| 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 05/15/09 |
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| Line(s) of | Line(s) of | |||
| Business | Insurance | |||
Specified Disease, Cancer, Dread Disease Insurance |
Individual Indemnity, per diem or principal sum policies for specific disease, cancer or other dread diseases policies |
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| Click here for interactive version of this document to be down loaded and submitted with this filing | Word Document - Alteration of this document will result in rejection of the filing |
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| 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 REVIEWSTANDARDS 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)" |
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| 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. |
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| Cover Letter and Letter of Submission | 50 IL Adm. Code 1405.20 (e) |
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). |
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| 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. | |
| 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 | |
| Entire Contract | 215 ILCS 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 5/357.3 | 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 5/357.6 | 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 5/357.12 | 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 5/357.7 | The company shall furnish those forms needed to submit proof of loss within 15 days. | |
| Payment of Claims | 215 ILCS 5/357.10 | Benefits may be assigned. Insurers may provide incentives to insureds to utilize services of a particular hospital or provider. | |
| Timely Payment of Claims | 215 ILCS 5/357.9 | Claims must be paid within 30 days following receipt of written due proof of loss. | |
| Timely Payment of Health Care Services | 215 ILCS 5/368a |
Periodic payments must be made within 60 days of insured's selection of a provider or effective date of selection, whichever is later. In case of retrospective enrollment only 30 days after notice by employer to insurer. Subsequent payments must be in monthly periodic cycle. Penalty payment of 9% per year. Payments other than periodic must be made within 30 days after receipt of due proof of loss. Same penalty provisions. |
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| Grace Period | 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 5/357.8 | Written proofs of loss should be submitted to the company within 90 days of loss. | |
| Physical examinations and autopsy | 215 ILCS 5/357.11 | Insurers, at their own expense, have the right and opportunity to examine the insured when, and as reasonably often as required, during a claim's pending period. It may also conduct an autopsy in the case of death when law does not forbid it. | |
| Change of Beneficiary | 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 5/357.5 | 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 Coverage | 215 ILCS 5/356c | The policy must state newborns covered from the moment of birth. If additional premium is required 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 | |||
| Mammography | 215 ILCS 5/356g(a) | Coverage of screening by low-dose mammography
for all women over 35;
Coverage requires baseline mammogram
for women 35-39 and annual mammogram for women 40 years of age and older.
Coverage includes a comprehensive ultrasound screening of an entire breast or breasts when a mammogram demonstrates medical necessity as described. Coverage must be provided at no cost to the insured and shall not be applied to an annual or lifetime maximum benefit. When coverage is available through contracted providers and such a provider is not utilized, plan provisions specific to the use of those non-contracted providers must be applied without distinction to the coverage required and shall be at least as favorable as for other radiological examinations covered by the policy or contract.
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| Clinical Breast Exam | 215 ILCS 5/356g.5 | Clinical breast examinations must be covered: (1) at a minimum every three years for women over 20 years of age but less than 40; and,
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| Reconstructive breast surgery | 215 ILCS 5/356g(b) 50 IL Adm. Code 2016 |
Coverage requires: reconstruction of breast upon which mastectomy performed; surgery and reconstruction of the other breast to produce a symmetrical appearance and prostheses and treatment for physical complications at all stages of mastectomy, including lymphdemas. | |
| Breast Cancer Pain Medication and Therapy | 215 ILCS 5/356g.5-1 | Coverage must include all medically necessary pain medication and pain therapy related to the treatment of breast cancer under the same terms and condition applicable to treatment of other conditions. The term “pain therapy” is defined. | |
