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

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

This regulation shall be effective after it has been accepted by the Legislature. Acceptance by the Legislature will occur 60 days after the regulation has been submitted to the Legislature, unless the Legislature passes a concurrent resolution stating in substance that the Legis…

The purpose of this subchapter is to record the policies and practices which the commissioner has traditionally applied to assure that individual health insurance benefits are reasonable in relation to the premiums charged, as required by N.J.S.A. 17B:26-1h, and to further expand…

All policies of insurance previously filed with the Commissioner which are not in compliance with this subchapter as of the operative date shall be deemed to be withdrawn from filing and disapproved. No new policy of insurance shall be delivered or issued for delivery in this Sta…

This subchapter shall apply to all individual health insurance policies delivered or issued for delivery in this State, except that it shall not apply to conversion policies issued pursuant to a contractual conversion privilege, it shall not apply to credit health insurance as de…

(a) The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise. 1. Terms related to policy renewability are: i. "Collectively renewable insurance" means all insurance which is made available on any…

(a) Each insurer shall include with each submission of new or revised rates the following information and material:1. An actuarial memorandum which shall include the following: i. The anticipated loss ratio; ii. The specific formulas and methodology used in calculating gross prem…

(a) For new forms, the benefits provided are presumed reasonable in relation to the premiums charged if the anticipated loss ratio meets the following standards: 1. For over 65 coverage, the ratio is at least 65 percent; 2. For accident only coverage, the ratio is at least 50 per…

(a) Each insurer shall maintain records of premiums, claims, and reserves on each policy form as required for the accident and health policy experience exhibit. (b) If the incurred/earned loss ratios for a particular policy form, based on a substantial volume of reasonably mature…

(a) Each insurer shall maintain on file with the department an up-to-date rate manual for all individual health insurance policies, riders, and endorsements currently available for sale in New Jersey. Such manual shall include: 1. Name of the insurer on each page; 2. Table of con…

If any provisions of this regulation or the application thereof to any person or circumstance shall be held invalid, the invalidity shall not affect the provisions or application of this regulation which can be given effect without the invalid provision or application, and for th…

If, after notice and hearing the commissioner finds that a person has violated this regulation a penalty, in addition to any other penalty, not exceeding $ 2,000 for each violation may be imposed and shall be collected and enforced pursuant to N.J.S.A. 2A:58-1 et seq. Notes N.J. …

The purpose of this subchapter is to prevent the exclusion of pregnancy-related surgery and sterilization procedures from certain second surgical opinion programs and to make maternity coverage available to insureds. Notes N.J. Admin. Code § 11:4-19.1

This subchapter shall apply to all group and individual health insurance policies as well as hospital and medical service corporation contracts delivered or issued for delivery in this State, except that this subchapter does not apply to individual or group health benefits plans,…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Health benefits plan" means a hospital and medical expense insurance policy, health service corporation contract, hospital service corp…

Every health insurer and medical service corporation offering individual and group policies in this State, with the exception of hospital service corporations, shall include in its programs for second surgical opinions, coverage for pregnancy-related surgery and sterilization pro…

(a) Each insurer issuing plans that are not health benefits plans shall make available benefits coverage for maternity care without regard to the marital status of its policyholders, subscribers, or other persons thereunder covered for expenses incurred in pregnancy and childbirt…

(a) The purpose of this subchapter is:1. To regulate the activities of insurers and producers with respect to the replacement of existing life insurance and annuities; and 2. To protect the interests of life insurance and annuity purchasers by establishing minimum standards of co…

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise. "Affiliate" means the term as defined in N.J.S.A. 17:27A-1a. "Annuity" means the term as defined in N.J.S.A. 17B:17-5. "Contract" means a…

(a) A producer who initiates an application shall submit to the insurer, with or as part of the application, a statement signed by both the applicant and the producer as to whether the applicant has existing policies or contracts. If the answer is "no," the producer's duties with…

(a) Where a replacement is involved in the transaction, the replacing insurer shall: 1. Verify that the required forms are received and are in compliance with this subchapter; 2. Ascertain that the sales material and illustrations used in the replacement meet the requirements of …

(a) Each insurer shall maintain a system of supervision and control to ensure compliance with the requirements of this subchapter. At a minimum, all such systems shall provide for the insurer to: 1. Inform its producers of the requirements of this subchapter and incorporate the r…

(a) Where a replacement is involved in the transaction, the existing insurer shall: 1. Retain and be able to produce all replacement notifications received, indexed by replacing insurer, for at least five years after replacement or until the conclusion of the next regular examina…

(a) In the case of an application that is initiated as a result of a direct response solicitation, the insurer shall require, with or as part of each completed application for a policy or contract, a statement asking whether the applicant, by applying for the proposed policy or c…

(a) Any failure to comply with the requirements of this subchapter shall be considered a violation of N.J.S.A. 17B:30-6. Such violations include, but are not limited to: 1. Any deceptive or misleading information set forth in sales material; 2. Failing to ask the applicant when c…

