New Mexico State Laws - Amazon Simple Storage ServicePDFs/LH_NM.pdf · Retention Question Answer...

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Table of ContentsTable of Contents

Life and Health Laws ...................................................................................................................... 3

Life Laws .........................................................................................................................................15

Retention Question Answer Key ..................................................................................................45

Key Word Index ..............................................................................................................................46

Life Students


Health Laws ....................................................................................................................................23


Key Word Index ..............................................................................................................................46

Health Students


Life Laws .........................................................................................................................................15

Health Laws ....................................................................................................................................23


Key Word Index ..............................................................................................................................46

Life & Health Students

New Mexico State Laws

This edition is valid starting January 2014

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Life and Health Laws

OVERVIEWThe purpose of this chapter is to acquaint the student with the insurance regulatory and licensing process in the state of New Mexico and inform the student of the ethical standards and practices expected of the insurance professional. The primary purpose of licensing is to protect the general public

NOTE: INFORMATION IN THIS CHAPTER MODIFIES OR AMENDS INFORMATION FROM PREVIOUS CHAPTERS.

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Licensing ProcessQualifi cationsAnyone who wants to transact business as an insurance producer must:1. Be at least 18 years of age.2. Have not been convicted of a felony involving dishonesty or breach of trust. 3. Submit the required application and fees.4. Successfully passed the examinations for the lines of authority for which the person has applied.5. Have a resident of this state for at least 30 days prior to application. 6. Be competent, trustworthy, and fi nancially responsible. 7. Be appointed by an insurer for agent license. 8. Be appointed by an agent for solicitor license.

Application1. Application for an agent’s license must be made to the Superintendent by the applicant through the

sponsoring insurer. 2. The applicant must furnish information concerning his/her identity, personal history, business

record, experience in the insurance business and other pertinent facts the Superintendent may require.

3. For a natural person, the application must also show whether:a. The applicant was ever previously licensed to transact any of kinds of insurance in this state or

elsewhere.b. Any license was ever refused, suspended or revoked.c. The applicant is indebted to any insurer claims.d. The applicant has ever had an insurance agency contract canceled and the facts of the

cancellation.4. For a business entity, the name of each partnership, corporation or professional corporation must be

registered with the Superintendent and the application must set forth the names of all the members, offi cers and directors of the partnership, corporation or professional corporation and the names of each natural individual who is to exercise the agency powers.

5. The Superintendent may require any application to be in the applicant’s handwriting and under the applicant’s oath.

6. All applications for an agent license must show the categories and types of insurance to be transacted and accompanied with a written certifi cate from the sponsoring insurer.

7. For a solicitor, the application must accompanied by written appointment by a licensed agent.8. The application must accompanied by the applicable license application fi ling fee. 9. New applicants must also submit standard FBI fi ngerprint cards. These may be obtained by

emailing: [email protected].

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10. The superintendent may obtain, at the expense of the applicant, criminal history information concerning each applicant, using the applicant’s fi ngerprints or other identifying information.

Types of LicenseesAn agent can be licensed for any single or combination of the following insurance categories:1. Life2. Health and Accident3. Industrial Life4. Industrial Health and Accident5. Debit6. Variable Annuity Contracts7. Casualty, Surety and Fidelity8. Fire and Marine9. Motor Vehicles10. Title Guaranty; or11. Any combination of these.

Vending Machine Sales1. Transacting insurance in New Mexico by a mechanical vending machine requires an agent’s

license. Each machine shall be supervised by the agent so licensed and shall issue policies only of authorized insurers.

2. The authorized insurer and the licensed agent shall display its evidence of authority to solicit applications and issue policies on or near each vending machine.

Persons Required to be Licensed1. Agent – A person appointed by an insurer to:

a. Solicit applications for insurance or annuity contracts.b. Countersign insurance policies or contracts. c. Perform such other services relative to such transactions as the insurer may authorize.

2. Broker – A person generally who, as an independent contractor and on behalf of the insured solicits, negotiates or procures insurance or annuity contracts. This does not include a surplus lines broker.

3. Solicitor – An individual employed by a licensed resident agent, for the same lines of insurance for which the agent is licensed, to solicit insurance and perform such other duties in handling the agent’s business. A solicitor may not be appointed or licensed through more than one agent. a. Whenever an agent employs any natural individual to represent him as a solicitor in the state of

New Mexico, the agent shall immediately notify the Superintendent and apply for a license in the same manner required to appoint a new person as an agent.

b. An agent must report the names and addresses of all persons employed by the agent as solicitors to the Superintendent annually. Solicitor licenses terminate on April 30 of the year after issuance or continuation if the employing or authorizing insurer agent does not apply for a continuation of appointment.

4. Consultant – A person who is paid to examine policies or annuities in order to give insurance advice. It is illegal to act as a consultant without being licensed as a consultant. To do so is a misdemeanor punishable by a fi ne up to $500, a prison term of 6 months or both. A consultant license shall be issued for 2 years. a. All services provided by consultants and fees charged must be specifi ed in written contract. b. Consultants cannot receive commissions from insurers or agents.

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LIFE AND HEALTH LAWS

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c. Regulations regarding consultants do not:1) Prohibit the customary advice offered by a licensed insurance agent or adjuster.2) Apply to an attorney permitted to engage in public accounting when he/she is acting within

the scope of that practice; or 3) Require licensure of a salaried employee of a group or its service company.

5. Nonresident Agent – An agent residing or (if a corporation or fi rm) domiciled in a state other than New Mexico or residing or domiciled in a foreign country. A nonresident person shall be granted a license if the person’s home state awards nonresident insurance producer licenses to residents of this state on the same basis. A nonresident agent must appoint the Superintendent as his/her agent for service of legal process.

6. Temporary License – The Superintendent of Insurance can issue a temporary insurance agent license for an initial period up to 90 days without requiring an examination. Except for debit or industrial insurance, the license can be extended an additional 90 days upon application and proof of good cause. A 2nd temporary license cannot be issued until the original license has been expired for at least 6 months. Temporary licenses may be granted in the following circumstances:a. The surviving spouse or court-appointed personal representative of a licensed insurance agent

who dies or becomes mentally or physically disabled: (a) for the sale of the insurance business owned by such insurance agent; (b) for the recovery or return of such insurance agent to the business; or (c) to provide for the training and licensing of new personnel to operate such insurance agent’s business.

b. Any member or employee of a business entity licensed as an insurance agent, upon the death or disability of an individual, designated in such business entity’s application or the insurance agent’s license.

c. The designee of an individual licensed as an insurance agent who is entering active service in the armed forces of the United States.

d. An individual designated by a licensed agent to replace an agent no longer associated with the agency.

e. A salaried employee of an insurer sent to this state by the insurer to take the place of a licensed agent or solicitor.

f. An applicant for license as a life insurance agent or life insurance solicitor, only for writing debit or industrial insurance. Temporary licensure for this type of insurance cannot be extended beyond the initial 90 days.

