North Carolina Department of Insurance
Life Health Division Checklists
COMPANY NAME: Rev. 11/04/09
NAIC Code (#####):
Lead Form #:
REVIEW
REQUIREMENTS REFERENCE COMMENTS REFERENCE
Please specify location
(Form/Page/Paragraph/Other) of
TYPE of FILING: CANCER complying provision/language or attach
explanation for an N/A response. If the
cell contains X's - then the issue is FYI.
ITEMS RELATED TO NEW LEGISLATION OR RECENTLY AMENDED ARE SHOWN IN BLUE.
FORMS
Must include on the cover, first or insert page a statement that the policy (certificate)
is a legal contract between the policy owner and the insurer and the statement,
NCGS 58-38-20
printed in larger or other contrasting type or color, "READ YOUR POLICY
(CERTIFICATE) CAREFULLY."
An index (table of contents) of major provisions in the certificate and policy is
NCGS 58-38-20(2)
required.
Provides the requirements for coverage for newborn infants, foster children, children
covered due to a court or an administrative order, and adoptive children. The
general statutes also requires the coverage of congenital defects or anomalies for
this specific group of children. For NCGS 58-51-30 and 58-51-125, children must be
covered from the moment of birth or date of placement if NO additional premiums
NCGS 58-51-30,
are required. If additional premiums are required to enroll the children, the member
58-51-120, and 58-
must pay the required premium by the stated enrollment period to avoid the
51-125
application of a late enrollee provision; such as non-coverage of pre-existing
condition. For NCGS 58-51-120, the enrollment period is waived when a parent is
required to enroll a child due to an administrative or a court order. Also, the section
prohibits the contract from requiring the child be claimed as dependent on federal
income tax return or requiring the child reside with the parent.
Provides for enrollment of a child because a parent is required by a court or
administrative order to provide health benefit plan cover for a child. The enrollment
period is waived when a parent is required to enroll a child due to an administrative
NCGS 58-51-120
or a court order. The section also prohibits the contract from requiring the child be
claimed as dependent on federal income tax return or requiring the child reside with
the parent.
Page 1
North Carolina Department of Insurance
Life Health Division Checklists
REVIEW
REQUIREMENTS REFERENCE COMMENTS REFERENCE
Please specify location
(Form/Page/Paragraph/Other) of
TYPE of FILING: CANCER complying provision/language or attach
explanation for an N/A response. If the
cell contains X's - then the issue is FYI.
Adopted children shall be treated as newborn infants from the moment of placement
NCGS 58-51-125 in the adoptive home regardless of whether or not a final decree of adoption has
become final.
NCGS 58-51-
An Entire Contract/Changes provision must be included in policy/certificate,
15(a)(1)
A Time Limit on Certain Defenses provision must be included in policy/certificate.
NCGS 58-51-
Fraudulent misstatments may not be contested in an accident only policy/certificate
15(a)(2)
after the coverage has been in force for more than two (2) years.
Fraudulent misstatements may not be used as a basis for contesting the master
policies or any certificate thereunder after coverage has been in force for more than
NCGS 58-51- two (2) years. Note that NCGS 58-51-15(a)(2)(a), permits the inclusion of a
15(a)(2)(a) provision for contesting a policy based upon fraudulent misstatements only in certain
major medical, catastrophic hospitalization, disability income policies and franchise
policies
NCGS 58-51-
A Grace Period provision must be included in policy/certificate.
15(a)(3)
NCGS 58-51-
A Reinstatement provision must be included in polic/certificate.
15(a)(4)
NCGS 58-51-
A Notice of Claim provision must be included in policy/certificate.
15(a)(5)
NCGS 58-51-
A Claim forms provision must be included in policy/certificate
15(a)(6)
NCGS 58-51- A Proofs of Loss provision must be included in the policy and certificate. Note that
15(a)(7) the time period for submitting proof of loss is 180 days.
