Chapter 28 Individual Health Insurance Contracts — Standard Provisions and Exclusions

Chapter 28 Individual Health Insurance Contracts — Standard Provisions and Exclusions | Library of Maryland Regulations

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Code of Maryland Regulations

Title 31 MARYLAND INSURANCE ADMINISTRATION

Subtitle 10 HEALTH INSURANCE — GENERAL

Chapter 28 Individual Health Insurance Contracts — Standard Provisions and Exclusions

Code of Maryland Regulations

Chapter 28 Individual Health Insurance Contracts — Standard Provisions and Exclusions

Administrative History Effective date: Regulations .01 — .04 adopted as an emergency provision effective January 1, 2002 (28:26 Md. R. 2270); adopted permanently effective June 10, 2002 (29:11 Md. R. 891) Regulation .02B amended effective October 18, 2010 (37:21 Md. R. 1438) Regulation .03A amended as an emergency provision effective May 9, 2003 (30:11 Md. R. 733); amended permanently effective October 27, 2003 (30:21 Md. R. 1531) Regulation .05 adopted effective October 18, 2010 (37:21 Md. R. 1438) Regulation .05B amended effective April 22, 2019 (46:8 Md. R. 402) Authority Insurance Article, §§ 2-109 , 12-203 (g), and 12-205 (b)( 4 ), Annotated Code of Maryland

.01 Scope. This chapter is applicable to each individual health insurance contract issued or delivered in Maryland on or after the effective date of this chapter.

.02 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Coverage period” means the interval of time the individual health insurance contract provides protection to the insured, in exchange for the payment of a particular premium. (2) "Individual health insurance contract" means a health insurance contract issued by an insurer to a policyholder that provides health insurance coverage for permissible individuals as described in Insurance Article, §15-201(c), Annotated Code of Maryland . (3) "Insured" means a person covered under an individual health insurance contract.

.03 Limitations and Exclusions. A. Crime. (1) Except as provided in §A(3) of this regulation , an individual health insurance contract may not include a limitation or exclusion for loss to which a contributing cause was the insured's commission of or attempt to commit a crime. (2) An individual health insurance contract may not include a limitation or exclusion for loss for which a contributing cause was the commission of or the attempt to commit a crime by an individual other than the insured. (3) A disability benefit or an accidental death and dismemberment benefit in an individual health insurance contract: (a) May be subject to exclusion or limitation for loss to which a contributing cause was the insured's commission of or attempt to commit a felony; and (b) May not be subject to an exclusion or limitation regarding the commission of or attempt to commit a crime that is more restrictive to the insured than the exclusion or limitation set forth in §A(3)(a) of this regulation . B. Illegal Occupation. (1) Except as provided in §B(2) of this regulation , an individual health insurance contract may not include a limitation or exclusion for loss to which a contributing cause was the insured's being engaged in an illegal occupation. (2) A disability benefit or an accidental death and dismemberment benefit in an individual health insurance contract: (a) May be subject to an exclusion or limitation for loss to which a contributing cause was the insured's being engaged in an illegal occupation; and (b) May not be subject to an exclusion or limitation regarding an illegal occupation that is more restrictive to the insured than the exclusion or limitation set forth in §B(2)(a) of this regulation . C. Intoxicants and Narcotics. (1) Except as provided in §C(2) of this regulation , an individual health insurance contract may not include a limitation or exclusion for loss: (a) Sustained or contracted in consequence of the insured's being intoxicated or under the influence of any drug; (b) Due to the use of alcohol; (c) Due to the use of drugs or narcotics; or (d) Due to alcoholism or drug addiction. (2) A disability benefit or an accidental death and dismemberment benefit in an individual health insurance contract: (a) May be subject to an exclusion or limitation for loss sustained or contracted in consequence of the insured's being intoxicated or under the influence of any narcotic unless administered on the advice of a physician; and (b) May not be subject to an exclusion or limitation regarding the use of alcohol or drugs that is more restrictive to the insured than the exclusion or limitation set forth in §C(2)(a) of this regulation . D. Preexisting Condition Limitation. If an individual health insurance contract contains a preexisting condition limitation or exclusion, the limitation or exclusion may not apply to a condition that the applicant revealed in the application for the contract, unless the condition is excluded by means of a signed waiver rider attached to the contract.

.04 Arbitration. If an insurer includes an arbitration provision in an individual health insurance contract, the arbitration provision may not require the insured to use arbitration to settle disputes with the insurer.

.05 Premium Due Date. A. Each individual health insurance contract shall specify the premium due date. B. The premium due date shall be no earlier than the date the coverage period begins. C. An insurer may offer each individual policyholder the option to pay the premium through an electronic payment. D. If the individual policyholder elects an electronic payment, the insurer may not debit or charge the amount of the premium due prior to the premium due date, except as authorized by the individual policyholder.

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