Contact Person: Illinois Division of Insurance 320 West Washington Street
Cindy Colonius Review Requirements Checklist Springfield, IL 62767-0001
217-782-4572    
Cindy.Colonius@Illinois.gov

Effective 9/18/08
Line(s) of   Line(s) of  
Business   Insurance  

Individual Accident Only

  

Individual Accident Only Policies

  
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Word Document - Alteration of this document will result in rejection of the filing
Illinois Insurance Code Link Illinois Compiled Statutes Online
Illinois Administrative Code Link Administrative Regulations Online
Product Coding Matrix Product Coding Matrix
REVIEW REQUIREMENTS REFERENCE

DESCRIPTION OF REVIEW

STANDARDS REQUIREMENTS

 LOCATION OF STANDARD IN FILING
    NOTE: These brief summaries do not include all requirements of all laws, regulations, bulletins, or requirements, so review actual law, regulation, bulletin, or requirement for details to ensure that forms are fully compliant before filing with the Department of Insurance.  
FORM FILING REQUIREMENTS  REFERENCE DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS LOCATION OF STANDARD IN FILING
Uniform Transmittal Document (Etrans) 50 IL Adm. Code 916 Form filings must now be submitted either by SERFF or CD-ROM. Please visit the Division's web site for the Universal Transmittal Document (Etrans) by clicking this link.
Scroll down to "Universal Transmittal Document Software (Etrans)"		  
Outline of Coverage 50 IL Adm. Code 2007.80b) An Outline of Coverage must be submitted with a uniform transmittal document and contain a unique filing number.  
Review Requirements Checklist Go to Review Requirements Checklists on DOI web site. See next column

Each filing must include a completed Review Requirements Checklist that must contain a completed “Location of Standard in Filing” column for each required element of the filing. Please indicate the proper page # and form # for each entry.

 
Cover Letter and Letter of Submission

50 IL Adm. Code 1405.20 (e)
50 IL Adm. Code 2001.30 (a) (3)

50 IL Adm. Code 916.40 (b)

In addition to referencing any previously approved form number(s) as required by 50 IL Adm. Code 1405.20(e), those references must also include the filing number and SERFF tracking number (if applicable and available) for the referenced forms.