7. Business Entity – A fi rm or corporation. In order for a business entity to transact insurance business in this state, each of its owners must have an agent’s license.

Maintenance and DurationLicense Expiration and Renewal1. Each license, other than insurance agent, continues in force until it is suspended, revoked or

otherwise terminated, subject to payment of the annual continuation fee. If the license is not continued by payment of the continuation fee, it is deemed to have terminated as of midnight on April 30. If the license is renewed within 30 days of expiration, the renewal fee is 150% of the normal renewal fee. An insurer must notify the Superintendent within 15 days of an agent’s appointment by the insurer. Note: The Superintendent may change the compliance date.

2. For an agent or broker, request must be made and signed by the licensee. 3. An agent license shall terminate:

a. If the agent is not appointed by an insurer within 60 days of obtaining the agent license. b. Upon death of the licensee.c. If the agent’s appointment has been terminated for 60 days.

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4. A cancelled license can be activated if the licensee has not been inactive for more than 5 years and all continuing education requirements have been met. If not already on fi le, a fi ngerprint card must be submitted.

5. If the Superintendent has reason to question a licensee’s competence, the Superintendent may require the licensee to pass an insurance examination as a condition for license renewal.

Change of Address A licensee must notify the Superintendent within 20 days of a change of address. Failure to notify the superintendent of a change of address within 20 days shall subject the licensee to a penalty of $50.

Continuing Education1. Title insurance licensees must annually complete 7 credit hours of approved courses covering title

insurance.2. All other licensees must annually complete 15 credit hours of approved courses covering some or all

of the kinds of insurance for which they are licensed.3. No licensee may carry over credit hours earned in one compliance year to the next compliance year.4. No additional credit will be granted to a licensee for completion of the same approved course more

than once in any 3-year period. 5. The superintendent may impose a penalty of up to $50 for a licensee’s failure to timely report

continuing education credits. 6. The Superintendent may charge, at the time of certifying each licensee’s continuing education

credits, a fee of $1.00 per credit hour of continuing education. Courses will not be credited until the Superintendent receives course completion documents and the applicable fees.

7. The continuing education requirements do not apply to holders of a limited license. 8. The credit period is from October 1 through September 30. Licensees must keep their continuing

education course records for at least 3 years.

Disciplinary Actions Suspension, Revocation or Refusal to Renew License1. The Superintendent may suspend, revoke or refuse renewal of any license issued for any of the

following causes:a. The licensee has engaged in an act or practice for which issuance of the license could have been

refused. b. The licensee has violated any insurance law, regulation, subpoena or order of the

Superintendent, or of another state’s insurance Superintendent.c. The license was obtained through fraud or misrepresentation.d. The licensee improperly withheld, misappropriated or converted any monies or properties

received in the course of doing business.e. The licensee misrepresented the provisions, terms and conditions of an insurance policy.f. The licensee has been convicted of a felony involving dishonesty or breach of trust.g. The licensee admitted to or was found to have committed any insurance unfair trade practice.h. Failure to pass any examination required by the Superintendent.

2. The Superintendent shall notify the licensee of any suspension, revocation or refusal to continue any license at least 20 days prior to such suspension, revocation or refusal to continue. In lieu of this, the Superintendent may order a hearing to be held at least 20 days from the date of a notice in order for the licensee to show cause why his/her license should not be revoked, suspended or refused renewal.

3. Suspension of a license may be effective for up to 1 year.4. During the period of suspension the licensee may not engage in any insurance transaction, other

than receipt and remittance of premiums paid for business transacted prior to the suspension.

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5. The superintendent shall not re-license any former licensee until it is shown that the former licensee is otherwise qualifi ed for the license and that the cause of the prior revocation or refusal to continue no longer exists.

6. Upon suspension, revocation, refusal to continue or other termination of the license, the licensee must surrender the license to the Superintendent.

7. A business entity licensed as an insurance producer may have its license suspended, revoked or denied renewal because of the actions of its designated individual authorized to conduct insurance transactions under the business’ license.

Cease and Desist Orders1. If the Superintendent determines that a person has engaged in an unfair method of competition, or

an unfair or deceptive act or practice, the Director shall issue an order requiring such person to cease and desist from engaging in such method of competition, act or practice.

2. If the Superintendent orders a person to cease and desist, the person must comply within 20 days, or within those 20 request a hearing.

3. After a hearing, the Superintendent will issue a fi nal order. If the hearing shows the licensee to be guilty of violations, he/she may be required to pay fi nes in addition to having his/her license suspended or revoked

Penalties and Fines1. In addition to denial, suspension, or revocation of certifi cate of authority or license, each violation

of the Code is punishable by a fi ne of up to $500.2. Where other monetary penalty is not expressly provided for, the administrative penalty shall be up

to $5,000 for each violation, except that if the violation is to be found willful and intentional, the penalty may be up to $10,000 for each violation.

3. In lieu of suspension, revocation, or refusal to continue a license the Superintendent may impose an administrative fi ne upon the licensee in amount of up to $500. The licensee has 60 days to pay fi nes and failure to pay will result in the license being suspended or revoked.

4. In addition to any administrative penalty, any license applicant who willfully misrepresents or willfully withholds requested material information, shall upon conviction be guilty of a misdemeanor punishable by a fi ne of up to $500.

State Regulation Superintendent’s General Duties and Powers 1. The Insurance Department shall be under the control and supervision of the Superintendent.2. The Superintendent may contract with a nongovernmental entity to perform ministerial functions

related to producer licensing.3. The Superintendent may make rules and regulations necessary for the administration or effectuation

of any provision of the Insurance Code.4. The Superintendent enforces and executes the duties imposed by the Insurance Code.5. The Superintendent may conduct examinations and investigations to determine if any person has

violated any provision of the Insurance Code.6. The Superintendent is authorized to protect nonpublic person information.7. The Superintendent may issue orders and notices.

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Company Regulation Certifi cate of Authority1. No person is permitted to act as an insurer and no insurer shall transact insurance in this state by

direct solicitation, solicitation through the mails or otherwise, without a Certifi cate of Authority issued by the Superintendent.

2. Any offi cer, director, agent, representative or employee of any insurer who willfully transacts any business of insurance without having the certifi cate, commits a misdemeanor and is subject to a fi ne up to $1,000.

