11 NCAC 12 — Life and Health Division

CHAPTER 12 - LIFE AND HEALTH DIVISION SECTION .0100 - GENERAL ORGANIZATION AND FUNCTIONS 11 NCAC 12 .0101 GENERAL PROVISIONS In this Chapter, unless the context otherwise requires: (1) "Deemer clause" or "deemer provision" shall mean any clause or provision which establishes a pe…

SECTION .0200 - DESCRIPTIONS OF FORMS 11 NCAC 12 .0201 PRE-EXISTING CONDITIONS AND RENEWABLE AT COMPANY OPTION The notices for pre-existing conditions and policies renewable at the option of the company are used as examples of acceptable wording for stickers placed on or notices …

11 NCAC 12 .0204 NOTICE FOR REVISION OF RATES FOR NON-PROFIT SERVICE CORP The form of notice of public hearing on revision of rates of nonprofit hospital, medical or dental service corporations is a guide for the preparation and publication of the notice of public hearing pursuan…

11 NCAC 12 .0208 MEDICARE AND MEDICAID - BUYER'S GUIDE (a) The North Carolina Buyer's Guide to Health Insurance and Medicare and Medicaid is provided pursuant to 11 NCAC 12 .0548. This form consists of information regarding North Carolina law and regulations pertaining to the peo…

SECTION .0300 - GENERAL PROVISIONS 11 NCAC 12 .0301 GENERAL PROVISIONS History Note: Authority G.S. 58-9; Eff. February 1, 1976; Readopted Eff. September 26, 1978; Repealed Eff. July 1, 1988.

11 NCAC 12 .0302 APPLICATION FOR INSURANCE REQUIRED History Note: Authority G.S. 58-344; Eff. February 1, 1976; Readopted Eff. September 26, 1978; Amended Eff. July 1, 1986; Repealed Eff. April 1, 1989.

11 NCAC 12 .0303 REBATES ON INSURANCE COMPANIES EMPLOYEES: PROHIBITED History Note: Authority G.S. 58-54.4(8); Eff. February 1, 1976; Readopted Eff. September 26, 1978; Repealed Eff. February 1, 1992.

11 NCAC 12 .0304 SEX DISCRIMINATION ON APPLICATIONS An insurer may not discriminate based on sex in any manner on a life or accident and health insurance application. History Note: Authority G.S. 57-1; 57-4; 58-9; 58-44; Eff. February 1, 1976; Readopted Eff. September 26, 1978; P…

11 NCAC 12 .0305 TWISTING OR OTHER PRACTICES INJURIOUS TO THE PUBLIC History Note: Authority G.S. 58-9(1); 58-42.1; 58-54.4; Eff. February 1, 1976; Readopted Eff. September 26, 1978; Repealed Eff. February 1, 1992.

11 NCAC 12 .0306 LIFE: HEALTH AND ACCIDENT COVERAGES: POLICY OUT OF STATE Where a group master policy is written upon application taken outside this jurisdiction covering individuals in this state the certificate covering lives within this state shall be considered "North Carolin…

11 NCAC 12 .0307 FILING APPROVAL: LIFE: ACCIDENT AND HEALTH FORMS History Note: Authority G.S. 58-2-40; 58-6-5; 58-51-1; 58-54-35; 58-55-30; 58-58-1; 58-65-1; 58-65-40; 58-67-50; 58-67-150; Eff. February 1, 1976; Amended Eff. November 1, 1976; Readopted Eff. September 26, 1978; A…

11 NCAC 12 .0308 BANK CREDIT CARD FACILITY AVAILABLE FOR PREMIUM PAYMENT History Note: Authority G.S. 58-61.2; Eff. February 1, 1976; Readopted Eff. September 26, 1978; Amended Eff. April 1, 1989; Temporary Repeal Eff. December 1, 1999; Repealed Eff. July 1, 2000.

11 NCAC 12 .0309 APPLICATION: BYLAWS: RULES: PART OF THE POLICY CONTRACT The bylaws or constitution of a mutual insurance company, association, order, society, or reciprocal exchange need not be attached to each policy in order to be a part of the policy contract if the policy co…

11 NCAC 12 .0310 INDUSTRIAL INSURANCE The following is departmental policy on industrial insurance. With respect to industrial business in this state an agent shall not be permitted to accept any money in payment of the premiums which are in arrears on any industrial insurance po…

11 NCAC 12 .0311 LIMITATION ON AMOUNT OF CREDIT INSURANCE WRITTEN History Note: Authority G.S. 57-1; 57-4; 58-9; 58-344; Eff. February 1, 1976; Readopted Eff. September 26, 1978; Repealed Eff. April 1, 1989.

