11 NCAC 12 — Life and Health Division

11 NCAC 12 .0521 ACCIDENT: HEALTH ADVERTISING: EXCEPTIONS AND LIMITATIONS When an advertisement which is an invitation to contract refers to either a dollar amount, or a period of time for which any benefit is payable, or the cost of the policy, or specific policy benefit, or the…

11 NCAC 12 .0522 ACCIDENT AND HEALTH ADVERTISING: PRE-EXISTING CONDITIONS An advertisement which is subject to the requirements of 11 NCAC 12 .0521 shall, in negative terms, disclose the extent to which any loss is not covered if the cause of such loss is traceable to a condition…

11 NCAC 12 .0523 ADVERTISING: RENEWABILITY AND TERMINATION When an advertisement which is an invitation to contract refers to either a dollar amount or a period of time for which any benefit is payable, or the cost of the policy, or the loss for which such benefit is payable, it …

11 NCAC 12 .0524 ACCIDENT AND HEALTH ADVERTISING: TESTIMONIALS Testimonials used in advertisements must be genuine, represent the current opinion of the author, be applicable to the policy advertised and be accurately reproduced. The insurer, in using a testimonial, makes as its …

11 NCAC 12 .0525 ACCIDENT AND HEALTH ADVERTISING: USE OF STATISTICS An advertisement relating to the dollar amounts of claims paid, the number of persons insured, or similar statistical information relating to any insurer or policy shall not use irrelevant facts, and shall not be…

11 NCAC 12 .0526 ACCIDENT AND HEALTH ADVERTISING OF PLAN OR POLICIES When a choice of the amount of benefits is referred to, an advertisement which is an invitation to contract shall disclose that the amount of benefits provided depends upon the plan selected and that the premium…

11 NCAC 12 .0527 ACCIDENT AND HEALTH ADVERTISING: COMPARISONS: STATEMENTS History Note: Authority G.S. 58-9(1); 58-54.4; Eff. February 1, 1976; Readopted Eff. September 26, 1978; Repealed Eff. February 1, 1992.

11 NCAC 12 .0528 ACCIDENT AND HEALTH ADVERTISING: LICENSING AND STATUS An advertisement which is intended to be seen or heard beyond the limits of the jurisdiction in which the insurer is licensed shall not imply licensing beyond those limits. An advertisement shall not create th…

11 NCAC 12 .0529 ACCIDENT AND HEALTH ADVERTISING: IDENTITY OF INSURER The name of the actual insurer shall be stated in all of its advertisements and the form number of the policy advertised shall be stated in an advertisement which is an invitation to contract. An advertisement …

11 NCAC 12 .0530 ACCIDENT AND HEALTH ADVERTISING: GROUP IMPLICATIONS An advertisement of a particular policy shall not state or imply that prospective insureds become group or quasi-group members covered under a group policy and as such enjoy special rates or underwriting privile…

11 NCAC 12 .0531 ADVERTISING: INTRODUCTORY OR SPECIAL OFFERS An advertisement of an individual policy shall not directly or by implication represent that a contract or combination of contracts is an introductory, initial or special offer, or that applicants will receive substanti…

11 NCAC 12 .0532 ACCIDENT: HEALTH ADVERTISING: STATEMENT ABOUT AN INSURER An advertisement shall not contain statements which are untrue in fact, or by implication misleading, with respect to the assets, corporate structure, financial standing, age or relative position of the ins…

11 NCAC 12 .0533 ACCIDENT AND HEALTH ADVERTISING: ADVERTISING FILE Each insurer shall maintain at its home or principal office a complete file containing every printed, published or prepared advertisement of its individual policies and typical printed, published or prepared adver…

11 NCAC 12 .0534 ACCIDENT AND HEALTH ADVERTISING: CERTIFICATE OF COMPLIANCE Each insurer required to file an annual statement which is now or which hereafter becomes subject to the provisions of these rules must file with this department, with its annual statement, a certificate …

11 NCAC 12 .0535 ACCIDENT AND HEALTH ADVERTISING: ADVERTISING EXPENSE Total advertising expense incurred by the insurer or by an affiliated corporation on behalf of the insurer for the purposes of solicitation and conservation of accident and health insurance business shall be in…

11 NCAC 12 .0536 ACCIDENT AND HEALTH ADVERTISING: PRIOR REVIEW OR APPROVAL The commissioner may, when in his discretion he deems it in the public interest, require the filing of all or any part of the advertising material of an insurer with this department for review prior to its…

11 NCAC 12 .0537 PRE-EXISTING CONDITIONS: INSURED'S AGE OVER 65 History Note: Authority G.S. 58-251.1; 58-252; Eff. February 1, 1976; Readopted Eff. September 26, 1978; Repealed Eff. February 1, 1992.