Letters of submission must generally describe the intent and use of the form being filed and, if applicable, how it will be used with any previously approved form(s).		  
Rates 215 ILCS 5/355 Rates must be submitted with a uniform transmittal document and contain a unique filing number.  
GENERAL REQUIREMENTS FOR ALL FILINGS REFERENCE DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS   
Accident and Health Required Provisions 215 ILCS 5/357.1 Each accident and health policy must contain the provisions contained in 3/357.2-3/357.13  
Form of Policy 215 ILCS 5/356a No policy of accident and health insurance may be delivered or issued for deliver to any person in this state unless it adheres to the provisions of this section.  
Entire Contract 215 ILCS 5/357.1
215 ILCS 5/357.2		 The policy, including the application and any amendments and riders, constitutes the entire contract of insurance and no change is valid unless approved by an executive officer of the company and unless such approval be endorsed hereon or attached hereto.  
Time Limit on Certain Defenses 215 ILCS 5/357.1
215 ILCS 5/357.3		 A policy is incontestable two years from the date of issue except for fraudulent misstatements made by the applicant on the application.  
Notice of Claim 215 ILCS 5/357.1
215 ILCS 5/357.6		 Written notice of claim should be submitted to the company within 20 days of the occurrence or commencement of any loss.  
Legal Action 215 ILCS 5/357.1
215 ILCS 5/357.12		 No such action shall be brought after 3 years from the date of due proof of loss is required to be furnished.  
Claim Forms 215 ILCS 5/357.1
215 ILCS 5/357.7		 The company shall furnish those forms needed to submit proofs of loss within 15 days.  
Payment of Claims 215 ILCS 5/357.1
215 ILCS 5/357.10		 Benefits may be assigned.  
Timely Payment of Claims 215 ILCS 5/357.1
215 ILCS 5/357.9		 Claims must be paid within 30 days following receipt of written due proof of loss.  
Grace Period 215 ILCS 5/357.1
215 ILCS 5/357.4		 A grace period of not less than 7 days (weekly premium), 10 days (monthly premium) and 31 days for all other policies is required.  
Proof of Loss 215 ILCS 5/357.1
215 ILCS 5/357.8		 Written proofs of loss should be submitted to the company within 90 days of loss.  
Physical Exam and Autopsy 215 ILCS 5/357.1
215 ILCS 5/357.11		 An insurer, at its own expense, has the right and opportunity to examine the insured when, and as often, as it may reasonably require during a claim's pending period. It may conduct an autopsy in the case of death where it is not forbidden by law.  
Change of Beneficiary 215 ILCS 5/357.1
215 ILCS 5/357.13		 The individual designating a beneficiary retains the right to change that designation unless he/she makes that designation irrevocable.  
Reinstatement 215 ILCS 5/357.1
215 ILCS 5/357.5		 A policy may be reinstated with or without an application as provided.  
Spousal Conversion 215 ILCS 5/356d Policies of accident and health must contain a conversion provision, made available without evidence of insurability, for dependent spouses upon a valid judgment of dissolution of the marriage if such application is made within 60 days following the date of judgment.  
Newborn Children 215 ILCS 5/356c The policy must state newborns are covered from the moment of birth. If additional premium is required the insurer may require notification within 31 days in order to have coverage continue.  
Pending & Adopted Children 215 ILCS 5/356h No policy that covers the insured's immediate family or children may exclude or limit coverage of an adopted child or a child not residing with the insured (foster child). A child residing with an insured pursuant to an interim court order of adoption is considered an adopted child.  
Disabled Dependents 215 ILCS 5/356b If a policy contains a provision for a limiting age for dependents, that provision will not be applicable to a handicapping condition that occurred before the attainment of the limiting age. This provision is only applicable for expense incurred policies.  
Over 65 Notice Requirement 215 ILCS 5/363a(6)(d) The outline of coverage requirement for individuals eligible for Medicare must contain the required notice on or attached to the first page of the outline of coverage.  
REQUIREMENTS RELATING TO POLICY FORM REVIEW      
Emergency Coverage Under the Influence of Alcohol or Narcotics 215 ILCS 5/367k No policy may exclude coverage for any emergency or other medical, hospital or surgical expenses incurred as a result of and related to an injury sustained while an insured is either intoxicated or under the influence of a narcotic, regardless of the conditions under which the substance is administered.  

Definition of Emergency Medical Condition

215 ILCS 5/155.36

215 ILCS 134/10

Insurers must use this definition that includes “prudent lay person” language.

