(a) Insurers offering for approval a basic benefit policy shall provide, separate from the policy, a disclosure to the insured that contains the following information:
- (1) An outline of the extent of coverage;
- (2) A specific list of the mandated benefits not provided;
- (3) An explanation of any managed care and cost control features, including all necessary telephone numbers and addresses; and
- (4) An explanation of the primary and preventive care features of the policy.
- (b) All disclosure statements shall use terminology and language which is easily understood by the average consumer.
- (c) The type used on the statements shall be pica size and the disclosure statement shall contain the following statement in 12-point boldfaced type: THIS IS A BASIC BENEFIT POLICY AND CONTAINS COVERAGE WHICH IS STRICTLY LIMITED IN NATURE AND DOES NOT CONTAIN BENEFITS WHICH WOULD BE PROVIDED UNDER A COMPREHENSIVE MAJOR MEDICAL POLICY. READ YOUR POLICY CAREFULLY.
(d) A place for the insured's signature shall be provided under the statement, and no policy shall be issued unless the:
- (1) Disclosure statement is properly signed by the insured; and
- (2) Original of such retained in the records of the insurer for the duration of coverage.
- (e) The insured shall be provided a copy of the statement so retained by the insurer.
- (f) All disclosure statements shall be filed along with the policy form for approval by the Insurance Commissioner.