11 NCAC 12 .0538 ACCIDENT: HEALTH PROMOTIONAL MATERIAL: STICKERS REQUIRED For all accident and health insurance promotional material of all kinds for presentation in person, by mail or otherwise by an insurer, or its representative to the insurance buying public, including but no…

11 NCAC 12 .0539 NOTICE FOR REVISION OF RATES FOR NON-PROFIT SERVICE CORP Notice of a public hearing on the revision of an existing schedule of rates or establishment of a new schedule of rates for a non-profit hospital, medical or dental service corporation shall be published on…

11 NCAC 12 .0540 BLANKET AND FRANCHISE POLICIES A group disability policy as interpreted under G.S. 58-14-5(4) does not include blanket and franchise policies. History Note: Authority G.S. 58-2-40; 58-14-5(4); Eff. February 1, 1976; Readopted Eff. September 26, 1978; Amended Eff.…

11 NCAC 12 .0541 NOTICE OF CLAIM: CREDIT INSURANCE The claimant shall have a minimum of 30 days to give written notice of claim. History Note: Authority G.S. 58-2-40; 58-57-25; Eff. February 1, 1976; Readopted Eff. September 26, 1978; Pursuant to G.S. 150B-21.3A, rule is necessar…

11 NCAC 12 .0542 ACCIDENT AND HEALTH APPLICATION: GUARANTEED ISSUE When an accident and health policy is sold on a guaranteed issue basis, the application for such insurance used in the solicitation may not contain health questions on the application. History Note: Authority G.S.…

11 NCAC 12 .0543 POLICIES CONTAINING A PRE-EXISTING CONDITION EXCLUSION All individual or franchise insurance policy forms and group certificates containing an exclusion for pre-existing conditions, or other language substantially similar to that set forth in form 11 NCAC 12 .020…

11 NCAC 12 .0544 POLICIES RENEWABLE AT THE OPTION OF THE COMPANY All individual or franchise insurance policy forms and group certificates that are renewable at the option of the company or other language substantially similar to that set forth in form 11 NCAC 12 .0201 shall disp…

11 NCAC 12 .0545 OFFSET OF INCREASED SOCIAL SECURITY: GROUP DISABILITY History Note: Authority G.S. 58-2-40; 58-51-1; 58-65-1; 58-65-40; Eff. September 26, 1978; Repealed Eff. July 1, 2012.

11 NCAC 12 .0546 DIAGNOSIS OF CANCER No insurer shall exclude a clinical diagnosis of cancer if, in the opinion of the attending physician, a positive diagnosis can not otherwise be made without jeopardizing the life of the claimant. The insurer may require that there be definiti…

11 NCAC 12 .0547 WAITING PERIOD History Note: Authority G.S. 57-1; 57-4; 58-249; 58-252; Eff. September 26, 1978; Repealed Eff. April 1, 1989.

11 NCAC 12 .0548 INSURANCE FOR MEDICARE ELIGIBLE (a) Direct response insurers providing accident and health insurance to persons eligible for Medicare by reason of age shall: (1) guarantee to the policyholder an unconditional 30 day right to return the policy for a full refund of…

11 NCAC 12 .0549 CONVERSION POLICIES: HOSPITAL ROOM RATES The dollar amount for the maximum hospital room and board daily expense benefit for Plan A of conversion policies required by G.S. 58-53-90 shall be one hundred seventy dollars ($170.00). History Note: Authority G.S. 58-2-…

11 NCAC 12 .0550 ORTHODONTIC COVERAGE LIMITATIONS No insurer providing benefits for orthodontic services and supplies shall condition receipt of those benefits upon a determination of the class of malocclusion or any measurement of the position of the teeth or jaws, but shall rel…

11 NCAC 12 .0551 CANCER INSURANCE REQUIREMENTS Cancer policy requirements. Cancer policies approved in this State shall comply with the following: (1) The policy shall have a pre-existing conditions sticker that complies with 11 NCAC 12 .0543 and reads as follows: NO RECOVERY FOR…

11 NCAC 12 .0552 TEMPOROMANDIBULAR JOINT DYSFUNCTION History Note: Authority G.S. 58-2-40; 58-51-1; 58-51-95; 58-65-85; Eff. July 1, 1986; Repealed Eff. February 1, 1996.