Unfair Claims Settlement PracticesThe following are considered acts constituting improper claim settlement practices:1. Misrepresenting to claimants pertinent facts or provisions in the insurance policy that relate to any

coverage at issue.2. Failing to promptly acknowledge communications pertinent to a claim.3. Failing to use reasonable standards in the prompt investigation of claims.4. Failing to attempt to promptly and fairly settle claims in which liability is clear.5. Compelling an insured to fi le suit by offering substantially less than what a lawsuit would award.6. Refusing to pay claims without conducting a reasonable investigation.7. Failing to affi rm or deny coverage on a claim within a reasonable time after receiving a proof of

loss.8. Attempting to settle a claim for less than the amount to which the claimant believed he/she was

entitled by reference to written or printed advertising material accompanying the application.9. Attempting to settle a claim based on an application that was altered by the agent or company

without notice to, or consent of, the insured.10. Making claim payments that are not accompanied by statements indicating the coverage under

which payments are being made.11. Delaying the investigation or payment of a claim by requiring the claimant to submit both a formal

proof of loss form and subsequent verifi cation when both submissions contain the same information.12. Failing to settle all catastrophic claims within a 90-day period after the assignment of a catastrophic

claim number when a catastrophic loss has been declared.13. Making known to claimants a policy of appealing arbitration awards that favor claimants, for the

purpose of compelling them to accept a lesser settlement than that awarded.14. Failing to promptly settle claims (where liability is clear) under one section of the policy coverage

in order to infl uence settlements under other sections.15. Failing, after payment of a claim, to inform insureds or benefi ciaries, upon request by them, of the

coverage under which payment has been made. 16. Failing to promptly provide an insured a reasonable explanation of the basis for denial of a claim or

for the offer of a compromise settlement. 17. Violating a provision of the Domestic Abuse Insurance Protection Act.

Complaint Record 1. An insurer shall maintain a complete record of all complaints it has received for the next 3 years,

or since date of last examination by the superintendent or other similar supervisory authority, whichever period is shorter. For purposes of this section “complaint” means any written communication primarily expressing a grievance.

2. The record must show the:a. Total number of complaints.b. Classifi cation by line of coverage.c. Nature of each complaint.


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d. Disposition of the complaint; ande. Time it took to process each complaint.

Agent Appointment/ Termination1. An appointing insurer must fi le the appointment of an agent, specifying the lines of insurance, to

the Superintendent. Every insurer must annually fi le an alphabetical list of all producers whose appointments are being continued and a list of those not being continued.

2. An insurer terminating an agent’s appointment must fi rst notify the agent at least 180 days prior to the date of termination.

3. Each appointment remains in effect until the agent’s license is revoked or otherwise terminated the appointment is terminated.

4. When an insurer discharges an agent, the insurer must notify the Superintendent of the termination of appointment.

Agent Regulation Sharing of Commissions1. An insurer or producer may not pay a commission, service fee, brokerage, or other valuable

consideration to a person for selling, soliciting, or negotiating insurance in this state if that person is required to be licensed and is not so licensed.

2. No person may accept a commission, service fee, brokerage, or other valuable consideration for selling, soliciting or negotiating insurance in this state if that person is required to be licensed and is not so licensed.

3. A producer may not share his/her commission with any person who is not licensed as a producer, or is not licensed in the line of authority for the type of policy sold.

4. No person may collect any premium for insurance which has not been or will not be provided. 5. No person may collect as premium, an amount in excess of the premium as specifi ed in the policy.

Fiduciary Duties 1. All fi duciary funds received or collected by a producer shall be trust funds received in a fi duciary

capacity.2. The producer must remit premiums within 15 days after receipt. 3. The producer must establish a separate account for funds belonging to others in order to avoid

commingling of fi duciary funds with his/her own funds. a. Funds belonging to more than one principal may be commingled as long as adequate records are

maintained to show the amount of funds being held for each principal. b. The licensee may commingle with such fi duciary funds any additional funds necessary for

advancing premiums, payment of return commissions or other contingencies. Note: Personal funds may be commingled with fi duciary funds IF the principal for whom such funds are held has waived the fund segregation requirements in writing.

Prohibited Premiums or Charges 1. No person can willfully collect any sum as premium or charge for insurance or other coverage,

unless coverage is provided or in due course to be provided by a policy issued by an insurer, subject to acceptance of the risk by the insurer.

2. No person can willfully collect any sum in excess of the premium or charge as specifi ed in the policy. This does not prohibit:a. Surplus lines brokers charging and collecting applicable taxes or fees in addition to the premium

required by the insurer.b. Life insurers charging and collecting amounts to be expended for a medical examination of an

applicant for life insurance or for reinstatement of a life insurance policy.

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Controlled Business 1. The Superintendent cannot issue or permit to remain in force a license he fi nds or has cause

to believe that the license has been or probably will be used chiefl y for the purpose of writing insurance on the lives, property or risks of:a. The licensee or proposed licensee.b. His family members.c. Employees, employer, business associates.d. Directors, offi cers, employees, or principal stockholders of a corporation by which he is

employed or retained, or of which he is an offi cer, director, or principal stockholder.2. A license is considered used for writing controlled business if, in any calendar year, commissions

or other compensation earned from business described in paragraph 1 above, comprised more than 50% of all commissions and compensation earned.

3. Exception – This does not prohibit the issuance or the remaining in force of a license to sell credit life, health and accident insurance, lienholders collateral protection insurance or mortgage guaranty insurance held by a creditor.

Unfair Trade PracticesThe following are considered to be an unfair method of competition or an unfair trade practice in the business of insurance:1. Boycott, Intimidation or Coercion – Entering into action resulting in an unreasonable restraint of,

or monopoly in, the business of insurance.2. Defamation – Making any false or maliciously critical statement regarding the fi nancial condition

of any person, with the intent to injure such person.3. False Advertising – Publishing or disseminating in any fashion, or through any media, any untrue,

deceptive, or misleading statement about the business of insurance or, with respect to any person, in the conduct of such person’s insurance business.

4. Twisting – Misrepresenting for the purpose of inducing or tending to induce the lapse, forfeiture, exchange, conversion, or surrender of any insurance policy.

5. Rebating – Offering any rebate of premiums payable, any special favor in dividends or other benefi ts, or any valuable consideration or inducement not specifi ed in the policy. Any applicant or insured who knowingly receives any rebate of premium, special favor or advantage, or dividends or profi ts, except dividends on participating policies, upon conviction, is guilty of a misdemeanor punishable by a fi ne of up to $1,000. The following are not considered rebates:a. Paying bonuses to policyholders or reducing premiums out of accumulated surplus.b. Making allowances for industrial policyholders who consistently mail or deliver their premium

to the insurer and save collection expenses. c. Adjusting premium rates for group policyholders when loss or expense experience is less than

anticipated.d. Reducing the premium rates for policies or annuities on salary savings, payroll deduction,

preauthorized check, bank draft or similar plans.e. Extending credit for the payment of any premium, and for which credit a reasonable rate of

interest is charged and collected. 6. Unfair Discrimination – Permitting individuals of the same class and equal life expectancy to be

charged different rates for life insurance or annuities. Permitting individuals of the same class and essentially the same hazard to be charged different rates for accident or health insurance. Refusing to insure or charging a different rate to an individual based solely on the person’s gender. Refusing to insure or charging a different rate for life or health insurance to an individual who is, has been, or may be a victim of domestic abuse.

