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

(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 recognize, permit and prescribe the use of mortality tables that reflect differences in mortality between Preferred and Standard lives in determining minimum reserve liabilities in accordance with N.J.S.A. 17B:19-8, N.J.A.C. 11:4-27 and N.…

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: "Commissioner" means the Commissioner of Banking and Insurance. "Department" means the New Jersey Department of Banking and Insurance. "2…

(a) At the election of the insurer, for each calendar year of issue, for any one or more specified plans of insurance and subject to satisfying the conditions stated in this subchapter, the 2001 CSO Preferred Class Structure Mortality Table may be substituted in place of the 2001…

(a) For each plan of insurance with separate rates for Preferred and Standard Nonsmoker lives, an insurer may use the Super Preferred Nonsmoker, Preferred Nonsmoker, and Residual Standard Nonsmoker tables to substitute for the Nonsmoker mortality table found in the 2001 CSO Morta…

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 rule and the application of the provision to other persons or circumstances shall not be affected. Notes N.J. Admin. Code § 11:4-27A.5…

This subchapter shall become effective on March 17, 2008. Notes N.J. Admin. Code § 11:4-27A.6

(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…

(a) The general order of benefit determination shall be as follows: 1. The primary plan shall pay or provide its benefits as if the secondary plan or plans did not exist. 2. A secondary plan shall take the benefits of another plan into account only when, under this subchapter, it…

(a) A plan determined to be a secondary plan pursuant to N.J.A.C. 11:4-28.6 may reduce its benefits so that the total benefits paid or provided by all plans during a claim determination period are not more than the total allowable expenses. Where a benefit is payable by both the …

An explanation of benefits provided to covered persons under a plan shall include the following language: "If you are covered by more than one health benefit plan, you should file all your claims with each plan and provide each plan with information regarding the other plans unde…

(a) A plan with order of benefit determination rules which comply with this subchapter (complying plan) shall coordinate its benefits with a plan that declares itself "excess" or "always secondary" or which uses order of benefit determination rules which are inconsistent with tho…

Payment of guaranteed annual endowment benefits in a policy shall not be made contingent on the payment of a premium falling due at the time such benefit would otherwise be payable or credited to the insured. Notes N.J. Admin. Code § 11:4-3.1

The gross premium for the guaranteed annual endowments shall be shown prominently and separately in the policy as distinct from the regular insurance gross premium. Notes N.J. Admin. Code § 11:4-3.2

The gross premium for any additional insurance effective after the first policy year, other than return of premiums, shall also be shown prominently and separately in the policy. Notes N.J. Admin. Code § 11:4-3.3

Annual coupons for the guaranteed annual endowments shall not be included as a part of policies containing guaranteed annual endowments. Notes N.J. Admin. Code § 11:4-3.4

Guaranteed annual endowments shall not be included as benefits in policies entitled to participate in dividends. Notes N.J. Admin. Code § 11:4-3.5

If any provision of this regulation or the application thereof to any person or circumstance is held invalid, the remainder of the regulation and the application of such provision to other persons or circumstances shall not be affected thereby. Notes N.J. Admin. Code § 11:4-3.6…

The effective date of this regulation shall be August 1, 1963. Notes N.J. Admin. Code § 11:4-3.7

The purpose of these rules is to regulate the content, filing and disclosure of information to individual policy owners and group certificate holders with respect to accelerated death benefit provisions of life insurance policies. Notes N.J. Admin. Code § 11:4-30.1

(a) Pursuant to N.J.S.A. 17B:25-18 and 17B:27-25, individual and group policies, riders and endorsements and group certificates with accelerated death benefit provisions must be filed by the Commissioner before they are delivered or issued for delivery in this State. (b) The foll…

(a) Prior to or concurrent with the election of the option to accelerate the payment of death benefits, the owner shall be given an illustration demonstrating the effect of the acceleration of the payment of death benefits on the cash value, death benefit, premium and policy or c…

(a) Insurers shall not discriminate among insureds on the basis of qualifying events covered under the policy. (b) Conditions for payment of accelerated death benefits may not be based on type of disease or the fact of institutionalization. However, it is not discriminatory to pr…

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 § 11:4-30.13

Notes N.J. Admin. Code § 11:4-30.14 Repealed by R.2000 d.170, effective 4/17/2000. See: 32 New Jersey Register 167(a), 32 New Jersey Register 1396(a). Section was "Effect on previously filed forms".

These rules shall apply to all accelerated death benefit provisions of individual and group life insurance policies delivered or issued for delivery in this State. Notes N.J. Admin. Code § 11:4-30.2 Amended by R.2012 d.096, effective 5/7/2012. See: 43 N.J.R. 3119(a), 44 N.J.R. 15…

The following terms, when used in this subchapter, shall have the following meanings: "Accelerated death benefits" means the advance payment of some or all of the death proceeds payable under a life insurance policy or group certificate: 1. To the owner or certificate holder, dur…

Accelerated death benefit provisions will be permitted in the form of either a surrender of the policy or a lien on the death benefits. Notes N.J. Admin. Code § 11:4-30.4 Amended by R.2012 d.096, effective 5/7/2012. See: 43 N.J.R. 3119(a), 44 N.J.R. 1531(a). Deleted "total or par…

(a) Under the surrender approach, the owner of a policy or certificate is permitted to accelerate the payment of all or part of the death benefit, as specified in the policy or certificate, through the acceleration of (all or part) of the death benefit. Under this approach, the c…

(a) Under the lien approach, the payment to the owner of the accelerated death benefit is treated as a lien on the death benefits of the policy. Expense charges may be added to the lien. Due and unpaid premiums may be included in the lien after the automatic premium loan, if avai…

(a) Payment options available to the owner shall include the right to receive the accelerated death benefit in lump sum and may include an option to receive the benefit in periodic payments for a term certain period (that is, without life contingencies). 1. In no event shall the …

(a) The following are required terms:1. Accelerated death benefit provisions shall specify the procedure to be followed to accelerate the payment of death benefits. Insurers are subject to N.J.S.A. 17B:25-11 with respect to any delay in processing requests to accelerate the payme…

(a) When a partial amount of the death benefit is accelerated: 1. The policy or group certificate shall be modified by an endorsement which includes a statement of cash values, policy loans, premiums and death benefits following acceleration. 2. The dividends or non-guaranteed el…

(a) The purpose of this subchapter is to provide: 1. Tables of select mortality factors and rules for their use; 2. Rules concerning a minimum standard for the valuation of plans with non-level premiums or benefits; and 3. Rules concerning a minimum standard for the valuation of …

The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Appointed actuary" means any individual who is appointed or retained in accordance with the requirements set forth at N.J.A.C. 11:1-21A.3…

(a) At the election of the insurer for any one or more specified plans of life insurance, the minimum mortality standard for basic reserves may be calculated using the 1980 CSO valuation tables with select mortality factors (or any other valuation mortality table adopted by the N…