  
Organ Transplant 215 ILCS 5/356k No accident and health insurer may deny reimbursement for an organ transplant as experimental or investigational unless supported by appropriate, required documentation.  
ADMINISTRATIVE CODE PROVISIONS      
Renewability 50 IL. Adm. Code 2007.80(a)(1) The renewal provision must appear on the first page of the policy.  
Pre-Existing Conditions 50 IL. Adm. Code 2005
50 IL. Adm. Code 2007.80(a)(5)		 The minimum definition for pre-existing condition is included within Rule 2005. A separate paragraph concerning pre-existing conditions limitations must be included in the contract that limits such conditions.  
Free Look 50 IL. Adm. Code 2007.80(a)(7)
215 ILCS 5/355a (5)(a)		 The policy must contain a 10-day free look provision.  
No Waiting or Probationary Period 50 IL Adm. Code 2007.60(a) Accident policies shall not contain a probationary or waiting period.  
Terms not Permitted 50 IL. Adm. Code 2007.50
50 IL Adm. Code 2001.20 h) 2)		 "External," "Violent," "Visible" or similar words of description or characterization are not allowed. The use of the term, "independent of all other causes" is ambiguous when used in the definition of injury and is not allowed.  
Allowable Exclusions 50 IL. Adm. Code 2007.60(e) No policy may limit or exclude coverage by type of illness, accident, treatment or medical condition except as provided.  
Required Statement Regarding Accident Only Policy 50 IL Adm. Code 2007.80(a)(6) Policies must contain the following statement on the face page: "THIS IS AN ACCIDENT ONLY POLICY AND IT DOES NOT PAY BENEFITS FOR LOSS FROM SICKNESS."  
Accident Only Benefit Requirement 50 IL Adm. Code 2007.70(b)(7) Accidental death and double dismemberment amounts under such policy shall be at least $1,000.00 and a single dismemberment shall be at least $500.00.  
Discrimination 50 IL. Adm. Code 2603 Provides guidelines on unfair discrimination based on sex, sexual preference or marital status.  
Right of Reimbursement and Subrogation 50 IL Adm Code 2020 Provides guidelines for reimbursement and subrogation rights due to negligence of a third party.  
Cash Value Rider Not Permitted 50 IL Adm. Code 2007.60(c) The Rule only allows cash value riders for disability, hospital indemnity and specified disease policies.  
OPTIONAL PROVISIONS      
Change of Occupation 215 ILCS 5/357.15 An insured who is injured or becomes sick after having changed occupations to one classified as either more or less hazardous, will have a suitable premium adjustment made as provided.  
Misstatement of Age 215 ILCS 5/357.16 If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age.  
Other Insurance in Company 215 ILCS 5/357.17 Excess coverage protection provisions.  
Insurance with Other Companies 215 ILCS 5/357.18 Excess coverage protection provisions for insurance with other companies for expense incurred type policies.  
Insurance with Other Companies 215 ILCS 5/357.19 Excess coverage protection provisions for insurance with other companies for indemnity type policies.  
Unpaid Premium 215 ILCS 5/357.21 Upon the payment of a claim under the policy, any premium then due and unpaid or covered by any note or written order may be deducted.  
Cancellation 215 ILCS 5/357.22 Cancellation provisions with prior notification requirements. Subject to HIPAA requirements.  
Disclosure of Conformity with State Statutes 215 ILCS 5/357.23 Any provision of the policy, which, on its effective date, is in conflict with the statutes of the state in which the insured resides on such date, is hereby amended to conform to the minimum requirements of such statutes.  
Illegal Occupation 215 ILCS 5/357.24 An insurer shall not be liable for any loss to which a contributing cause was the insured's commission of or attempt to commit a felony or to which a contributing cause was the insured's being engaged in an illegal occupation.  
Pro-rata Refund 215 ILCS 5/357.31 Insurers must provide pro-rata refunds of premium upon receipt of proper notification of insured's death. Refund may not be based on short-rate table.  
GENERAL INFORMATION
Discretionary Authority 215ILCS 5/143(1)
50 IL Adm. Code 2001.3		 Insurers are not permitted to place discretionary authority language in contracts of accident and health.  
Use of SSN on ID Cards

815 ILCS 505 2QQ

215 ILCS 138/15

The focus of HB 4712 is on any card required for an individual to access products or services, while SB 2545 is more limited in that it just focuses on insurance cards.

HB 4712 prevents a person from:

· Publicly posting or displaying an individual's SSN;

· Printing an individual's SSN on any card required for the individual to access products or services, however, an entity providing an insurance card must print on the card a unique identification number as required by 215 ILCS 138/15.

· Being required to transmit an SSN over the Internet to access a web site unless the connection is secure or the SSN is encrypted;

· Requiring the individual to use his/her SSN to access a web site unless a PIN number or other authentication device is also used; and,

· Printing an individual's SSN on any materials mailed to an individual unless required by state or federal law.

Insurers are required to comply with both provisions.

 
DEPARTMENT POSITIONS      
Term in Definition of Injury 215 ILCS 5/143(1) The term, "of all other causes" is considered ambiguous when used in the definition of injury.  
Felonious Assault 215 ILCS 5/143(1) The policy may contain a Felonious Assault provision but the following language is prohibited, "Felonious Assault inflicted by persons other than fellow employees or members of the insured's family or household." An assault can be committed by an immediate family member or fellow employee that would constitute a willful and unlawful use of force and is considered a felony or misdemeanor in most jurisdictions in the United States.  
Prohibited Language 215 ILCS 5/143(1) The following language is prohibited in a this policy, "The Assault must not be either a moving violation as defined under the applicable state or motor vehicle laws." A motor vehicle can be used to cause an assault and therefore, may entail a moving violation. As long as language is clear and does not contain language as stated above, this benefit is allowed.  
Prohibited Benefits 215 ILCS 5/143(1) Educational benefits, spousal training benefits, child day care benefits and other such types of benefits may be approved only after receipt of the company's reserving standards for these benefits. In addition, you must furnish us with actuarial data that these benefits are reasonable in relation to the premium charged.  
HIV/AIDS Questions on Application 215 ILCS 5/143(1)
Questions designed to elicit information regarding AIDS, ARC and HIV must be specifically related to the testing, diagnosis or treatment done by a physician or an appropriately licensed clinical professional acting within the scope of his/her license.