7. Unfair Discrimination Based on Blindness – Refusing to insure, or refusing to continue to insure, or limiting the amount, extent or kind of coverage available to an individual, or charging an

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individual a different rate for the same coverage solely because of blindness or partial blindness, except where based on sound actuarial principles or actual or reasonably anticipated experience.

8. Unfair Discrimination - Selection of Insurer – No person may require a debtor to acquire insurance through a particular insurer or producer as a condition to the lending of money or extension of credit.

9. Unfair Discrimination based on Health Deterioration – No insurer may cancel or change the premiums, benefi ts or conditions of an individual health insurance policy because of deterioration of the insured’s health after the policy has been issued.

10. Misrepresentations – Making, issuing or circulating any statement that misrepresents the benefi ts, advantages, conditions or terms of any insurance policy. a. Misrepresents the benefi ts, advantages, conditions or terms of any insurance policy.b. Makes any false or misleading statement as to dividends or share of surplus previously paid on

any policy.c. Is misleading or a misrepresentation as to the fi nancial condition of any person, or as to the

reserve system upon which any life insurer operates.d. Uses any policy name or title that misrepresents its true nature.e. Misrepresents any policy as being shares of stock. f. Fails to disclose material facts which prevent other statements made from being misleading.

11. False Statements – An agent, broker, solicitor, examining physician, applicant or other person shall not knowingly or willfully make a false or fraudulent statement or representation as to a material fact in an insurance application or claim. A false statement or representation made under oath shall constitute and be punishable as perjury. Violations are classed as follows when the potential loss to the insurer is: a. $250 or less is a petty misdemeanor.b. More than $250 but less than $500 is a misdemeanor.c. More than $500 up to $2,500 is a 4th degree felony.d. More than $2,500 up ot $20,000 is a 3rd degree felony.e. More than $20,000 is a 2nd Degree Felony.

Examination of Books and Records1. The Superintendent may conduct an examination to determine if any person has violated the laws of

this state.2. The Superintendent may conduct an examination of any insurer as often as the Superintendent

deems appropriate, but not less than once every 5 years.

Insurance Fraud Act1. The purpose of the Insurance Fraud Act is to permit the full utilization of the expertise of the

Superintendent to:a. Investigate and detect insurance fraud more effectively. b. Halt insurance fraud. c. Work with state, local and federal law enforcement and regulatory agencies against insurance

fraud. 2. Insurance fraud means any act or practice in connection with an insurance transaction that

constitutes a crime under the Criminal Code or the Insurance Code.3. The Superintendent may:

a. Conduct independent investigations when he/she has reason to believe that insurance fraud is being committed.

b. Respond to notice or complaints generated by federal, state, county, and local law enforcement. c. Review and respond to notices or reports of insurance fraud submitted by any person.

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d. Assemble evidence, prepare charges, and prosecute or assist in prosecution. e. Assist any agency in the investigation of fraud.

4. Each insurer or insurance professional who has reason to believe that an insurance fraud has been or is being committed must notify the Superintendent.

5. Each insurer who reported $10,000,000 or more in direct written premiums for the previous year, must establish an ant-fraud plan.

6. A person is not subject to civil liability for fi ling reports, providing information, or cooperating with an investigation or examination of insurance fraud, provided it is without malice.

7. All claim forms and applications for insurance must contain a statement which states substantially the following: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.”

8. The Insurance Fraud Fund is established in the State Treasury. The Superintendent may assess a fee from insurers to deposit into the Insurance Fraud Fund for implementation the provisions of the Insurance Fraud Act.

9. The Superintendent may make rules necessary for the administration of the Insurance Fraud Act.

Consumer Information Privacy Act1. Nonpublic Personal Information – Nonpublic personal fi nancial information and nonpublic

personal health information.2. Nonpublic Personal Financial Information – Personally identifi able fi nancial information; and

any list, description or other grouping of consumers (and publicly available information pertaining to them) that is derived using any personally identifi able fi nancial information that is not publicly available. Nonpublic personal fi nancial information does not include:a. Health information.b. Publicly available information. c. Any list, description or other group of consumers (and publicly available information pertaining

to them) that is derived without using any personally identifi able fi nancial information that is not publicly available.

3. Nonpublic Personal Health Information – Health information:a. That identifi es an individual who is the subject of the information; orb. With respect to which there is a reasonable basis to believe that the information could be used to

identify an individual.4. A licensee must provide a notice that refl ects its privacy policies and practices to:

a. An individual who becomes the licensee’s customer, not later than when the licensee establishes a customer relationship.

b. A consumer, when the licensee request authorization to disclose any nonpublic personal fi nancial information about the consumer to any nonaffi liated third party and for which no authorization is required.

c. Each consumer jointly entering the same contract or obtaining the same product.5. As a general rule, a licensee establishes a customer relationship at the time the licensee and the

consumer enter into a continuing relationship.6. When an existing customer obtains a new insurance product or service from a licensee, the licensee

may satisfy the initial notice requirements as follows:a. The licensee may provide a revised policy notice that covers the customer’s new insurance

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b. If the initial, revised or annual notice that the licensee most recently provided to that customer was accurate with respect to the new insurance product or service, the licensee does not need to provide a new privacy notice.

7. An insurer or licensee must provide a notice of information practices to all applicants or policyholders as follows:a. With a written application, disclosure notice must be given at the time of delivery of the policy

or at the time when the collection of personal information is taken from a source other than the applicant.

b. In the case of a renewal policy, at least annually.8. The notice must be in writing and contain the following information:

a. A statement that information may be collected from persons other than the individual who is to be insured.

b. A list of the categories and types of information that may be collected.c. The types of disclosure.d. Policies and practices used to protect the confi dentiality of personal information.e. A description of the insured’s rights and how the rights may be exercised.f. The categories of affi liates and nonaffi liated third parties to whom nonpublic personal

information may be disclosed.9. If a licensee does not disclose, and does not wish to reserve the right to disclose, nonpublic personal

fi nancial information, the licensee may simply state the fact.10. A licensee may not disclose any nonpublic personal health information to any party, including

affi liates, and may not disclose any nonpublic personal fi nancial information to a nonaffi liated third party unless:a. The licensee has provided the initial notice to the consumer.b. The licensee has provided a notice regarding request for authorization to the consumer. c. An authorization is obtained from the consumer whose nonpublic personal information is to be

disclosed.11. A licensee may not disclose, other than to a consumer reporting agency, a policy number or similar

form of access number or access code for a consumer’s policy or account to any nonaffi liated third party for use in telemarketing, direct mail marketing or other marketing through electronic mail to the consumer.

12. The requirements for initial notice and for notice and authorization do not apply if the licensee discloses nonpublic personal information only to the extent necessary to effect, administer or enforce a transaction that a consumer requests or authorizes, or in connection with: a. Servicing or processing an insurance product or service that a consumer requests or authorizes.b. Maintaining or servicing the consumer’s account.c. A proposed or actual securitization, secondary market sale or similar transaction related to a

transaction of the consumer.d. Reinsurance or stop loss or excess loss insurance.

