New York Individual Health Insurance Policy Provisions

Entire Contract; Changes

This policy including endorsements and attached papers constitutes the entire contract. No change is valid until approved by an executive officer of the insurer and attached as an endorsement. Agents and brokers cannot change policies or waive provisions.

Time Limit on Certain Defenses

Two years from the date of issue no misstatements except fraudulent misstatements made by the insured on the application may be used to void the policy or deny a claim for loss incurred or disability.

Grace Period (Weekly Premium)

Must be not less than 7 days.

Grace Period (Monthly Premium)

Must be not less than 10 days.

Grace Period (All Other Policies)

Must be not less than 31 days.

Reinstatement Timeline

A policy is automatically reinstated on the 45th day following the issuance of a conditional receipt if a new application was required.

Reinstatement Accident Coverage

Covers only losses resulting from accidental injury sustained after the date of reinstatement.

Reinstatement Sickness Coverage

Covers loss due to sickness beginning 10 days after the date of reinstatement.

Coordination of Benefits (COB)

The process insurers use to determine the primary vs. secondary order of payment when a patient is covered by more than one health plan. Total reimbursement cannot exceed 100% of the claim.

COB: Employee vs. Dependent

The plan covering the patient as an employee is primary over a plan covering them as a dependent.

COB: Children of Divorced Parents

The plan of the parent with custody is primary. The step-parent's plan is secondary. The non-custodial parent's plan pays third.

COB: Active vs. Inactive

Active employee plans are generally primary over retiree or laid-off plans.

Insurance with Other Insurers

If valid coverage exists with another insurer without prior written notice to the current insurer, the current insurer is only responsible for the amount of loss they would have covered if they had knowledge.

Unpaid Premium

Insurers in New York are permitted to deduct any premium amount that has remained unpaid by the insured from any claim payment due.

Cancellation (Under 90 Days)

The insurer may cancel the policy for any reason with a 10-day notice to the insured and will return unearned premium on a pro-rata basis.

Conformity with State Statutes

Any policy provision in conflict with the laws of the state where the insured resides is automatically amended to conform to the minimum requirements of state statutes.

Illegal Occupation Exclusion

The insurer is not liable for any loss if a contributing factor was the insured's commission or attempted commission of a felony or engaging in an illegal occupation.

Intoxicants and Narcotics Exclusion

The insurer is not liable for any loss sustained while the insured was intoxicated or under the influence of any narcotic unless administered on the advice of a physician.

Renewability Rule

No New York insurer may refuse to renew hospital, surgical, or medical expense policies unless there is nonpayment, fraud, class discontinuance, market exit, or moving out of the service area.

Insuring Clause

Found on the first page of a health policy; explains conditions under which benefits will be paid and identifies the insurer and the insured.

Free Look (Right to Return)

All health policies must allow the policyholder 10 days after delivery to return the policy for a full refund if not satisfied for any reason.

Consideration Clause

Requires a premium (valuable consideration) to be submitted with the application to create a valid contract; lists premium amount, frequency, effective date, and initial term.

Prospective Review Timeline

The carrier must notify the insured regarding a preauthorization request as soon as possible but never later than 15 days after the request. Adverse determinations must include reasons.

Concurrent Review

Occurs when a previously certified procedure experiences a reduction in benefits; considered an adverse determination and notice must be given to allow time for a grievance.

Retrospective Review Timeline

The reviewer must make a determination within 30 days of receiving the claim. A reason for denial must accompany the notice if an adverse determination is made.