11 NCAC 12 .0553 EXCESS INSURANCE: NON-DUPLICATION OF COVERAGE (a) An accident and health policy with a nonduplication of coverage benefit may be permitted, if it contains the following sticker on the face in red: EXCESS INSURANCE This policy is not intended to be issued where ot…

11 NCAC 12 .0554 STOP-LOSS COVERAGE - REQUIREMENTS History Note: Authority G.S. 58-9; 58-249; 58-254.7; Eff. April 1, 1989; Repealed Eff. February 1, 1992.

11 NCAC 12 .0555 LONG-TERM CARE POLICY REQUIREMENTS (a) Definitions: (1) Long-Term Care Insurance is defined as any contract of insurance offering institutional or noninstitutional support in order to restore deteriorating health and to maintain functional independence. Such serv…

11 NCAC 12 .0556 HOME HEALTH CARE POLICY REQUIREMENT All Home Health Care Policies shall have the notice printed in contrasting type or color on the face of the policy as follows: "This Is Not A Long-Term Care Policy - This Policy Provides Home Health Care Benefits Only - Read Ca…

11 NCAC 12 .0557 POLICIES CONTAINING A TERMINATION OR CANCELLATION PROVISION (a) Any policy or certificate of insurance that may be terminated for reasons other than non-payment of premium or the insured's stated age must be affixed with a notice referring the insured to the rene…

11 NCAC 12 .0558 PREMIUM REVISION History Note: Authority G.S. 58-9; 58-249; 58-254.7; Eff. April 1, 1989; Repealed Eff. February 1, 1992.

11 NCAC 12 .0559 PRECERTIFICATION Policies requiring precertification must contain a disclosure of penalties for benefits and services that are not precertified. History Note: Authority G.S. 58-2-40; 58-50-60; Eff. February 1, 1992; Pursuant to G.S. 150B-21.3A, rule is necessary …

11 NCAC 12 .0560 UNIFORM CLAIM FORMS History Note: Authority G.S. 58-2-40; 58-3-171; Filed as a Temporary Adoption Eff. January 1, 1994 for a period of 180 days or until the permanent rule becomes effective, whichever is sooner; Eff. April 1, 1994; Repealed Eff. July 1, 2012.

11 NCAC 12 .0561 DEDUCTIBLES AND COPAYMENTS BASED ON REAL COST (a) As used in this Rule: (1) "Health benefit plan" means any accident and health insurance policy or certificate; a nonprofit hospital or medical service corporation contract; a health maintenance organization subscr…

11 NCAC 12 .0562 UNEARNED PREMIUM As used in this Rule, "unearned premium" means that portion of the premium representing the unexpired portion of the policy term. All insurers of individual health or accident and health insurance shall in the event of cancellation or the death o…

11 NCAC 12 .0563 WEIGHTED AVERAGE: MENTAL ILLNESS BENEFITS COVERAGE (a) The definitions contained in G.S. 58-3-220(h) are incorporated into this rule by reference. (b) To exercise the option under G.S. 58-3-220(f), at the time of submission for approval of a group health benefit …

SECTION .0600 - REPLACEMENT REGULATIONS 11 NCAC 12 .0601 PURPOSE and scope The purpose of the rules in this Section are: (1) To regulate the activities of insurers and producers with respect to the replacement of existing life insurance and annuities. (2) To protect the interests…

11 NCAC 12 .0602 DEFINITION OF REPLACEMENT When used in the rules in this Section, "replacement" means a transaction in which a new policy or contract is to be purchased, and it is known or should be known to the proposing producer, or to the proposing insurer if there is no prod…

11 NCAC 12 .0603 OTHER DEFINITIONS When used in the rules in this Section: (1) "Direct-response solicitation" means a solicitation through a sponsoring or endorsing entity, or individually, solely through mails, telephone, the Internet or other mass communication media. (2) "Exis…

11 NCAC 12 .0604 EXEMPTIONS (a) Unless otherwise stated in Chapter 58 of the North Carolina General Statutes, this Section shall not apply to transactions involving: (1) Credit life insurance; (2) Group life insurance or group annuities where there is no direct solicitation of in…