapter shall apply to all life insurance policy or annuity contract forms delivered or issued for delivery, marketed, use…

The following words and terms, where used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise. "Funeral insurance policy" means any insurance policy or annuity contract (other than "credit life insurance" as defined at N.J.S.A. 45:…

(a) No insurer shall deliver or issue for delivery any funeral insurance policy in this State that has not been filed pursuant to law on or after December 21, 1993, or as otherwise permitted under this subchapter. (b) The requirements of this subchapter apply to all previously fi…

(a) The submission for the filing of any funeral insurance policy shall be accompanied by a copy of the prepaid funeral agreement to which the policy is related. The prepaid funeral agreement shall provide that: 1. Cancellation of the funeral arrangements will not cancel or other…

(a) A funeral insurance policy shall be identified in the policy form as a life insurance policy or annuity contract. (b) Funeral insurance policies identified as life insurance shall provide, at a minimum, the following benefits in relation to premiums: 1. The guaranteed death b…

If any provision of this subchapter, or its application to any person or circumstances, is held invalid, the remainder of this subchapter and its application to other persons or circumstances shall not be affected. Notes N.J. Admin. Code § 11:4-25.6

If after notice and an opportunity for hearing, the Commissioner of Insurance finds that a person has violated this regulation or the enabling legislation, a penalty, in addition to any other penalty, not exceeding $ 2,000 for each violation, may be imposed and shall be collected…

The purpose of this subchapter is to recognize the following mortality tables: the 1983 Table "a", the 1983 GAM Table, the Annuity 2000 Mortality Table, the 2012 IAR Table, and the 1994 GAR Table, for use in determining the minimum standard of valuation for annuity and pure endow…

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. "Annuity 2000 Mortality Table" means that mortality table developed by the Society of Actuaries Committee on Life Insurance Research and shown…

(a) Except as provided in (b) and (c) below, the 1983 Table "a" is recognized and approved as an individual annuity mortality table for valuation and, at the option of the company, may be used for purposes of determining the minimum standard of valuation for any individual annuit…

(a) In using the 2012 IAR Mortality Table, the mortality rate for a person age x in year (2012 + n) is calculated as follows: q[x]<2012+n> = q[x]<2012> (1 - G2[x]). The resulting q[x]<2012+n> shall be rounded to three decimal places per 1,000 (for example, 0.741 deaths per 1,000)…

(a) Except as provided in (b) and (c) below, the 1983 GAM Table, the 1983 Table "a" and the 1994 GAR Table are recognized and approved as group annuity mortality tables for valuation and, at the option of the company, any one of these tables may be used for purposes of valuation …

(a) In using the 1994 GAR Table, the mortality rate for a person age x in year (1994+n) is calculated as follows: q[x]<1994> + n = q[x]<1994> (1 - AA[x]) where the q[x]<1994> and AA[x]s are as specified in the 1994 GAR Table. Notes N.J. Admin. Code § 11:4-26.6 Renumbered from N.J…

If any provision of this subchapter or the application thereof to any person or circumstances is for any reason held to be invalid, the remainder of the subchapter and the application of such provision to other persons or circumstances shall not be affected thereby. Notes N.J. Ad…

This subchapter sets forth the requirements for the use of the 2001 Commissioner's Standard Ordinary (CSO) Mortality Table in accordance with N.J.S.A. 17B:19-8a(i), N.J.S.A. 17B:25-19h(viii), N.J.A.C. 11:4-32.3(a) and N.J.A.C. 11:4-32.3(b). Notes N.J. Admin. Code § 11:4-27.1…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "2001 CSO Mortality Table" means that mortality table, consisting of separate rates of mortality for male and female lives, developed by…

(a) At the election of the insurer for any one or more specified plans of insurance and subject to the conditions stated in this subchapter, the 2001 CSO Mortality Table may be used as the minimum standard for policies issued on or after January 1, 2005 and before January 1, 2009…

(a) For each plan of insurance with separate rates for smokers and nonsmokers, an insurer may use: 1. Composite mortality tables to determine minimum reserve liabilities and minimum cash surrender values and amounts of paid-up nonforfeiture benefits; 2. Smoker and nonsmoker morta…

(a) Subject to the transition dates for use of the 2001 CSO Mortality table in N.J.A.C. 11:4-27.3, the 2001 CSO Mortality Table may be used in applying N.J.A.C. 11:4-32 in the following manner. 1. The net level reserve premium is based on the ultimate mortality rates in the 2001 …

(a) For any ordinary life insurance policy delivered or issued for delivery in this State on and after January 1, 2005 that uses the same premium rates and charges for male and female lives, or is issued in circumstances where applicable law does not permit distinctions on the ba…

(a) Because the smoker and nonsmoker mortality tables do not extend below age 15, the Department shall permit the following uses of the composite and smoker and nonsmoker mortality tables for juvenile insureds, as hereafter provided: 1. Insurers may use the composite mortality ta…

If any provision of this subchapter or its application to any person or circumstance is, for any reason, held to be invalid, the remainder of the subchapter and the application of the provision in question to other persons or circumstances shall not be affected. Notes N.J. Admin.…

(a) The purpose of this subchapter is to:1. Discourage overinsurance and avoid duplication of benefits by permitting a reduction of benefits when a person is covered by more than one plan providing benefits or services for medical, dental, or other care or treatment; 2. Avoid cla…

A term such as "usual and customary", "usual and prevailing", or "reasonable and customary", may be substituted for the term "necessary, reasonable and customary" in a contract. Terms such as "medical care" or "dental care" may be substituted for "health care" in a contract to de…

(a) Administration of coordination of benefits provisions for all plans shall be in compliance with this subchapter by January 1, 2003. (b) All plans shall include the notice required pursuant to N.J.A.C. 11:4-28.8 in their explanation of benefits forms by January 1, 2003. (c) Ex…

If any provision of this subchapter or the application thereof to any person or circumstance is held invalid, the remainder of the subchapter and the application of such provision to other persons or circumstances shall not be affected thereby. Notes N.J. Admin. Code § 11:4-28.12…

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: "Allowable expense" means the charge for any health care service, supply or other item of expense for which the covered person is liable,…

(a) The use of COB provisions in group contracts providing health care benefits shall be permissive; any plan may elect to be always "primary". Where COB is used, it shall be included in group contracts providing health care benefits subject to the following conditions: 1. If a g…

(a) Appendix A of this subchapter contains Model COB Provisions that may be used in group contracts, and is incorporated herein by reference as part of this subchapter. The use of the Model COB Provisions shall be subject to (b) below, N.J.A.C. 11:4-28.5 and 28.6. (b) A group con…

(a) A group contract shall not reduce benefits on the basis that: 1. Another plan exists; 2. A person is or could have been covered under another plan, except with respect to Part B of Medicare; or 3. A person has elected an option under another plan providing a lower level of be…