13. A valid authorization must be in written or electronic form and contain the following:a. A general description of the type(s) of information to be disclosed.b. A general description of the receiving parties, the purpose of disclosure, and how the

information will be used.c. The signature of the consumer.d. Length of time for which the authorization is valid, notice that the consumer or customer may

revoke the authorization at any time, and the procedure for revocation.e. Identity of the individual who is the subject of the personal information.f. The authorization is valid for 24 months.


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14. A consumer or customer who is the subject of nonpublic personal information may revoke an authorization at any time.

15. A licensee must retain the authorization or a copy thereof in the record of the individual who is the subject of nonpublic personal information.

16. A licensee may not unfairly discriminate against any consumer because that consumer has not granted authorization for the disclosure of his/her nonpublic personal information.

17. Privacy notices must use clear, concise everyday language. They should use bullet lists when possible, avoid multiple negatives, and avoid legal terms with which the insured is not familiar.

Federal RegulationThe Fair Credit & Reporting Act1. Under this law, insurance applicants must be informed that the insurer might conduct a fi nancial

investigation through a credit bureau.2. The applicant must be informed of any adverse information found by the insurer.3. The applicant must be provided information on how to dispute and correct any adverse or false

information.

Fraud and False Statements These prohibitions and penalties apply to fraud and false statements affecting insurance persons whose activities affect interstate commerce: 1. It is prohibited to:

a. Make any false statement or intentionally overvalue any asset in fi nancial reports to infl uence an offi cial’s or agency’s actions.

b. Embezzle. c. Make a material false entry in any book, report, or statement with the intent to deceive any

offi cial or examiner. d. Use threats or force to infl uence, obstruct, or impede a legal proceeding.

2. A false entry or statement endangering an insurer and contributing to its conservation, rehabilitation, or liquidation is punishable by imprisonment up to 15 years. Any fi ne shall be remitted to the insurer’s policyholders, claimants, and creditors.

3. A false statement is punishable by a fi ne of $50,000 per violation or the compensation the person receives or offers for the violation, whichever is greater.

4. All other prohibited acts are punishable by a fi ne, imprisonment for up to 10 years, or both.

15 Life & Health

Life Laws

16Life & Health

17 Life & Health

Life Laws Insurable Interest1. New Mexico recognizes love and affection as a basis for insurable interest between close relatives.

It also recognizes insurable interest between persons involved jointly in a business, corporation, or shares of stock.

2. Insurable interest is not required if the insured consents by signing the policy and a charity, school, or religious institution is irrevocably designated as the benefi ciary.

3. A person at least 15 years of age is deemed competent to obtain life insurance. The benefi ciary must be the minor’s estate or a person having an insurable interest in the minor’s life.

4. For a life or health policy to be valid, the insured must consent to the coverage, except for:a. Group or blanket coverage.b. Coverage obtained by the insured’s spouse.c. Coverage on a minor obtained by the insured’s legal guardian; ord. Family policies, which may be signed by either parent, stepparent, a guardian or by either

spouse.

Variable Products1. An insurer issuing variable life insurance or annuities must establish one or more separate accounts

in which to allocate the assets for these types of contracts.2. Assets allocated to a separate account must be valued at their market value on the date of valuation. 3. No transfer of assets may be made between any of an insurer’s separate accounts unless such

transfer is for the purpose of establishing the account or to support the contracts to which the separate account pertains.

4. Variable contracts must contain a statement of the procedures to be followed by the insurer in determining the dollar amount of such variable benefi ts.

5. Variable contracts must state that the dollar amount of variable benefi ts will vary to refl ect investment experience.

6. Variable accounts shall be credited with income, gains and losses, realized or unrealized, from assets allocated to a separate account without regard to other income, gains or losses of the insurer.

Advertising1. Insurers must keep a copy of all advertisements, each 1 being notated as to its use and policy form

numbers associated with it, and kept on fi le at least 3 years. 2. Insurance advertisements and other sales material must be accurate, not misleading or deceptive.

Insurance advertising and other sales materials regarding insurance must include disclosures containing language that is the same or substantially similar to the following:a. Insurance is not a lending institution deposit account and is not insured by its federal deposit

insuring agency.b. Where applicable, insurance involves investment risk, including potential loss of principal.

3. Life & Health Guaranty Association – It is a prohibited unfair trade practice for any person to advertise the existence of the Life & Health Insurance Guaranty Association as an inducement to purchase insurance.

Illustrations 1. A basic illustration of a life policy’s benefi ts must:

a. State: 1) The insurer’s name and address. 2) The underwriting classifi cation.


18Life & Health

3) The policy’s generic name, product name, if different, and form number. 4) The initial death benefi t. 5) Any dividend option and non-guaranteed benefi ts. 6) That any non-guaranteed elements are unlikely to remain constant as shown, and that the

producer has explained this fact. Note: This statement must be signed by the applicant and the producer.

7) Any other information required by law. b. Describe the policy, the premium, and any features, riders, or options shown. c. Include a numeric summary of the benefi t values and the premium as well as a narrative

summary. 2. When using an illustration in the sale of a life insurance policy, an insurer, its producers or other

authorized representatives shall not: a. Represent the policy as anything other than a life insurance policy; b. Use or describe non-guaranteed elements in a manner that is misleading or has the capacity or

tendency to mislead; c. State or imply that the payment or amount of non-guaranteed elements is guaranteed; d. Use an illustration that does not comply with the New Mexico requirements;e. Use an incomplete illustration; f. Represent in any way that premium payments will not be required in order to maintain the

illustrated death benefi ts, unless that is the fact;g. Use the term “vanish” or “vanishing premium,” or a similar term to describe a plan for using non-

guaranteed elements to pay a portion of future premiums; h. Use an illustration that is lapse-supported, except for policies that can never develop

nonforfeiture values; ori. Use an illustration that is not self-supporting.

3. Illustrations must contain a statement expressing the following: “This illustration assumes that the currently illustrated non-guaranteed elements will continue unchanged for all years shown. This is not likely to occur, and actual results may be more or less favorable than those shown.”

4. A basic illustration shall include a numeric summary of the death benefi ts and values and the premium outlay and contract premium, as applicable. This summary shall be shown for at least policy years 5, 10, 20 and at age 70. In addition, if coverage would cease prior to policy maturity or age 100, the year in which coverage ceases shall be identifi ed.

5. The producer and applicant must both sign and date the basic illustration and any revised illustration (which is used if the policy is issued other than as solicited) or must both sign a statement that no illustration was used. The statement shall be as follows: “I have received a copy of this illustration and understand that any non-guaranteed elements illustrated are subject to change and could be either higher or lower. The agent has told me they are not guaranteed.” The producer must sign and date the following statement: “I certify that this illustration has been presented to the applicant and that I have explained that any non-guaranteed elements illustrated are subject to change. I have made no statements that are inconsistent with the illustration.”

