Cal. Code Regs. tit. 10, § 2540.5
(b) Prototype Standard Supplemental Disclosure Form for Policies Providing Basic Hospital Expense Coverage. “Basic Hospital Expense Coverage” provides benefits for expenses incurred for daily hospital room and board and miscellaneous hospital services incurred as a result of covered accident or sickness. Benefits may be subject to a deductible amount and to a co-payment requirement.
(d) [Other benefits, if any.]
[4] Exceptions, Reductions and Limitations of This (Policy).
(Benefits are not provided for physicians' or surgeons' fees.)
[5] (Renewability) of This (Policy).
[6] (Premium) for This (Policy).
(COMPANY NAME) BASIC HOSPITAL EXPENSE COVERAGE OUTLINE OF COVERAGE
[1] Read Your (Policy) Carefully. This outline of coverage provides a very brief description of some important features of your (policy). This is not the insurance contract and only the actual (policy) provisions will control. The (policy) itself sets forth, in detail, the rights and obligations of both you and (your insurance company). It is, therefore, important that you Read Your (Policy) Carefully!
[2] Basic Hospital Expense Coverage. This category of coverage is designed to provide to persons insured benefits for hospital expenses incurred as a result of a covered accident or sickness. Benefits may be provided for daily hospital room and board, miscellaneous hospital services, and hospital outpatient services, subject to any limitations, deductibles and co-payment requirements set forth in the (policy). Benefits are not provided for physicians; or surgeons; fees or unlimited hospital expenses.
[3] Benefits of This (Policy).
(c) Prototype Standard Supplemental Disclosure Form for Policies Providing Basic Medical-Surgical Expense Coverage. “Basic Medical-Surgical Expense Coverage” provides benefits for expenses incurred for surgical, anesthesia and in-hospital medical services incurred as a result of covered accident or sickness. Benefits may be subject to a deductible amount and to a co-payment requirement.
(d) [Other benefits, if any.]
[4] Exceptions, Reductions and Limitations of This (Policy).
(Benefits are not provided for hospital expenses)
[5] (Renewability) of This (Policy).
[6] (Premium) for This (Policy).
(COMPANY NAME) BASIC MEDICAL-SURGICAL EXPENSE COVERAGE OUTLINE OF COVERAGE
[1] Read Your (Policy) Carefully. This outline of coverage provides a very brief description of some important features of your (policy). This is not the insurance contract and only the actual (policy) provisions will control. The (policy) itself sets forth, in detail, the rights and obligations of both you and (your insurance company). It is, therefore, important that you Read Your (Policy) Carefully!
[2] Basic Medical-Surgical Expense Coverage. This category of coverage is designed to provide to persons insured benefits for medical-surgical expenses incurred as a result of a covered accident or sickness. Benefits may be provided for surgical services, anesthesia services, and in-hospital medical services, subject to any limitations, deductibles and co-payment requirements set forth in the (policy). Benefits are not provided for unlimited hospital expenses or medical-surgical expenses.
[3] Benefits of This (Policy).
(d) Prototype Standard Supplemental Disclosure Form for Policies Providing Basic Hospital and Medical-Surgical Expense Coverage. “Basic Hospital and Medical-Surgical Coverage” provides benefits for expenses incurred for daily hospital room and board, miscellaneous hospital services, surgical, anesthesia and in-hospital medical services incurred as a result of covered accident or sickness. Benefits may be subject to a deductible amount and to a co-payment requirement.
(g) [Other benefits, if any.]
[4] Exceptions, Reductions and Limitations of This (Policy).
[5] (Renewability) of This (Policy).
[6] (Premium) for This (Policy).
(COMPANY NAME) BASIC HOSPITAL AND MEDICAL-SURGICAL EXPENSE COVERAGE OUTLINE OF COVERAGE
[1] Read Your (Policy) Carefully. This outline of coverage provides a very brief description of some important features of your (policy). This is not the insurance contract and only the actual (policy) provisions will control. The (policy) itself sets forth, in detail, the rights and obligations of both you and (your insurance company). It is, therefore, important that you Read Your (Policy) Carefully!
[2] Basic Hospital and Medical-Surgical Expense Coverage. This category of coverage is designed to provide to persons insured benefits for hospital and medical-surgical expenses incurred as a result of a covered accident or sickness. Benefits may be provided for daily hospital room and board, miscellaneous hospital services, hospital outpatient services, surgical services, anesthesia services, and in--hospital medical services, subject to any limitations, deductibles and co-payment requirements set forth in the (policy). Benefits are not provided for unlimited hospital or medical-surgical expenses.