NCGS 58-51-
A Time of Payment of Claims provision must be included in policy/certificate.
15(a)(8)
NCGS 58-51-
A Payment of Claims provision must be included in policy/certificate.
15(a)(9)
NCGS 58-51- A Physical Examinations and Autopsy provision must be included in
15(a)(10) policy/certificate.
NCGS 58-51-
A Legal Actions provision must be included in policy/certificate.
15(a)(11)
Page 2
North Carolina Department of Insurance
Life Health Division Checklists
REVIEW
REQUIREMENTS REFERENCE COMMENTS REFERENCE
Please specify location
(Form/Page/Paragraph/Other) of
TYPE of FILING: CANCER complying provision/language or attach
explanation for an N/A response. If the
cell contains X's - then the issue is FYI.
NCGS 58-51-
A Change in Beneficiary provision must be included in policy/certificate.
15(a)(12)
The standard contractual provisions required by NCGS 58-51-15(a) and (b), or any
provisions used in lieu thereof, shall be printed in the consecutive order specified in
NCGS 58-51-15(d) the statute, or as a unit provided that the resulting policy shall not be in whole or in
part unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to
whom the policy offered, delivered or issued.
Effective October 1, 2009, pursuant to G.S. 58-51-15(i) as adopted in House Bill
1183, all certificates of coverage issued under group policies that are delivered
or issued for delivery in this State shall include the appropriate standard
NCGS 58-51-15(i)
provisions as outlined in G.S. 58-51-15. This includes certificates of coverage
issued under policies issued and delivered to a trust or association outside of
this State that cover persons in this State.
A foster child shall be treated the same as newborn infants and eligible for coverage
NCGS 58-51-30
on the same basis upon placement in the foster home.
T11 NCAC
A pre-existing cautionary notice must appear on the face page.
12.0543
T11 NCAC Requires insurer to accept a clinical diagnosis of cancer if a positive diagnosis
12.0546 cannot otherwise be made without jeopardizing the life of the claimant
Pre-existing condition notification must comply with T11 NCAC 12.0543 and read as
T11 NCAC follows: NO RECOVERY FOR PRE-EXISTING DIAGNOSED CANCER ---- READ
12.0551(1) CAREFULLY No benefits will be provided during the first 12 months of the policy for
cancer diagnosed before the 30th day after the effective date shown in the schedule.
T11 NCAC The definition of cancer must include clinical diagnosis as well as postmortem
12.0551(2) diagnosis.
T11 NCAC A cancer policy may not have a waiting period any longer than 30 days from the
12.0551(3) effective date.
T11 NCAC
Benefits must be provided for unrelated cancers diagnosed after the effective date.
12.0551(4)
T11 NCAC
Cancellation disclosure is required on the face page of the policy and certificate
12.0557
Page 3
North Carolina Department of Insurance
Life Health Division Checklists
REVIEW
REQUIREMENTS REFERENCE COMMENTS REFERENCE
Please specify location
(Form/Page/Paragraph/Other) of
TYPE of FILING: CANCER complying provision/language or attach
explanation for an N/A response. If the
cell contains X's - then the issue is FYI.
T11 NCAC A refund of unearned premium must be made in the event of death or at the
12.0562 insured's request to discontinue coverage. Applies to individual policies only.
Policies and certificates issued for delivery to persons eligible for Medicare must
contain a notice printed or attached to the first page of the outline of coverage
delivered to insureds under the policy; or if no outline of coverage is delivered, to the
T11 NCAC first page of the policy or certificate. The notice shall be in no less than 12 point type
12.0824(d) and shall contain the following language: "THIS [POLICY OR CERTIFICATE] IS
NOT A MEDICARE SUPPLEMENT [POLICY OR CERTIFICATE]. If you are eligible
for Medicare, review the Guide to Health Insurance for People with Medicare, which
is available from the company."
