Free Individual Accident and Health Provisions Study Guide
New York Accident & Health exam — Individual Accident and Health Provisions.
The uniform individual accident and health policy provisions come from the NAIC model law and are explained in the national Individual Accident and Health Provisions guide. New York's version is Insurance Law 3216, and it differs from the model in several tested ways: a 10-to-20-day free look, 120 days for proof of loss, and an insurer cancellation right limited to the first 90 days. Minimum standards for policy forms are in Regulation 62 (11 NYCRR 52).
Policy rules
- Free look: individual A&H policies must allow return for a full refund within a period of not less than 10 nor more than 20 days after delivery (Ins. Law 3216(c)(10)).
- Dependents: for hospital, medical, surgical or prescription drug coverage, a child is a dependent until 26, married or not, regardless of dependence, residence, student status or employment (3216(a)(4)).
- Disabled children: coverage continues past the limiting age while the child stays incapable and dependent, with proof due within 31 days of reaching that age (3216(c)(4)(A)).
- Newborns are covered from birth. Adopted newborns are covered from birth if the insured takes custody when the baby leaves the hospital and files the adoption petition within 30 days of birth (3216(c)(4)(C)).
- Misrepresentation: for hospital, medical, surgical or drug coverage, a misstatement must be material and intentional to void the policy (Ins. Law 3105(b)(2)).
- An insurer can't deny or cancel A&H coverage solely because the insured was exposed to DES (Ins. Law 3225).
Required provisions (Ins. Law 3216(d)(1))
| Provision | New York rule |
|---|---|
| Time limit on certain defenses | After two years from issue, no misstatement except a fraudulent one can void the policy or deny a claim, and pre-existing conditions not excluded by name can't be used to deny a claim. An alternative version runs two years during the insured's lifetime, not counting periods of disability. |
| Grace period | At least 7 days for weekly premiums, 10 days for monthly and 31 days for other modes. If the insurer keeps the right to refuse renewal, it gives at least 30 days' written notice of nonrenewal. |
| Reinstatement | If the insurer requires an application and gives a conditional receipt, the policy is reinstated on the 45th day unless disapproved in writing. It covers injuries after reinstatement and sickness beginning more than 10 days later. |
| Notice of claim | Within 20 days after the loss, or as soon as reasonably possible. |
| Claim forms | Furnished within 15 days after notice, or the claimant may send proof in any written form. |
| Proof of loss | Within 120 days after the loss (for periodic benefits, 90 days after the end of each period). Late proof is accepted if given as soon as reasonably possible, but no later than one year, absent legal incapacity. |
| Time of payment of claims | Periodic benefits at least monthly, with any balance paid immediately on proof. |
| Legal actions | No suit until 60 days after proof of loss is furnished, and none more than three years after proof was required. |
| Change of beneficiary | Reserved to the insured unless the designation is irrevocable. |
Optional provisions (Ins. Law 3216(d)(2))
- Cancellation: in New York, the insurer may cancel only within the first 90 days after issue, effective at least 10 days after notice, with a pro rata refund (3216(d)(2)(H)).
- Relation of earnings to insurance: benefits are prorated if total loss-of-time coverage exceeds the greater of earnings when disability began or average monthly earnings for the prior two years (3216(d)(2)(F)).
- Illegal occupation: losses to which committing a felony or an illegal occupation contributed may be excluded (3216(d)(2)(J)).
Advertising
Regulation 34 requires A&H advertising to be truthful and not misleading and to disclose exceptions, reductions and limitations that affect the advertised benefits (11 NYCRR 215).
Common exam traps
- Free look: 10 to 20 days for individual A&H in New York.
- Proof of loss: 120 days, not 90 (except 90 days after each period for periodic benefits).
- Insurer cancellation only in the first 90 days, on 10 days' notice.
- Nonrenewal notice in the grace provision: 30 days.
- Adopted newborns: custody at hospital release and a petition within 30 days of birth.
- Medical coverage misstatements must be intentional as well as material.
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Practice questions are study aids generated for exam preparation and are not actual exam questions. Content is provided for educational purposes and is not legal advice. Verify current statutes, rules, and exam specifications with the Insurance Department and the exam administrator before relying on it.