[3] Benefits of this (Policy)
(e) Prototype Standard Supplemental Disclosure Form for Policies Providing Hospital Confinement Indemnity Coverage. “Hospital Confinement Indemnity Coverage” provides a stipulated daily benefit for hospital confinement as a result of covered accident or sickness. Benefits may be subject to elimination periods.
(c) [Other benefits, if any.]
[4] Exceptions, Reductions and Limitations of This (Policy). (Benefits are not provided for physicians' or surgeons' fees nor for miscellaneous hospital services.) [The foregoing sentence may be modified to reflect the benefits provided by the policy.]
[5] (Renewability) of This (Policy).
[6] (Premiums for This (Policy).
(COMPANY NAME) HOSPITAL CONFINEMENT INDEMNITY COVERAGE OUTLINE OF COVERAGE
[1] Read Your (Policy) Carefully. This outline of coverage provides a very brief description of some important features of your (policy). This is not the insurance contract and only the actual (policy) provisions will control. The (policy) itself sets forth, in detail, the rights and obligations of both you and (your insurance company). It is, therefore, important that you Read Your (Policy) Carefully!
[2] Hospital Confinement Indemnity Coverage. This category of coverage is designed to provide, to persons insured, a fixed daily benefit during periods of hospitalization resulting from a covered accident or sickness, subject to any limitations set forth in the (policy). This coverage does not provide any benefits other than the fixed daily indemnity for hospital confinement. [The last sentence may be omitted or modified to reflect the benefits provided by the policy.]
[3] Benefits of This (Policy).
(f) Prototype Standard Supplemental Disclosure Form for Policies Providing Major Medical Expense Coverage. “Major Medical Expense Coverage” provides benefits for major hospital, medical and surgical expenses incurred as a result of covered accident or sickness. Benefits are provided for daily hospital room and board, miscellaneous hospital services, surgical and anesthesia services, in-hospital medical services and prosthetic appliances, among other expenses. The maximum benefit for covered charges must at least equal $10,000. Benefits are subject to substantial fixed or variable deductibles, and may be subject to a co-payment requirement.
(i) [Other benefits, if any.]
[4] Exceptions, Reductions and Limitations of This (Policy). (This coverage does not provide basic hospital and medical coverage.)
[5] (Renewability) of This (Policy).
[6] (Premium) for This (Policy).
(COMPANY NAME) MAJOR MEDICAL EXPENSE COVERAGE OUTLINE OF COVERAGE
[1] Read Your (Policy) Carefully. This outline of coverage provides a very brief description of some important features of your (policy). This is not the insurance contract and only the actual (policy) provisions will control. The (policy) itself sets forth, in detail, the rights and obligations of both you and (your insurance company). It is, therefore, important that you Read Your (Policy) Carefully!
[2] Major Medical Expense Coverage. This category of coverage is designed to provide, to persons insured, benefits for major hospital, medical, and surgical expenses incurred as a result of a covered accident or sickness. Benefits may be provided for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-hospital medical services, out of hospital care, and prosthetic appliances, subject to any deductibles, co-payment provisions, or other limitations which may be set forth in the (policy). Basic hospital or basic medical insurance coverage is not provided.
[3] Benefits of This (Policy).
(g) Prototype Standard Supplemental Disclosure Form for Policies Providing Disability Income Protection Coverage. “Disability Income Protection provides benefits on account of the insured's inability, as a result of covered accident or sickness, to perform certain activities as defined in the policy.
(COMPANY NAME) DISABILITY INCOME PROTECTION COVERAGE OUTLINE OF COVERAGE
[1] Read Your (Policy) Carefully. This outline of coverage provides a very brief description of some important features of your (policy). This is not the insurance contract and only the actual (policy) provisions will control. The (policy) itself sets forth, in detail, the rights and obligations of both you and (your insurance company). It is, therefore, important that you Read Your (Policy) Carefully!
[2] Disability Income Protection Coverage. This category of coverage is designed to provide, to persons insured, benefits for disabilities resulting from a covered accident or sickness, subject to any limitations set forth in the (policy). Benefits are not provided for basic hospital, basic medical-surgical, or major-medical expenses.
[3] Benefits of This (Policy). [The benefit description shall briefly describe the definition or definitions of total disability used in the policy. Benefit and elimination periods may be stated in the time units used in the policy.]
[4] Exceptions, Reductions and Limitations of This (Policy).
(No benefits are provided for hospital, medical or surgical expenses.) [The foregoing sentence may be omitted or modified to reflect the benefits provided by the policy.]
[5] (Renewability) of This (Policy).