11 NCAC 12 .0312 ACCIDENTAL DEATH BENEFIT: INHALATION OF GAS: ETC A policy or rider providing benefits for accidental death may not exclude the following: (1) The involuntary inhalation of gas and fumes and the involuntary taking of poison. (2) Accidental death as a result of inv…

11 NCAC 12 .0313 DISABILITY BENEFIT: CONFINEMENT INDOORS A policy or rider providing benefits for disability may not require confinement indoors or at home. History Note: Authority G.S. 58-2-40(1); Eff. February 1, 1976; Readopted Eff. September 26, 1978; Pursuant to G.S. 150B-21…

11 NCAC 12 .0314 INSURER LIABILITY: PREMIUM ACCEPTED FROM INELIGIBLE DEBTOR History Note: Authority G.S. 57-1; 57-4; 58-9; 58-344; Eff. February 1, 1976; Readopted Eff. September 26, 1978; Repealed Eff. April 1, 1989.

11 NCAC 12 .0317 ORIGIN OF SICKNESS: DESCRIPTION The use of a term more restrictive than "first manifested" in the determination of when a disease or sickness begins is prohibited. The term "prudent person" cannot be used as a condition to establish when a disease or sickness beg…

11 NCAC 12 .0318 PREMIUM INCREASES: GROUP History Note: Authority G.S. 57-1; 57-4; 58-9; 58-195; 58-249; 58-254.7; 58-293; Eff. September 26, 1978; Repealed Eff. February 1, 1992.

11 NCAC 12 .0319 SUBROGATION PROHIBITED Life or accident and health insurance forms shall not contain a provision allowing subrogation of benefits. History Note: Authority G.S. 58-2-40; 58-51-1; 58-51-85; 58-51-95; 58-58-1; 58-65-1; 58-65-40; Eff. September 26, 1978; Pursuant to …

11 NCAC 12 .0320 SOUND HEALTH SHALL BE DEFINED An application for life and accident and health insurance shall not contain a question asking if the applicant is in sound or good health unless the term is defined. History Note: Authority G.S. 58-2-40; 58-58-1; 58-65-1; 58-65-40; E…

11 NCAC 12 .0321 RATE FILING: HMO History Note: Authority G.S. 58-67-50; 58-67-150; Eff. January 22, 1980; Amended Eff. February 1, 1992; Repealed Eff. July 1, 2020.

11 NCAC 12 .0322 REGULAR CARE AND ATTENDANCE OF A PHYSICIAN As used in life, accident and health and disability policies, "regular care and attendance of a physician" shall not be construed to require insureds to see or be under the care of a physician on a regular basis if it ca…

11 NCAC 12 .0323 COMPLICATION OF PREGNANCY Complications of pregnancy may not be treated differently from any other illness or sickness under the contract. A non-elective cesarean section is considered a complication of pregnancy. History Note: Authority G.S. 58-2-40; 58-3-120; 5…

11 NCAC 12 .0324 HIV AND AIDS DISCRIMINATION PROHIBITED Human Immunodeficiency Virus (HIV) infection (symptomatic and asymptomatic) and Acquired Immune Deficiency Syndrome (AIDS) must be treated as any other illness or sickness under health insurance policy provisions and policy …

11 NCAC 12 .0325 OCCUPATIONAL INJURIES OR DISEASES History Note: Authority G.S. 58-2-40; 58-3-150; 58-51-1; 58-51-85; 58-51-95; Eff. February 1, 1992; Amended Eff. October 1, 1994; Repealed Eff. July 1, 2012.

11 NCAC 12 .0326 APPLICATION FOR INSURANCE REQUIRED (a) Applications for individual life, and accident or health insurance and annuities intended to insure North Carolina residents shall, except in the case of direct response business, be signed by a North Carolina licensed agent…

11 ncac 12 .0327 y2k interim claim payments History Note: Authority G.S. 58-2-40; 58-2-235; Temporary Adoption Eff. January 1, 2000; Amended Eff. July 1, 2000; Repealed Eff. September 1, 2002.

11 NCAC 12 .0328 Eligible individual coverage (a) As used in this Rule, "designated health plan" means a guaranteed available plan an insurer must issue to an eligible individual under G.S. 58-68-60. (b) As used in this Rule, "eligible individual" has the same meaning as in G.S. …

11 NCAC 12 .0329 SUBMISSION REQUIREMENTS: FORM AND RATE FILINGS Any insurer, as defined by G.S. 58-1-5(3), that files with the Commissioner for review or approval product forms of life, annuity, accident and health, multiple employer welfare arrangements or managed care provider …

11 NCAC 12 .0330 NOTICE OF A CLOSED BLOCK OF INDIVIDUAL business (a) Definitions. As used in this rule: (1) "Accident and health coverage" has the same meaning as in G.S. 58-3-275. (2) "Block of business" has the same meaning as in G.S. 58-3-275. (3) "Closed block of business" ha…

11 NCAC 12 .0331 HEALTH INSURANCE RISK POOL NOTICE LANGUAGE REQUIREMENTS History Note: Authority G.S. 58-2-40; 58-3-276; Eff. February 1, 2010; Repealed Eff. August 23, 2013 pursuant to G.S. 150B-21.7; Expired Eff. June 1, 2018 pursuant to G.S. 150B-21.3A.

