Guidelines for Group and Individual Accident Only Policies (Please refer to HC-63 for rescission information)

[LOGO] STATE OF CONNECTICUT INSURANCE DEPARTMENT Bulletin HC-62 December 29, 2004 TO: ALL HEALTH CARE CENTERS AND INSURERS LICENSED TO WRITE ACCIDENT AND HEALTH INSURANCE RE: GUIDELINES FOR GROUP AND INDIVIDUAL ACCIDENT ONLY POLICIES The purpose of this bulletin is to provide guidance to carriers regarding allowable benefits for accident only health insurance. Section 505-9(G) of the Connecticut Regulations defines accident only coverage as a "policy of accident insurance that provides coverage, singly or in combination, for death, dismemberment, disability, or hospital and medical care caused by accident." Allowable benefits must be related to the accident and the injured insured. The provisions of this bulletin also apply to combination policies that offer accident only coverage on a life policy. If income replacement is added for the injured insured, the policy must meet the minimum standards of both accident only and disability insurance. If sickness benefits related to an illness or disease rather than the accident are included, such benefits must fit into one of the health insurance categories as set forth in Connecticut General Statute Section 38a-469. The resulting combination policy must meet the minimum standards of both accident only and the appropriate category for the sickness benefits. It has come to the attention of the Department that forms are being marketed that are not in compliance with the minimum standards set forth in the statutes and regulations for combination policies described above. Any previously approved policies that do not conform to these standards should no longer be marketed. To facilitate filing reviews, the list that follows describes benefits contained in recent submissions that are related to an accident and the injured insured that will be approved for accident only policies. Benefits that do not meet this definition are provided in the list that follows. These lists are not intended to be all inclusive. Benefits not listed will be reviewed under the basic guideline that any such benefit should be related to the accident and the injured insured. Accident only benefits/provisions that relate to the accident and injured insured: - Loss of digits, hands, arms, legs, feet, sight - Loss of use of digits, hands, arms, legs, feet - Loss due to quadriplegia, paraplegia, hemiplegia, uniplegia - Paralysis - Loss of speech - Loss of hearing www.state.ct.us/cid/ P. O. Box 816 Hartford, CT 06142-0816 An Equal Opportunity Employer - Coma - Critical Burn - Brain damage (cannot use ADL trigger) - Hospital and medical benefits related to accident - Waiver of premium - Extension of Benefits/Waiver of premium for surviving spouse and dependents - Rehabilitation expense - Vocational/occupational training expense - Felonious assault including but not limited to: Hijacking/skyjacking Kidnapping, hostage taken - Extended care facility benefit if benefit period is less than 12 months - Home or vehicle modification - Accidental death benefit - Repatriation of remains benefit - Medical evacuation or transfer/family travel expense - Disappearance in lieu of death benefit (NOTE: Recovery of this benefit not allowed.) # **Benefits/provisions that do not meet the accident only definition:** - ADL triggers - Dependent care expenses - Educational benefits (Tuition reimbursement) - Child education benefit - Spouse training/education benefit - Income replacement or monthly payment due to disability (Allowed if filed as combination policy and meets all DI requirements) - Spousal income replacement - COBRA premium - Funeral expenses - Survivor benefits - Bereavement counseling - Occupational Hepatitis or Occupational Immunodeficiency Virus - Wellness or preventative benefits - Medical benefits not related to the accident - Additional benefits for seat belts or air bags - Additional benefit if accident due to natural disaster - Additional benefit based on accident occurring on common carrier Susan F. Cogswell Insurance Commissioner