6. Supplemental Illustrations – A supplemental illustration may be provided so long as: a. It is appended to, accompanied by or preceded by a basic illustration that complies with this

rule;b. The non-guaranteed elements shown are not more favorable than the corresponding elements

used in the basic illustration; c. It contains the same statement required of a basic illustration that non-guaranteed elements are not

guaranteed. 7. The producer must give the applicant a copy of any such signed document before submitting

the original to the insurer. The original must be submitted with the application or, if a revised illustration, by the time the policy is delivered.

LIFE LAWS

19 Life & Health

8. If the insurer issues a policy, it must keep the original and any revised illustration, a statement that the policy was applied for other than as illustrated or a statement that no illustration was used for 3 years after the policy is no longer in force.

9. If an illustration is used when soliciting a life policy containing a nonforfeiture provision, the insurer must give each policyowner an annual report on the policy’s status. The report must provide an in-force illustration and disclose any adverse change in non-guaranteed elements.

Policy Summary and Buyer’s Guide1. The insurer shall provide, to all prospective purchasers must be provided with a buyer’s guide and a

policy summary prior to accepting the applicant’s initial premium or premium deposit.2. If the policy contains a 10-day free look provision, the buyer’s guide and policy summary must be

delivered with the policy or prior to delivery of the policy. 3. A buyer’s guide and a policy summary must be provided to any prospective purchaser upon request. 4. Failure of an insurer to provide or deliver a buyer’s guide or a policy summary constitutes an

omission which misrepresents the benefi ts, advantages, conditions or terms of an insurance policy.5. Every policy summary must provide at least the following information:

a. The name and address of the insurance agent or, if no agent is involved the procedure to get a response regarding the policy summary.

b. The full name and home offi ce or administrative offi ce address of the company the life insurance policy is to be or has been written.

c. The generic name of the basic policy and each rider.d. Illustration of the premium and benefi t patterns.e. The annual premium for the basic policy.f. The annual premium for each optional rider.g. The amount payable upon death at the beginning of the policy year regardless of the cause of

death, other than suicide or other specifi cally enumerated exclusions.h. The total guaranteed cash surrender values at the end of the year with values shown separately

for the basic policy and each rider; andi. Any endowment amounts payable under the policy which are not included under cash surrender

values above.j. The date on which the policy summary is prepared.

Note: The policy summary should display guarantees only.

Policy Replacement1. The objective of the rule regarding replacements is:

a. To regulate the activities of insurers and producers with respect to the replacement of existing life insurance and annuities.

b. To protect the interests of life insurance and annuity purchasers by establishing minimum standards of conduct in replacement or fi nanced purchase transactions, for the purpose of:1) Assuring that purchasers receive information with which a decision can be made in his/her

own best interest.2) Reduce the opportunity for misrepresentation and incomplete disclosure; and3) Establish penalties for failure to comply with requirements of this Rule.

2. Replacement means any transaction in which new life insurance or an annuity is to be purchased, and it is known, or should be known to the agent, that the existing contract(s) will be:a. Lapsed, forfeited, surrendered or terminated.b. Converted to effect a reduction in the amount of existing insurance, or term of which the

coverage would remain in force.c. Reissued with a reduction in cash values.


20Life & Health

d. Assigned as collateral for a loan or subjected to substantial borrowing of loan values in single or multiple transactions.

e. Converted into paid-up insurance, continued as extended term insurance or another form of nonforfeiture benefi t.

3. Each producer who initiates the application shall submit to the insurer with or as part of each application: a. A statement signed by the applicant as to whether replacement of existing life insurance or

annuity is involved. b. A signed statement as to whether the producer knows replacement is or may be involved.

4. Where a replacement is involved, the producer must: a. Present to the applicant, not later than at the time of taking the application, a Notice Regarding

Replacement. b. Obtain with or as part of each application a list of all existing life insurance and/or annuities to

be replaced. c. Leave with the applicant the original or a copy of written or printed communications used for

presentation to the applicant. d. Submit to the replacing insurer with the application a copy of the Replacement Notice.

5. Each insurer must: a. Notifying each insurer whose insurance is being replaced within 5 working days and furnishing

a copy of any illustration or policy summary within 5 business days of any request.b. Keep a copy of a signed Notifi cation Regarding Replacement for at least 5 years after the policy

is no longer in force. c. Provide a 30-day free look provision for the policy owner.

Life Insurance Group Policies Plan Sponsors1. Employee Group – A group life policy may be issued to an employer, or to the trustees of a fund

established by an employer, to insure employees of the employer, subject to the following:a. The employer or trustees shall be deemed the policyholder. b. The premium for the policy shall be paid either from the employer’s funds or from funds

contributed by the insured employees, or from both. c. A policy on which no part of the premium is to be derived from funds contributed by the insured

employees must insure all eligible employees, except those who reject coverage. 2. Debtor Group – A group life policy may be issued to a creditor to insure debtors of the creditor,

subject to the following:a. The creditor shall be deemed the policyholder. b. The premium for the policy shall be paid either from the creditor’s funds or from funds

collected by the insured debtors, or from both. c. A policy on which no part of the premium is to be derived from funds collected by the insured

debtors must insure all debtors.d. The amount of insurance on the life of any debtor may not exceed the greater of the scheduled

or actual amount of unpaid indebtedness. e. An insurer may exclude any debtors whose evidence of individual insurability is not satisfactory

to the insurer. 3. Labor Union Group – A group life policy may be issued to a labor which shall be deemed the

policyholder, to insure members of such union, subject to the following requirements: a. The premium for the policy shall be paid either from the union’s funds or from funds collected

by the eligible members, or from both.

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12

LIFE LAWS

21 Life & Health

b. A policy on which no part of the premium is to be derived from funds collected by the eligible members must insure all eligible members.

c. An insurer may exclude or limit the coverage on any person whose evidence of individual insurability is not satisfactory to the insurer.

4. Trustee Group – A group life policy may be issued to a trust or to the trustee of a fund established by 2 or more employers, or by 1 or more labor unions ,or by 1 or more employers and 1 or more labor unions, to insure employees of the employers or members of the unions.a. All of the employees or all of the members of the unions or organizations shall be eligible for

coverage. This includes retired employees and directors. b. The policy premiums shall be paid from funds contributed by either the employer(s), the union

or similar employee organizations, the insured persons, or from all these groups. c. An insurer may exclude or limit the coverage on any person whose evidence of individual

insurability is not satisfactory to the insurer.5. Association Group – A group life policy can be issued to any association organized for purposes

other than that of obtaining insurance and insure at least 25 members.

Conversion Rights1. A group life policy must provide that if the insurance on a person covered under the policy

ceases because of termination of employment or of membership in the class eligible for coverage, the person is entitled to have issued an individual policy of life insurance, without evidence of insurability. The application for the individual policy must be submitted and the fi rst premium is paid to the insurer within 31 days after termination.