11 NCAC 12 .0332 review/audit of third party administrators (a) Definitions. As used in this rule: (1) "Certification" means the certification required by G.S. 58-56-26(c). (2) "Insurer" has the same meaning as in G.S. 58-56-2(4). (3) "Third party administrator" or "TPA" has the …

SECTION .0400 - LIFE: GENERAL NATURE 11 NCAC 12 .0401 LIFE: GENERAL NATURE History Note: Authority G.S. 58-9; Eff. February 1, 1976; Readopted Eff. September 26, 1978; Repealed Eff. July 1, 1988.

11 NCAC 12 .0402 FAMILY LIFE POLICIES AND DEPENDENT TERM RIDERS History Note: Authority G.S. 58-195; Eff. February 1, 1976; Readopted Eff. September 26, 1978; Repealed Eff. February 1, 1992.

11 NCAC 12 .0403 TERMINATION OF LIFE INSURANCE: EMPLOYEE-EMPLOYER CONTRACTS Individual life policies issued pursuant to G.S. 58-58-150 may be terminated by the insurance company when the following conditions occur: (1) All like policies issued to employees of an employer are term…

11 NCAC 12 .0404 APPLICATIONS WHICH FINANCE THE FIRST YEAR'S PREMIUM (a) Applications to be used with the sale of life insurance in which the first year's premium is financed shall comply with 11 NCAC 4 .0318. (b) The information required in Subsection (a) of this Rule may be att…

11 NCAC 12 .0405 LIFE INSURANCE: TOTAL AND PERMANENT DISABILITY BENEFITS Departmental policy with regard to total and permanent disability provisions of life insurance policies is as follows: (1) Total and permanent disability provisions of individual or group life insurance and …

11 NCAC 12 .0406 GROUP LIFE INSURANCE: COLLECTION FEE No insurance company licensed in North Carolina will be permitted to pay a collection fee to any person for the collection of premiums under group life insurance contracts, salary savings plans, or any other plan of group life…

11 NCAC 12 .0407 GROUP LIFE INSURANCE: DEPENDENT BENEFIT Dependent life insurance may be written in connection with group life insurance in amounts as allowed by an insurer's underwriting practices. History Note: Authority G.S. 58-2-40; 58-58-135; Eff. February 1, 1976; Readopted…

11 NCAC 12 .0414 GROUP LIFE: STATE EMPLOYEES: OTHER POLITICAL SUBDIVISION History Note: Authority G.S. 58-210(6); Eff. February 1, 1976; Readopted Eff. September 26, 1978; Repealed Eff. February 1, 1992.

11 NCAC 12 .0415 LIFE APPLICATION All life and annuity applications used to solicit life insurance or annuities in North Carolina shall inquire whether or not the replacement of existing life insurance or annuities is involved in the transaction. History Note: Authority G.S. 58-2…

11 NCAC 12 .0416 LIFE APPLICATION: GUARANTEED ISSUE When a life insurance policy or certificate is sold on a guaranteed issue basis, the application for such life insurance used in the solicitation may not contain questions or statements regarding an applicant's health. History N…

11 NCAC 12 .0419 FILING AND APPROVAL OF VARIABLE ANNUITY CONTRACTS After a life insurance company has been granted the authority to write variable annuities the company must submit its variable annuity contract forms to the department for approval. The same requirements which are…

11 NCAC 12 .0420 APPROVAL OF CONTRACTS: ADDITIONAL INFORMATION REQUIRED A company submitting variable annuity contracts to the Department for approval shall furnish the following information with each variable annuity contract filing: (1) Evidence that a copy of all appropriate i…

11 NCAC 12 .0421 PREPARATION OF VARIABLE ANNUITY CONTRACT FILINGS A company submitting variable annuity contracts to the department for approval must prepare such filings in the following manner: (1) Separate filings should be made for individual and group contracts, with all sup…

11 NCAC 12 .0422 CONTRACTS PROVIDING FOR VARIABLE BENEFITS Any variable contract providing benefits payable in variable amounts delivered or issued for delivery in this state shall contain a statement of the essential features of the procedures to be followed by the company in de…

11 NCAC 12 .0423 REQUIRED REPORTS ON VARIABLE ANNUITY BUSINESS Any company issuing individual variable annuity contracts shall mail to the contract holder at least once in each contract year after the first year at his last address known to the company, a statement or statements …

11 NCAC 12 .0424 LIFE INSURANCE ADVERTISING: DEFINITIONS For the purpose of 11 NCAC 12 .0424 to .0433: (1) "Policy" shall include any policy, plan, certificate, contract, agreement, statement of coverage, rider, or endorsement which provides for life insurance or annuity benefits…