SECTION 3.3054. Preexisting Conditions Provisions

(a) The policy must clearly disclose the intent of the insurer as to the applicability or nonapplicability of coverage to preexisting conditions. In accordance with §3.3018 of this title (relating to Policy Definition of Preexisting Condition), a policy offering individual hospital, medical or surgical coverage also must clearly disclose and explain the conditions under which Texas law requires an insurer to not apply a preexisting condition provision, or to limit application of the provision, to an individual who has previous creditable coverage. If coverage of the policy is not to be applicable to preexisting conditions, the policy shall specify, in substance, that coverage applies only to accidental bodily injuries resulting from accidents occurring after the effective date of coverage and sicknesses which first manifest themselves subsequent to the effective date of coverage or expiration of any applicable probationary period.

(b) In regards to individuals who are not exempt from preexisting condition provisions under §3.3018 of this title (relating to Policy Definition of Preexisting Condition):

(1) If an insurer elects to use a simplified application form for individual applicants, the policy must cover any loss occurring after 12 months which results from any preexisting condition not specifically excluded from coverage by the terms of the policy.

(2) No individual policy of accident and sickness insurance delivered or issued for delivery in this state to a person age 65 or over may contain a provision excluding from coverage any loss due to a preexisting condition, not specifically excluded from coverage by name or specific description in an exclusion endorsement or rider effective on the date of the loss, for a period in excess of six months from the effective date of the coverage under the policy; provided, however, that if the commissioner finds that the public interest would be served thereby, it may authorize a policy provision excluding coverage for preexisting conditions for a period in excess of six months but in no event shall such period exceed one year.

Source Note: The provisions of this §3.3054 adopted to be effective January 26, 1977, 2 TexReg 159; amended to be effective December 22, 1997, 22 TexReg 12503.