2. In the event that a group policy terminates, every insured and covered dependent who has been so insured for at least 5 years prior to such termination is entitled to convert to an individual policy of life insurance without evidence of insurability. The amount of the individual policy may not exceed the smaller of: a. The amount of the person’s life insurance ceasing because of the termination; or b. $10,000.

3. If an insured or covered dependent dies during the period within which he/she would have been entitled to convert to an individual policy, the amount of life insurance which he/she would have been entitled to shall be paid as a claim under the group policy, regardless of whether application for the individual policy or the payment of the fi rst premium has been made.

4. If any individual entitled to a conversion right is not given notice of the existence of such right at least 15 days prior to the expiration date of the application period, the individual has an additional 15 days to exercise such right.

5. The conversion privilege must be available:a. To a surviving dependent if the policy terminates by reason of the employee’s death; andb. To the dependent of the employee or member who ceases to be a dependent under the group

policy because of divorce or otherwise.

Continuation of Coverage1. Where active employment is a condition of insurance, a group life policy must allow an insured to

continue coverage during the insured’s total disability by timely payment of his/her portion of the premium, if any that would have been required had total disability not occurred.

2. The continuation shall last for 6 months from the date the total disability started, but not beyond the earlier of:a. Approval by the insurer of continuation of the coverage under any disability provision which

the group policy may contain; or b. The discontinuance of the group policy.


22Life & Health

Life Insurance Policy Provisions Individual PoliciesThe following laws apply to life policy provisions:1. Grace Period – The grace period must be 30 days or, at the insurer’s option, one month of at least

30 days, except that an industrial life policy with premiums payable more frequently than monthly may have a grace period of 4 weeks. a. Interest may be charged for the days a policy is in force during the grace period, at a rate not to

exceed 6%.b. If a claim is paid during the grace period, any unpaid premium and interest may be deducted

from the claim payment.2. Reinstatement – This period is 2 years for industrial life policies and 3 years for all other life

policies. Reinstatement is subject to the incontestability clause from the date of reinstatement. 3. Incontestability – The insurer cannot contest statements contained in the application once the

policy has been in force for 2 years. 4. Exclusions – An individual life policy may exclude coverage for foreign residency. 5. Payment of Claims – A claim must be paid within 2 months or the period allowed by the policy,

whichever is less. 6. Settlement of Death Benefi t – Settlement is due on receipt of proof of death and, at the insurer’s

option, surrender of the policy or proof of the interest of the claimant. If an insurer does specify a particular period in which settlement will be made, that period cannot be over 2 months from the receipt of the proofs.

7. Entire Contract – The policy, or the policy and the application (if a copy of the application is attached to the policy when issued), shall constitute the entire contract between the parties. Statements contained in an application shall, in the absence of fraud, be deemed representations and not warranties.

8. Misstatement of Age – If the insured’s or any other person’s age considered in determining the premium or benefi t has been misstated, any amount payable or benefi t accruing under the policy shall what the premium would have purchased at the correct age.

9. Payment of Premiums – All policies must state the premium amount and payment time/method.

Provisions Prohibited in Individual Life Insurance1. An individual life policy cannot be backdated more than 1 year in New Mexico. 2. A policy cannot require a solicitor and agent to be the same person and any acts or representations

made by a solicitor cannot be binding on the insured.3. Industrial Policy – A policy of industrial life insurance cannot contain any of the following

provisions:a. The insurer denying liability under the policy because the insured has previously obtained other

insurance from the same insurer.b The insurer’s right to declare a policy void because the insured has had any disease, ailment, or

institutional, hospital, medical or surgical treatment or attention, unless the treatment was:1) Less than 2 years before applying for the policy; and2) The result of a condition material to the risk.

c. The insurer having the right to declare a policy void because the insured has been rejected for insurance, unless it can be shown that such rejection would have led the insurer to refuse to issue a policy.

23 Life & Health

Health Laws

24Life & Health

25 Life & Health

Health Laws AdvertisingThe following laws apply to health insurance advertisements. 1. An advertisement must:

a. Identify the insurer and, if applicable, the policy. b. Identify the end of any initial open enrollment period, if advertising a particular policy. c. Identify the source of any statistics used. d. Disclose any limited provider network. e. Disclose any waiting, elimination, or probationary periods. f. Disclose, if for a policy solicited by direct response:

1) Coverage limits and exclusions. 2) Any renewability, cancellation, and modifi cation provisions. 3) Any option in benefi t amounts. 4) If benefi ts are available only through a combination of policies.

2. An advertisement may not: a. Be untrue or misleading. b. Describe a policy as “low cost” because it is sold by direct response. c. Defame another insurer or its products. d. Imply:

1) Government endorsement. 2) That the reader is legally required to respond. 3) That an individual policy is a special offer.

e. Falsely imply: 1) Endorsement. 2) That an insurer is licensed in any specifi c jurisdiction. 3) That prospects will enjoy special rates if they become members of a particular group. 4) That applicants for an individual policy will receive advantages for applying within a

limited time. 5) That the offer of an individual policy is limited to a specifi c group of individuals.

f. Use the existence of the Life & Health Guaranty Association as in inducement to purchase insurance.

3. Testimonials and endorsements must: a. Be genuine. b. Represent the author’s current views. c. Apply to the policy advertised. d. Be accurately reproduced. e. Disclose if the provider was paid for the testimonial or endorsement. f. Disclose if the provider is a spokesperson for, meaning he/she has a fi nancial interest in, the

product or insurer being advertised. 4. An insurer must:

a. Assume responsibility for its advertisements. b. Annually certify that its advertisements comply with state law. c. Maintain a record of any testimonial referring to benefi ts for 4 years or until the next

examination by the Superintendent, whichever is later. d. Maintain a record of all advertisements for 5 years or until the next examination by the

Superintendent, whichever is later.

Individual Underwriting1. Unfair Discrimination – No insurer or person can make or permit any unfair discrimination:

a Between individuals of the same class, equal expectation of life or hazard in rates charged for any contract of life insurance or of life annuity, in dividends or other benefi ts payable, or in any other of the terms and conditions.

b. Blindness.c. Cancelation or changing premiums, benefi ts or conditions of an individual health insurance

policy or contract solely because of the insured’s health deteriorated after the policy was issuedd. If a policy is converted to individual coverage, it must provide benefi ts and coverages closely

approximating the policy from which the conversion was made.2. Genetic Testing – A test of a person’s DNA, gene products or chromosomes that indicates a

propensity for or susceptibility to illness, disease, impairment or other disorders, whether physical or mental. The test is meant to reveal genetic or chromosomal damage due to environmental factors or indicate carrier status for disease or disorder.a. Obtaining genetic information or samples for genetic analysis without the person’s informed

and written consent is not permitted. b. Genetic information cannot be the cause of an insurer discrimination against an insured or

applicant. c. A health insurer cannot consider a genetic propensity, susceptibility, or carrier status as a

preexisting condition for the purpose of limiting or excluding benefi ts, establishing rates or providing coverage.

d. It is unlawful to use genetic information in employment, recruiting, housing, lending decisions, or in extending public accommodations and services.

e. When collecting genetic information for insurance transactions, the applicant or insured must receive in writing that the information might be used, transmitted, or retained solely for the purpose of transacting insurance business. Exception: Genetic information may not be retained if it violates religious tenets or practices of the person, his representative, or the parent / guardian of a minor child.

f. Excluded from genetic testing are routine physical measurements, chemical, blood and urine analysis, tests for drugs, tests for the presence of HIV and any other tests/analyses commonly accepted in clinical practice.