[6] (Premium for This (Policy).
(h) Prototype Standard Supplemental Disclosure Form for Policies Providing Accident Only Coverage. “Accident Only Coverage” provides benefits of the nature specified in the policy for losses resulting to the insured from covered accidents. Any policy whose principal benefits are limited to accidental losses shall be included in this category, unless it falls within the following subsection. Benefits payable may vary according to accidental cause.
(COMPANY NAME) ACCIDENT ONLY COVERAGE OUTLINE OF COVERAGE
[1] Read Your (Policy) Carefully. This outline of coverage provides a very brief description of some important features of your (policy). This is not the insurance contract and only the actual (policy) provisions will control. The (policy) itself sets forth, in detail, the rights and obligations of both you and (your insurance company). It is, therefore, important that you Read Your (Policy) Carefully!
[2] Accident Only Coverage. This category of coverage is designed to provide, to persons insured, benefits for certain losses resulting from a covered accident ONLY, subject to any limitations contained in the (policy). Benefits are not provided for basic hospital, basic medical-surgical, or major-medical expenses.
[3] Benefits of This (Policy). [Prototype disclosure forms for other types of coverage should be used as guides in drafting the benefit description, where appropriate. Where policy benefits vary according to accidental cause, this paragraph shall prominently set forth the circumstances under which benefits are payable which are lesser than the maximum amount payable under the policy.]
[4] Exceptions, Reductions and Limitations of This (Policy). (No benefits are provided for any loss resulting from sickness.) [The foregoing sentence may be omitted or modified to reflect the benefits provided by the policy.]
[5] (Renewability) of This (Policy).
[6] (Premium for This (Policy).
(i) Prototype Standard Supplemental Disclosure Form for Policies Providing Specified Disease or Specified Accident Coverage.
“Specified Disease or Specified Accident Coverage” provides benefits of the nature specified in the policy only for losses resulting from the disease or type of accident specified in the policy.
(COMPANY NAME) (SPECIFIED DISEASE) (SPECIFIED ACCIDENT) COVERAGE OUTLINE OF COVERAGE
[1] Read Your (Policy) Carefully. This outline of coverage provides a very brief description of some important features of your (policy). This is not the insurance contract and only the actual (policy) provisions will control. The (policy) itself sets forth, in detail, the rights and obligations of both you and (your insurance company). It is, therefore, important that you Read Your (Policy) Carefully!
[2] (Specified Disease) (Specified Accident) Coverage. This category of coverage is designed to provide, to persons insured, benefits ONLY when certain losses occur as a result of (specified diseases) (specified accidents). Benefits are not provided for basic hospital, basic medical-surgical, or major-medical expenses.
[3] Benefits of This (Policy). [Prototype disclosure forms for other types of coverage should be used as guides in drafting the benefit description, where appropriate. Where specified accident policy benefits vary according to accidental cause, this paragraph shall prominently set forth the circumstances under which benefits are payable which are lesser than the maximum amount payable under the policy.]
[4] Exceptions, Reductions and Limitations of This (Policy). (Benefits are not provided for losses caused by anything other than [specified diseases][specified accidents].)
[5] (Renewability) of This (Policy).
[6] (Premium for This (Policy).
(j) Prototype Standard Supplemental Disclosure Form for Policies Providing Comprehensive Major Medical Expense Coverage.
(i) [Other benefits, if any.]
[4] Exceptions, Reductions and Limitations of This (Policy).
[5] (Renewability) of This (Policy).
[6] (Premium) for This (Policy).
“Comprehensive Major Medical Expense Coverage” provides those benefits enumerated in subsection (f) of this section, except that coverage is not designed to supplement other coverage and may be subject only to modest fixed deductible amounts. Benefits may also be subject to a co-payment requirement.
(COMPANY NAME) COMPREHENSIVE MAJOR MEDICAL EXPENSE COVERAGE OUTLINE OF COVERAGE
[1] Read Your (Policy) Carefully. This outline of coverage provides a very brief description of some important features of your (policy). This is not the insurance contract and only the actual (policy) provisions will control. The (policy) itself sets forth, in detail, the rights and obligations of both you and (your insurance company). It is, therefore, important that you Read Your (Policy) Carefully!
[2] Comprehensive Major Medical Expense Coverage. This category of coverage is designed to provide, to persons insured, benefits for major hospital, medical, and surgical expenses incurred as a result of a covered accident or sickness. Benefits may be provided for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-house medical services, out of hospital care, and prosthetic appliances, subject to any deductibles, co-payment provisions, or other limitations which may be set forth in the (policy).
[3] Benefits of This (Policy).
