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12. Individual Policy Provisions

The purpose of this chapter is to explain the provisions and clauses that promote consistency and continuity among health insurance policies. Because health insurance contracts are not standardized, Mandatory Uniform Provisions are required to protect the interests of the insured. In addition, Optional and Standard Provisions further define the rights and responsibilities of both the insurer and the insured. The provisions discussed in this chapter apply specifically to individual accident and health insurance policies, including medical expense coverage, disability income insurance, Medicare Supplement (Medigap) policies, and Long-Term Care insurance.

📄️ 12.1 Mandatory Uniform Provisions

The Mandatory Uniform Provisions, established by the National Association of Insurance Commissioners (NAIC), are legally required to be included in all individual accident and health insurance policies. While insurers may use alternative wording, it must be at least as favorable to the insured as the standard language. Insurers are not permitted to include additional provisions that limit or alter the intent of these required provisions. There are 12 Mandatory Uniform Provisions, all of which are designed to protect the rights and interests of the insured.