| Post Mastectomy Care | 215 ILCS 5/356t | Coverage must provide inpatient treatment following mastectomy for length of time to be determined by attending physician; must also provide for availability of post-discharge physician office visit or in-home nurse visit within 48 hours of discharge. | |
| Colorectal cancer screening | 215 ILCS 5/356x | Must cover all colorectal cancer exams and lab tests for colorectal cancer as prescribed by a physician according to stated guidelines; may not impose greater copays, ded or waiting periods. | |
| Prescription Inhalants | 215 ILCS 5/356z.4 | If policy provides RX coverage it may not deny or limit coverage for prescription inhalants when diagnosis is asthma or other life-threatening bronchial ailments; additional guidelines provided. | |
| Bone Mass Measurement/Osteoporosis | 215 ILCS 5/356z.6 | Coverage must include medically necessary bone mass measurement and diagnosis and treatment of osteoporosis the same as any other illness. | |
| ADMINISTRATIVE CODE PROVISIONS | |||
| Minimum Standards | 50 IL. Adm. Code 2007.70 b) 8) | Specified disease coverage policies will meet the minimum standards of 50 IL Adm. Code 2007.70(b)(8)(B)(C) or (D) as applicable. | |
| Renewability | 50 IL. Adm. Code 2007.70
b) 8) A) v) 50 IL. Adm. Code 2007.80 a) 1) |
Policies for specified disease coverage must be at least guaranteed renewable. The renewal provision must appear on the first page of the policy. |
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| Pre-Existing Conditions | 50 IL. Adm. Code 2005 50 IL Adm. 2007.70(b)(1)(I) 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. | |
| Replacement Question | 50 IL Adm. Code 2007.90a) | The application must contain a replacement question designed to elicit information concerning whether the policy will replace any existing accident and health coverage. | |
| 30-Day Waiting Period | 50 IL Adm. Code 2007.70 b) 8) A) vi) | No specified disease policy shall contain a waiting or probationary period greater than 30 days. | |
| Return of Premium | 50 IL. Adm. Code 2007.60(c)(1-8) | The provision is allowed in disability, hospital confinement or specified disease under certain conditions. | |
| Prominent Statement Requirement | 50 IL. Adm. Code 2007.80 a) 10) | All specified disease policies must contain the notice required by this provision. "This is a limited policy. Read it carefully." | |
| Acceptable Clinical Diagnosis | 50 IL Adm. Code 2007.70 b) 8) A) iii) | Any policy that requires a pathological diagnosis to confirm proof of loss must provide that if the pathological diagnosis is inappropriate a clinical diagnosis will suffice instead. | |
| Coverage for Other Clinical Diagnosis Required | 50 IL. Adm. Code 2007.70 b) 8) A) iv) | Specified disease policies must provide benefits for any other condition or disease directly caused or aggravated by the specified disease or the treatment of such disease. | |
| Other Coverage | 50 IL. Adm. Code 2007.70 b) 8) A) viii) | Coverage for specified disease must be paid regardless of other individual coverage available. | |
| First Day Coverage | 50 IL. Adm. Code 2007.70 b) 8) A) ix) | After the waiting period, coverage must be from the first day of medical care or confinement. | |
| Prohibited Penalty Due to Death | 50 IL. Adm. Code 2007.70 b) 8) A) ix) | Coverage must begin the first day of medical care or hospital confinement. If the diagnosis is made after the date of death the insurer may not use a time limit provision within the policy to deny benefits. | |
| Skin Cancer Benefits | 50 IL.
Adm. Code 2007.70 b) 8) A) x) 215 ILCS 5/143(1) |
Skin cancer benefits may not be limited in a cancer policy as that condition is a risk purported to be assumed within the policy, itself. | |
| INDEMNITY BENEFITS | |||
| Hospital Benefit | 50 IL Adm. Code 2007.70 b) 8) D) i | The fixed sum hospital payment must be at least $100/day for 365 days. | |
| Surgery, Chemotherapy and Radiation Therapy | 50 IL Adm. Code 2007.70 b) 8) D) ii) | There must be a fixed sum payment equal to one-half of the hospital in-patient benefit for each day of hospital or non-hospital outpatient surgery, chemotherapy and radiation therapy for at least 365 days of treatment. | |
| Optional Benefits tied to a confinement in a skilled nursing home or to receipt of home health care | 50 IL Adm. Code 2007.70 b) 8) D) iii) | There must be a fixed sum payment equal to one-fourth the hospital inpatient benefit for each day of skilled nursing home care for at least 100 days (approximately $25/day or $2,500 maximum benefit). The benefit for home health care is identical. Benefits may be no more restrictive than those under Medicare. | |
| NON-CANCER COVERAGE EXPENSE INCURRED BENEFITS | |||
| Coverage for a Specifically Named Disease or Diseases | 50 IL Adm. Code 2007.70 b) 8) B) | Benefits are based on an expense incurred basis for a specifically named disease or diseases with a deductible not in excess of $250, and an overall aggregate per person limit of not less than $10,000 per two year benefit period. | |
| Hospital Room & Board | 50 IL Adm. Code 2007.70 b) 8) B) i | See Requirements above for Non-Cancer Benefit | |