(k) Disclosure Forms for Medicare Supplement Policies: Special Instructions. The name, address and telephone number of a representative of the insurer or the General Agent shall be inserted in the blank in the sentence following Paragraph (8). (Such representative may not be the agent, if any, who solicited or delivered the policy.) Such representative shall be located in this State unless a toll-free “800” telephone number is specified.
Insurers shall establish affirmative procedures for insuring that Medicare Supplement Policy Disclosure Forms are properly delivered pursuant to Insurance Code Sections 10601(e) and 10605, where solicitation is made on an other-than-direct response basis. Such procedures could include physically attaching disclosure forms to field-issued policies; requiring return to the insurer of copies of disclosure forms signed by prospective insureds; or requiring separately signed acknowledgments of receipt on application for insurance when such applications are returned to the insurer. (This requirement shall not be construed to mean that insurers need not establish reasonable procedures for insuring that other categories of disclosure forms are properly delivered to prospective insureds.)
(l) Prototype Standard Supplemental Disclosure Form for Policies Providing Medicare Supplement Coverage.
(b) (For direct response:) (insert company's name) is not connected with Medicare.
[4] (A brief summary of the major benefit gaps in Medicare Parts A and B with a parallel description of supplemental benefits, including dollar amounts, provided by the Medicare Supplement Coverage in the following order:)
Service
Benefit
Medicare pays
This Policy Pays
You Pay
HOSPITALIZATION--Semiprivate room and board, general nursing
First 60 days
All But $( )
and miscellaneous hospital services and supplies Includes meals,
61st to
All but $( )
90th day
a day
special care units, drugs, lab tests, diagnostic X-rays, medical supplies,
90th to
All but $( )
150th day
a day
operating and recovery room, anesthesia and rehabilitation services
Beyond 150
Nothing
days
POST HOSPITAL SKILLED NURSING CARE--In a facility approved by
First 20
100% of costs
days
Medicare you must have been in a hospital for at least
Additional
All but $( )
80 days
a day
three days and enter the facility within 14 days after hospital discharge
Beyond 100
Nothing
days
MEDICAL EXPENSE
Physician's services in-patient and out-patient medical services and supplies at a hospital, physical and Speech therapy and ambulance.
80% of reasonable charge [after $( ) deductible]
[5] (A statement that the policy does or does not cover the following:)
(i) Dental care or dentures, checkups, routine immunizations, cosmetic surgery, routine foot care, examinations for the cost of eyeglasses or hearing aids.
[6] (A description of any policy provisions which excludes, eliminates, resists, reduces, limits, delays or in any other manner operates to qualify payment of the benefits described in (4) above, including conspicuous statements:)
(b) (That the Health Care Financing Administration or its Medicare publications should be consulted for further details and limitation.)
[7] (A description of policy provisions respecting renewability or continuation of coverage, including any reservation of right to change premium.)
[8] (The amount of premium for this policy.)
If you have questions about this (policy), please write or call___.
(COMPANY NAME) MEDICARE SUPPLEMENT COVERAGE OUTLINE OF COVERAGE
[1] Read Your (Policy) Carefully. This outline of coverage provides a very brief description of some important features of your (policy). This is not the insurance contract and only the actual (policy) provisions will control. The (policy) itself sets forth, in detail, the rights and obligations of both you and (your insurance company). It is, therefore, important that you READ YOUR POLICY CAREFULLY!
[2] Medicare Supplement Coverage--Policies of this category are designed to supplement Medicare by covering some hospital, medical, and surgical services which are partially covered by Medicare. Coverage is provided for hospital in-patient charges and some physician charges, subject to any deductibles and co-payment provisions which may be in addition to those provided by Medicare, and subject to other limitations which may be set forth in the policy. The policy does not provide benefits for custodial care such as help in walking, getting in and out of bed, eating, dressing, bathing and taking medicine (delete if such coverage is provided).
[3] (a) (For agents:) Neither (insert company's name) nor its agents are connected with Medicare.
Note: Authority cited: Sections 790.10, 10608 and 10195(g), Insurance Code. Reference: Sections 10195(g) and 10603, Insurance Code.
1. Amendment filed 1-8-76; effective thirtieth day thereafter (Register 76, No. 2).
2. Amendment of subsections (e)(4), (h)(4), repealer and new subsection (k) and new subsections (l), (m) and (n) filed 4-5-78; designated effective 1-1-79 (Register 78, No. 14).
3. Repealer of subsections (k)-(n) and new subsections (k) and (l) filed 3-31-83; effective thirtieth day thereafter (Register 83, No. 14).