11 NCAC 04 .0313             PROVISIONS OF CONTRACTS

In order to prevent unfair discrimination among insureds, the following phrases and provisions commonly found in life, accident, health and disability contracts, if not expressly defined in such contracts, shall be construed by the Department in the following manner:

(1)           Regular Care and Attendance of a Physician.  As used in life, accident and health and disability policies, "regular care and attendance of a physician" shall not be construed to require insureds to see or be under the care of a physician on a regular basis if it can be shown that the insured has reached his maximum point of recovery yet is still disabled under the terms of the insurance contract.  This requirement shall not, however, restrict the right of the insurer at its own expense, to periodically examine or cause to have examined the insured according to the terms of the contract of insurance.

(2)           Premature Baby.  A premature baby shall not be considered a well baby.  The protection afforded newborn infants under G.S. 58-51-30 shall be provided to premature babies.

(3)           Medical Necessity.  "Medical necessity" shall be construed as including treatment which restores not only the insured's physical but also his mental well-being.  As used in this Section, "restoration of mental well-being" does not require coverage of psychiatric disorders when such disorders are excluded under the express terms of the contract.

(4)           Sound Health.  The question, "Are you in sound health?" shall be considered ambiguous, and therefore answers to that question on an insurance application shall not be used as the basis for rescission of a policy or denial of a claim.


History Note:        Authority G.S. 58-2-40; 58-3-150; 58-51-1; 58-63-15; 58-63-65; 58-65-1; 58-65-40; 58-65-95; 58-67-65; 58-67-150;

Eff. December 15, 1979;

Amended Eff. July 1, 2012; April 8, 2002; April 1, 1989.