11 NCAC 12 — Life and Health Division

11 NCAC 12 .1604 ACCOUNTING Funds necessary to cover liabilities under retained asset accounts shall be reported on the annual statement. History Note: Authority G.S. 58-2-40; 58-2-165; 58-58-1; 58-58-110; Eff. February 1, 1996; Pursuant to G.S. 150B-21.3A, rule is necessary with…

11 NCAC 12 .1710 DEFINITIONS (a) The definitions contained in G.S. 58-58-205 apply to this Section. (b) The following definitions shall apply to this Section: (1) "Division" means the Life and Health Division of the Department of Insurance. (2) "Insured" means the person covered …

11 NCAC 12 .1711 license requirements (a) In addition to the information required by G.S. 58-58-210, applicants for provider licenses shall submit the following: (1) A plan of operation, including the manner in which the provider proposes to operate in North Carolina and the type…

11 NCAC 12 .1712 Viatical settlement brokers (a) Applications for broker licenses shall be made with the Agent Services Division of the Department of Insurance. (b) A broker shall not, without the written agreement of the viator obtained before performing any services in connecti…

11 NCAC 12 .1713 Standards for evaluation of reasonable payments (a) Insureds who are terminally or chronically ill shall receive no less than the following payouts for viaticating a policy. The percentage may be reduced by 5% for viaticating a policy written by an insurer rated …

11 NCAC 12 .1714 Reporting requirements (a) On June 1 of each calendar year, each licensed provider shall make a report of all viatical settlement transactions in which the viators are residents of this State. The report shall contain the following information for the previous ca…

11 NCAC 12 .1715 General rules (a) With respect to a policy containing a provision for double or additional indemnity for accidental death, the additional payment shall remain payable to the beneficiary last named by the viator before entering into the viatical settlement contrac…

11 NCAC 12 .1716 CONTRACTS AND PAYMENT OF PROCEEDS (a) Two specimen copies of each contract, application, brochure, and proposal shall be filed with the Division for approval under G.S. 58-58-220. (b) In addition to the requirements in G.S. 58-58-250, every contract shall include…

11 NCAC 12 .1717 advertising MATERIAL History Note: Authority G.S. 58-2-40; 58-58-220; 58-58-300; Temporary Adoption Eff. April 1, 2002; Temporary Adoption Expired December 27, 2002.

11 NCAC 12 .1718 disclosure (a) The provider, upon receipt of an application to viaticate and after determining the value to be offered in return for the assignment or transfer of the death benefit or ownership of a policy to the provider, shall deliver a proposal to the viator b…

11 NCAC 12 .1719 prohibited practices (a) A provider or broker shall obtain from a person that is provided with patient identifying information a signed affirmation that the person or entity will not further divulge the information without procuring the express, written consent o…

11 NCAC 12 .1720 insurance company practices (a) Every life insurance company licensed in this State shall respond to a request for verification of coverage from a provider or a broker within 30 calendar days after the date a request is received. The insurer shall inform the prov…

SECTION .1800 - PPO BENEFIT PLAN PRODUCT LIMITATIONS 11 NCAC 12 .1801 APPLICABILITY This Section applies to any insurer or service corporation that, under G.S. 58-50-56, offers a preferred provider benefit plan. History Note: Authority G.S. 58-2-40; 58-50-56; Temporary Adoption E…

11 NCAC 12 .1802 DEFINITIONS The definitions contained in G.S. 58-50-56(a) are incorporated into this Section by reference and as used in this Section, the following terms have the meanings ascribed to them: (1) "Coinsurance" means the percentage of an allowed charge or expense, …

11 NCAC 12 .1803 GENERAL REQUIREMENTS No insurer shall provide any PPO benefit plan unless it complies with the following: (1) Where the covered benefits of a PPO benefit plan include coinsurance, the difference in coinsurance rates between in-network covered services and out-of-…

11 NCAC 12 .1804 DISCLOSURE REQUIREMENTS (a) If an enrollee utilizes out-of-network covered services, the explanation of benefits shall contain an explanation of coverage for out-of-network covered services that allows each enrollee to determine his or her obligations with respec…

Section .1900 – domestic violence – prohibited acts 11 NCAC 12 .1901 DEFINITIONS As used in this Section, the following terms have the meanings ascribed to them: (1) "Abuse" means the occurrence of one or more of the following acts by a current or former family member, household …

11 NCAC 12 .1902 UNFAIR OR DECEPTIVE ACTS OR PRACTICES (a) The following are unfair or deceptive acts or practices in the business of insurance: (1) To deny, refuse to issue, renew or reissue, cancel or otherwise terminate a health benefit plan, or restrict or exclude health bene…

11 NCAC 12 .1903 JUSTIFICATION OF ADVERSE INSURANCE DECISIONS An insurer or insurance professional that takes an action that adversely affects an applicant or insured on the basis of a medical condition that the health insurer or insurance professional knows or has reason to know…