If any provisions of this subchapter shall be held invalid, the remainder of the subchapter shall not be affected thereby. Notes N.J. Admin. Code § 11:4-2.9

The purpose of this subchapter is to eliminate unfair discrimination in the underwriting, insuring and rating of individuals who are normal insurance risks in spite of blindness, partial blindness, or other physical or mental impairments. Notes N.J. Admin. Code § 11:4-20.1

(a) The following are hereby identified as acts or practices which constitute unfair discrimination between individuals of the same class: 1. Refusing to insure, or refusing to continue to insure, or limiting the amount, extent or kind of coverage available to an individual, or c…

(a) The purpose of this subchapter is to establish guidelines for the filing and review of limited death benefit policy forms which will: 1. Make life insurance available to people who are otherwise uninsurable; 2. Assure that limited death policies are not sold by producers in p…

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise. "Advertising" means any advertising materials and sales presentations in the following categories: 1. Printed and published material, aud…

(a) No limited death benefit policy shall be issued in this State unless the insurer has, at the time of application, obtained from the applicant a signed and dated statement attesting that the applicant understands that he or she may qualify for a full death benefit policy which…

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 § 11:4-21.4

The purpose of this subchapter is to permit individual life insurance policies to provide the same cash surrender values and paid-up nonforfeiture benefits to both men and women. No change in minimum valuation standards is intended by these rules. Notes N.J. Admin. Code § 11:4-22…

The following words and terms when used in this subchapter shall have the following meanings: "1980 CSO Table, with or without Ten Year Select Mortality Factors" means that mortality table, consisting of separate rates of mortality for male and female lives, developed by the Soci…

(a) For any policy of insurance on the life of either a male or female insured delivered or issued for delivery in this State after September 11, 1981, a life insurer which has elected or which elects an operative date under N.J.S.A. 17B:25-19h(xi) may file with the Department of…

(a) In determining minimum cash surrender values, and amounts of paid up nonforfeiture benefits for any policy of insurance on the life of either a male or female insured on a form of insurance with separate rates for smokers and nonsmokers delivered or issued for delivery in thi…

(a) The preceding rules in this subchapter are intended to address use of gender blended mortality tables as a minimum standard for cash surrender values and paid-up nonforfeiture benefits in the Norris market. (b) The use of gender blended mortality tables as the basis for cash …

Forms which have been filed by the Commissioner pursuant to N.J.S.A. 17B:25-18 containing provisions not in compliance with these rules shall be deemed withdrawn as of September 18, 1996. Notes N.J. Admin. Code § 11:4-22.6 New Rule, R.1996 d.148, effective 3/18/1996. See: 27 New …

It shall not be a violation of N.J.S.A. 17B:30-12c. for an insurer to issue the same kind of policy of life insurance on both a sex-distinct and sex-neutral basis. Notes N.J. Admin. Code § 11:4-22.7 Recodified: This section was N.J.A.C. 11:4-22.4. See: 19 New Jersey Register 1399…

If any provision of this subchapter or the application thereof to any person or circumstance 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. Adm…

This subchapter provides for the reasonable standardization of coverage and the simplification of terms and benefits of Medicare supplement policies; facilitates comparison of such policies in order to increase public understanding; eliminates provisions which may be misleading o…

(a) Every carrier providing Medicare supplement policies and certificates shall comply with Section 1882(c)(3) of the Social Security Act as enacted by Section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 ( P.L. 100-203) by: 1. Acceptance of notice from a Medica…

(a) For both the entire past and future periods for which revised or existing rates are computed to provide coverage, Medicare supplement policy forms or certificate forms shall be expected to return to policyholders and certificateholders, in the form of aggregate benefits under…

(a) Eligible persons are those individuals described in (c) below who seek to enroll under the policy during the period specified in (d) below, and who submit evidence of the date of termination, disenrollment, or Medicare Part D enrollment with the application for a Medicare sup…

(a) No carrier shall deliver or issue for delivery in this State any Medicare supplement policy or certificate, any written application therefor, or any printed rider or endorsements to be applied thereto, unless the forms thereof have been submitted to and filed by the Commissio…

(a) No carrier or other entity shall provide to any producer a first year commission or first year compensation for the sale of Medicare supplement policies or certificates in an amount which exceeds 200 percent of the commission or compensation to be provided by that insurer or …

(a) General rules concerning required disclosure provisions include the following: 1. Medicare supplement policies and certificates shall include a renewal or continuation provision. The language or specification of such provision shall be consistent with the type of policy or ce…

(a) Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant currently has a Medicare supplement or Medicare Advantage, Medicaid coverage or another health insurance policy or certificat…

(a) Every carrier providing Medicare supplement policies or certificates in this State shall file with the Commissioner a copy of all advertisements to which residents of this State will have access, and through which the carrier intends, or by implication purports to the reasona…

(a) Every carrier, directly or through its producers, shall: 1. Establish marketing procedures to assure that any comparison of policies by its agents or other producers will be fair and accurate; 2. Establish marketing procedures to assure excessive coverage is not sold or issue…