(1) All disability insurers offering individual policies that provide benefits in the form of illness-triggered fixed payments, hospital confinement fixed payments or other fixed payment insurance, must issue a disclosure form in substantially the format and content outlined below. The disclosure form must be provided to all applicants at the time of solicitation and completion of the application form for coverage. Every insurer must have a mechanism in place to verify delivery of the disclosure to the applicant.
(2) The type size and font of the disclosure form must be easily read and be no smaller than 10 point.
(3) The insurer's disclosure form must be filed for approval with the commissioner prior to use.
(4) The standard disclosure form replaces any outline of coverage that would otherwise be required for fixed payment policies and must include, at a minimum, the following information:
(Insurer's name and address)
important information about the
coverage you are being offered
Save this statement! It may be important to you in the future. The Washington State Insurance Commissioner requires that we give you the following information about fixed payment benefits.
This coverage is not comprehensive health care insurance and will not cover the cost of most hospital and other medical services.
This disclosure document provides a very brief description of the important features of the coverage you are considering. It is not an insurance contract and only the actual policy provisions will control. The policy itself will include in detail the rights and obligations of both you and (insurer's name).
This coverage is designed to pay you a fixed dollar amount regardless of the amount that the provider charges. Payments are not based on a percentage of the provider's charge and are paid in addition to any other health plan coverage you may have.
caution: If you are also covered under a High Deductible Health Plan (HDHP) and are contributing to a Health Savings Account (HSA), before you purchase this policy you should check with your tax advisor to be sure that you will continue to be eligible to contribute to the HSA if you purchase this coverage.
The benefits under this policy are summarized below.
• Type of coverage:
• Benefit amount:
• Benefit trigger (identify any periods of no coverage such as eligibility or waiting periods):
• Duration of coverage:
• Renewability of coverage:
Policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described above include the following:
(List all exclusions including those that relate to limitations for preexisting conditions.)