§ 2220.8. Exceptions, Limitations and Reductions.

STANDARDS

(a) A benefit shall be deemed not sufficient to be of real economic value to the insured if it is subject to exceptions, limitations or reductions concerning any subject matter other than the following:

(b) War; service in armed forces; workers' compensation; participation in a riot or insurrection; suicide or attempted suicide; intentionally self-inflicted injury; voluntary or involuntary inhalation of gas; mental or emotional disorders or functional nervous disorders; pregnancy or childbirth; treatment on or to the teeth or gums except when necessitated by accident; hallucinatory drugs; while a passenger other than a fare-paying passenger in any aircraft or while passenger in a military aircraft or acting as pilot or crew in any aircraft; facilities for treatment of armed forces members or ex-members except when an actual charge is made; services for which no charge is made in the absence of insurance; services covered under any governmental plan except those governmental plans which by law either define or specify disability insurance coverage as primary; rest cure or routine medical examinations; eye refractions or eye glasses; hearing aids; surgery for cosmetic purposes; motorcycle use; racing contests; professional athletics; hazardous avocations (when the hazardous avocation is specified specifically); reasonable territorial limits.

(c) A limitation which constitutes a reasonable definition of the losses covered and the benefits provided shall not be construed as materially lessening the value of the benefit if the definition is not otherwise inconsistent with any provision of this Article.

(d) The words “exceptions, limitations, or reductions” as used in this section shall not prohibit any provision which the Insurance Code specifies permissible or which is approved by the Insurance Commissioner, and shall not include any provision contained in any insuring paragraph or paragraphs that modifies solely the subject thereof, where such insuring paragraph or paragraphs, including such provision, constitutes, over all, an affirmative definition of one of the hazards, a class of hazards or all of the hazards which the policy insures against and which the Insurance Commissioner deems to be a reasonable definition or statement of one or more of the hazards which the policy insures against.

(e) This section shall not apply to any matter contained in any rider the original or copy of which is signed by the insured and issued for attachment to the policy when the policy is issued or reinstated when the rider is used solely to waiver coverage for existing specified medical or physical conditions which actually exist. Such a rider may also be used to waive coverage for specified hazardous avocations.

The words and phrases designated in this section as “subject matters” of exceptions, limitations and reductions are to be given a broad generic interpretation and do not control the actual words or phrases used are not less favorable to the insured person than the words or phrases used in this section.

HISTORY

1. Amendment of subsection (b) filed 12-2-75; designated effective 1-1-76 (Register 75, No.49).