| Treatment by a Legally Qualified Physician or Surgeon | 50 IL Adm. Code 2007.70 b) 8) B) ii) | See Requirements above for Non-Cancer Benefit | |
| Private Duty Nurse | 50 IL Adm. Code 2007.70 b) 8) B) iii) | See Requirements above for Non-Cancer Benefit | |
| X-ray, Radium, Cobalt, Nuclear Medicine and Therapeutic Procedures Used in Diagnosis and Treatment | 50 IL Adm. Code 2007.70 b) 8) B) iv) | See Requirements above for Non-Cancer Benefit | |
| Ambulance | 50 IL Adm. Code 2007.70 b) 8) B) v) | See Requirements above for Non-Cancer Benefit | |
| Blood Transfusions | 50 IL Adm. Code 2007.70 b) 8) B) vi) | See Requirements above for Non-Cancer Benefit | |
| Prescription Medications | 50 IL Adm. Code 2007.70 b) 8) B) vii) | See Requirements above for Non-Cancer Benefit | |
| Durable Medical Equipment | 50 IL Adm. Code 2007.70 b) 8) B) viii) | See Requirements above for Non-Cancer Benefit | |
| Medically Necessary Braces, Crutches, and Wheel Chairs | 50 IL Adm. Code 2007.70 b) 8) B) ix) | See Requirements above for Non-Cancer Benefit | |
| Emergency Transportation | 50 IL Adm. Code 2007.70 b) 8) x) | See Requirements above for Non-Cancer Benefit | |
| Other Necessary Incurred Expenses | 50 IL Adm. Code 2007.70 b) 8) B) xi) | See Requirements above for Non-Cancer Benefit | |
| CANCER-ONLY EXPENSE INCURRED BENEFITS | |||
| Cancer-only or in Combination with One or More Specified Diseases | 50 IL. Adm. Code 2007.70 b) 8) C) | Benefits are based on an expense incurred basis, not in excess of reasonable and customary with a deductible not in excess of $250, and an overall aggregate per person limit of not less than $10,000 per person per two year benefit period. | |
| Treatment by a Legally Qualified Physician or Surgeon | 50 IL Adm. Code 2007.70 b) 8) C) i | See Requirements above for Cancer-only Benefit | |
| X-ray, Radium, Cobalt, Nuclear Medicine and Therapeutic Procedures Used in Diagnosis and Treatment | 50 IL Adm. Code 2007.70 b) 8) C) ii) | See Requirements above for Cancer-only Benefit | |
| Hospital Room & Board | 50 IL. Adm. Code 2007.70 b) 8) C) iii) | See Requirements above for Cancer-only Benefit | |
| Blood Transfusions | 50 IL. Adm. Code 2007.70 b) 8) C) iv) | See Requirements above for Cancer-only Benefit | |
| Prescription Medications | 50 IL. Adm. Code 2007.70 b) 8) C) v) | See Requirements above for Cancer-only Benefit | |
| Ambulance | 50 IL. Adm. Code 2007.70 b) 8) C) vi) | See Requirements above for Cancer-only Benefit | |
| Private Duty Nurses | 50 IL. Adm. Code 2007.70 b) 8) C) vii) | See Requirements above for Cancer-only Benefit | |
| Other Necessary Incurred Expenses | 50 IL. Adm. Code 2007.70 b) 8) C) viii) | This benefit is to include coverage of any other expenses necessarily incurred in the treatment of the disease; however, items (i), (ii), (iv), (v), and (vi) plus the remaining six items (below) in this category are to be included, but may be subject to copayments not to exceed 20% of covered charges when rendered on an outpatient basis. | |
| Medically Necessary Braces, Crutches, and Wheel Chairs | 50 IL. Adm. Code 2007.70 b) 8) C) ix) | See Requirements Above for Other Necessary Incurred Expenses | |
| Emergency Transportation | 50 IL. Adm. Code 2007.70 b) 8) C) x) | See Requirements Above for Other Necessary Incurred Expenses | |
| Home Health Care | 50 IL. Adm. Code 2007.70 b) 8) C) XI) | See Requirements Above for Other Necessary Incurred Expenses | |
| Physical, Speech, Hearing and Occupational Therapy | 50 IL. Adm. Code 2007.70 b) 8) C) xii) | See Requirements Above for Other Necessary Incurred Expenses | |
| Special Equipment | 50 IL. Adm. Code 2007.70 b) 8) C) xiii) | See Requirements Above for Other Necessary Incurred Expenses | |
| Reconstructive Surgery | 50 IL. Adm. Code 2007.70 b) 8) C) xiv) | See Requirements Above for Other Necessary Incurred Expenses | |
| Prosthetics | 50 IL. Adm. Code 2007.70 b) 8) C) xv) | See Requirements Above for Other Necessary Incurred Expenses | |
| Nursing Home Care for Non-Custodial Services | 50 IL. Adm. Code 2007.70 b) 8) C) xvi) | See Requirements Above for Other Necessary Incurred Expenses | |
| 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. | |
| 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. | |
| 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 | 215 ILCS 5/143(1) 50 IL Adm. Code 2001.3 |
Insurers are not permitted to place discretionary authority language in contracts of accident and health. | |
| DEPARTMENT POSITIONS | |||
| Prohibition on Pre-existing Conditions | 50 IL.
Adm. Code 2007.70 b) 8) A) ix) 215 ILCS 5/143(1) |
First diagnosis or lump sum benefit policies cannot use pre-existing condition language or "manifest" language. Such language would be ambiguous and misleading. | |
| 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. |
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| Precertification Penalties | 215 ILCS 5/143(1) | The Division will permit a failure to precertify a hospital admission penalty of the lesser of up to $1,000 or 50% of the billed charge. The penalty may be no more frequent than a per confinement basis. |