GENERAL INFORMATION ABOUT FORMS
NCGS 58-38-
A certified Flesch Scale readability analysis and test score of at least 50 is required. XXXXX
30(b)(1)
The filing letter must include a unique identifying form number of each form
T11 NCAC
submitted and it's descriptive title. A properly completed NAIC Adopted Uniform XXXXX
12.0329(1)(d)
Transmittal Document will be accepted in lieu of a filing letter.
T11 NCAC All forms must be identified by a form number in the lower left-hand corner of the first
XXXXX
12.0329(3)(d) page.
Alll variable text and benefit ranges in a form shall be identified by the use of
T11 NCAC
brackets. An explanation of the limits and extent of variability for each bracketed XXXXX
12.0329(3)(a)
area must be included
T11 NCAC Rates must be filed by age and mode of payment accompanied by an Actuarial
XXXXX
12.0329(3)(c) Memorandum for each form requiring a premium.
A red-line comparison shall be provided with the initial submission of a form that is a
T11 NCAC revision of a previously approved form. The submission shall include a signed
XXXXX
12.0329(3)(g) statement by an Officer of the Company certifying that no other changes, other than
those red-lined, were made to the form(s).
T11 NCAC If an application, rider or endorsement is filed separately, the policy form(s) with
XXXXX
12.0329(3)(b) which the submitted form is to be used must be identified.
Prohibits the use of a term more restrictive than "first manifested" in determining
T11 NCAC when a disease or sickness begins. Also, the referenced rule prohibits your use of
XXXXX
12.0317 the term "prudent person" as a condition to establish when a disease or sickness
begins.
Page 4
North Carolina Department of Insurance
Life Health Division Checklists
REVIEW
REQUIREMENTS REFERENCE COMMENTS REFERENCE
Please specify location
(Form/Page/Paragraph/Other) of
TYPE of FILING: CANCER complying provision/language or attach
explanation for an N/A response. If the
cell contains X's - then the issue is FYI.
T11 NCAC
Prohibits subrogation in all health insurance policy forms. XXXXX
12.0319
Applications that contain the Acronyms AIDS or HIV must also contain a definition
T11 NCAC
of such abbreviations. The Life and Health Division will accept as a valid definition XXXXX
12.0324
the full and proper phrase for which the acronym stands.
Pursuant to amendments to G.S. 58-56-26(c) as adopted in House Bill 1183, as
of July 1, 2010, all insurers who contract with third party administrators, as
NCGS 58-56-26(c) XXXXX
defined in G.S. 58-56-2(5) shall annually file with the Department a certification
of completion of the audits required by G.S. 58-56-26(c).
A health policy may limit or exclude benefits because the nature of the loss is due to
NCGS 58-51-16 the insured being under the influence of drugs or alcohol. DOES NOT APPLY TO XXXXX
MEDICAL EXPENSE POLICIES AS DEFINED IN SUBSECTION (c).
The notice relating to coverage under the NC Life & Health Guaranty
Association as required by G.S. 58-62-86 that was included in your submission
does appear to be consistent with the most recently approved notice as
NCGS 58-62-86 & included in Bulletin 09-B-03 issued October 16, 2009. You may access the
XXXXX
Bulletin 09-B-03 bulletin and the revised notice on the Department's website at:
http://www.ncdoi.com/LS/ls_bulletins.asp . Insurers must use the amended
notice with affected policies that are delivered on or after December 15, 2009
(60 days after approval of the notice).
RATES
Group rates shall be guaranteed for the first contract year and adjusted no more
NCGS 58-51-80(g) often than once every 6 months thereafter, based on at least 12 months of
experience. Any rate adjustment shall be preceded by a written 45 day notice.
All increases in rates must be guaranteed to a single policyholder for no less than 12
months by implementing the rate increase on the policy anniversary date. As an
NCGS 58-51-95(f) alternate, such approved rates may be applicable to all policyholders at one time if
the insurer chooses to apply for such relief with respect to such policies no more
frequently than once in a 12-month period.
Page 5
North Carolina Department of Insurance
Life Health Division Checklists
REVIEW
REQUIREMENTS REFERENCE COMMENTS REFERENCE
Please specify location
(Form/Page/Paragraph/Other) of
TYPE of FILING: CANCER complying provision/language or attach
explanation for an N/A response. If the
cell contains X's - then the issue is FYI.
GENERAL INFORMATION ABOUT RATES
The classification of the risks and the premiums rates must be filed with the
NCGS 58-51-95(a) XXXXX
Commissioner.
An actuarial statement that the benefits provided are reasonable in relation to the
NCGS 58-51-95(c) XXXXX
premiums charged must be included with all rates.
Increases in rates chargeable must be filed with and approved by the Commissioner
prior to the use of the rates in this State. Such rates must be found to be not
NCGS 58-51-95(f) XXXXX
excessive, not inadequate, and not unfairly discriminatory and exhibit a reasonable
relation to the benefits provided by such policies.
T11 NCAC Rates must be filed by age and mode of payment accompanied by an Actuarial
XXXXX
12.0329(3)(c) Memorandum for each form requiring a premium.
T11 NCAC
The guideline loss ratio shall be as promulgated by the NAIC. XXXXX
16.0201
Contains the data requirements for rate revision submissions. All information must
T11 NCAC
be submitted within 45 days of the Department's receipt of the rate revision or the XXXXX
16.0205
filing will be closed.
T11 NCAC Establishment of a class within a policy form or group of policy forms for rate revision
XXXXX
16.0206 purposes so as to eliminate the possibility of new entrants into the class is prohibited
APPLICATIONS
T11 NCAC Insurer may not discriminate based on sex in any manner on a life or accident and
12.0304 health insurance application.
Prohibits the use of any provision in any accident or health insurance form which
T11 NCAC allows for subrogation of benefits. No-fault vehicle is viewed as subrogation in North
12.0319 Carolina. Furthermore, no offset from a third party liability carrier may reduce
benefits payable under the policy.
Applications that contain the Acronyms AIDS or HIV must also contain a definition
T11 NCAC
of such abbreviations. The Life and Health Division will accept as a valid definition
12.0324
the full and proper phrase for which the acronym stands.
Applications for individual life, and accident or health insurance and annuities
T11 NCAC
intended to insure North Carolina residents shall, except in case of direct response
12.0326(a)
business, be signed by a North Carolina licensed agent.
T11 NCAC Insurance applications shall not include questions relating to an applicant's
12.0326(b) membership in substance or chemical dependency support groups.
Page 6
North Carolina Department of Insurance
Life Health Division Checklists
REVIEW
REQUIREMENTS REFERENCE COMMENTS REFERENCE
Please specify location
(Form/Page/Paragraph/Other) of
TYPE of FILING: CANCER complying provision/language or attach
explanation for an N/A response. If the
cell contains X's - then the issue is FYI.
Applications used in solicitation for Accident and Health insurance on a mass
T11 NCAC
marketing basis may not require information on pre-existing conditions dating back
12.0506
more than 5 years prior to date of the application.
Any application or enrollment form that is taken by an agent shall contain a
NCGS 58-50-5 certificate of the agent that he has truly and accurately recorded on the application or
enrollment form the information supplied by the insured.
A detailed reason or explanation as to why a requirement is not
applicable must be provided on a separate page for those
requirements referenced by N/A
I, the filer, acknowledge that I have prepared the submitted form(s) in
accordance with the checklist and to the best of my knowledge this file
is in substantial compliance with all of the above listed reference
point’s.
Signature of Filer Date
The Life and Health Division checklist is intended to expedite the Departments overall review time of new
form filings. The checklist serves as a basic guide to assist the Industry in preparation of new form filings
prior to submission. The checklist is not a substitute for Departmental review. All forms must comply with
State Insurance Law.
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