Individual Health Policy Provisions Required Provisions1. Every policy of individual health insurance must contain the following:

a. The entire premium. b. The time at which insurance takes effect and terminates. c. It purports to insure only 1 person, except for dependents. d. The exclusions and reductions are captioned and clearly set forth.e. Reinstatement is effective if the insurer does not deny reinstatement within 30 days after

receiving a reinstatement application. Note: If the policy is guaranteed renewable until the insured reaches age 50, back premiums may not be collected for more than 60 days.

f. Any benefi ts for a continuous loss must be paid at least once per month. g. Any legal action against the insurer must begin within 3 years after proof of loss was required to

be fi led. 2. Time Limit on Certain Defenses – Health insurance policies must contain a provision providing

that after 2 years from the date of issue, no misstatements, except fraudulent, made by the applicant in the application for such policy may be used to void the policy or to deny a claim. Insurers may


26Life & Health

waive this limit when the insured reaches age 50 or if the policy was issued after age 44, then 5 years from the issue date. However, any period of disability is not counted toward the 2 year probation period.

3. Preexisting Condition Exclusions – Health insurance policies may contain preexisting condition provisions under which coverage may be excluded for a period of 6 months following the effective date of coverage for a condition that manifested itself within six months prior to the effective date of coverage. However, a claim shall not be reduced or denied on the grounds of preexisting conditions if the claim results from a disease or physical condition that was disclosed on the application and is not excluded from coverage by name or a specifi c description.

4. Payment of Claims – Indemnity for loss of life is payable in accordance with the benefi ciary designation. If no such designation is effective, such indemnity is payable to the estate of the insured.

5. Reinstatement – A policy will be reinstated within 30 days after required premiums are paid and a conditional receipt is given. Premiums paid in relation to reinstatement may cover no more than 60 days of previously unpaid coverage.

6. Legal Actions – In New Mexico, an insured cannot bring legal action against an insurer for nonpayment of claim after 3 years has elapsed since the proof of claim was submitted.

7. Entire Contract – The policy must have a statement that the policy, including the endorsements and attached papers, if any, constitutes the entire contract of insurance. No change shall be valid until approved by an executive offi cer of the insurer and the approval with the insured’s signature is attached. No agent has authority to change this policy or to waive any of its provisions.

8. Grace Period – Health policy grace periods are as follows:a. 7 days for weekly premium policies.b. 10 days for monthly premium policies. c. 31 days for all other policies.

Note: The policy must state that the grace period is ineffective if the insurer provides a notice of nonrenewal at least 5 days before the policy termination.

9. Claim Procedures – Written notice of claim must be given to the insurer within 20 days after the event or start of any loss covered by the policy, or as soon thereafter as is reasonably possible. In a policy providing a loss-of-time benefi t that may be payable for at least 2 years, the insured shall at least once every 6 months give notice to the insurer that the disability is continuing. Delay in the giving of such notice shall not impair the insured’s right to any benefi t that would otherwise have been paid during the period of 6 months preceding the date on which such notice is actually given.

10. Physical Examination and Autopsy – The insurance company at its own expense shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim and to make an autopsy in case of death where it is not forbidden by law.

11. Change of Benefi ciary – Unless the insured makes an irrevocable designation of benefi ciary, the right to change of benefi ciary is reserved to the insured. The benefi ciary’s consent is not required to surrender, assign, change the benefi ciary or make any other changes to the policy.

Optional Provisions 1. Change of Occupation2. Misstatement of Age3. Other Insurance With Same Insurer4. Other Insurance With Different Insurer5. Unpaid Premium6. Cancellation

HEALTH LAWS

27 Life & Health

Note: If an insurer is going to discontinue a particular coverage, it must notify covered persons at least 90 days in advance. If an insurer is going to discontinue all health coverage, it must notify all insureds at least 180 days in advance and cannot reenter the market for 5 years.

7. Conformity With State Statutes.

Individual Disability Insurance Loss of Time Benefi t Adjustment1. Disability benefi ts will not exceed the greater of the disabled person’s:

a. Monthly wage; orb. Average monthly wage for the 2 years prior to the disability.

2. If disability benefi ts are greater than the disabled person’s monthly wage or average monthly wage for the previous 2 years, then any excess premium paid will be returned.Example: John pays $50 per month for disability coverage and the policy will pay up to $3,000 per month in benefi ts. However, John earns only $2,000 in benefi ts and the premiums for that amount of coverage is only $42. If he uses the policy benefi ts in the amount of his monthly wages, the excess premium he has been paying ($8 per month) will be returned.

3. Disability benefi ts must be at least $200 per month unless the policy specifi es a lower allowable amount.

Medical Plans New Mexico Eligibility Requirements and Benefi t Offers (Individual and Group)1. Dependent Child Age Limit – The Patient Protection and Affordable Care Act of 2010 requires all

states to allow children to be covered on a parent’s health insurance up to age 26. 2. Continued Coverage of Handicapped Children – To be covered at age 26 and beyond, the child

must be handicapped and incapable of self-sustaining employment or otherwise be dependent upon his parents for subsistence. The insured must provide supporting documentation of the incapacity to the insurer within 31 days of the dependent child reaching the limiting age. The insurer may require subsequent documentation but after 2 years, such supporting documentation can be required only annually.

3. Newborn Children – Individual and group disability insurance policies which provide coverage for dependent children of the insured must provide coverage for newborn children including adopted newborn children for 31 days from and after the moment of birth or placement for adoption. The coverage for newly born children must cover injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities and, where necessary to protect the life of the infant, transportation, including air transport, to the nearest available tertiary care facility for newly born infants. It also covers circumcision of male infants.

4. Adopted Children – An individual or group health insurance policy must cover adopted children of the insured on the same basis as other dependents. Coverage begins when the child is placed in the home, even if the adoption process is not yet completed. Coverage shall include care and treatment for conditions existing prior to placement in the adoptive home.

5. Child Enrollment; Noncustodial Parents – An insurer may not deny enrollment of a child under the health plan of the child’s parent on the grounds that the child: a. Was born out of wedlock.b. Is not claimed as a dependent on the parent’s federal tax return; or c. Does not reside with the parent or in the insurer’s service area.

6. When a child has health coverage through an insurer of a noncustodial parent, the insurer shall:a. Provide such information to the custodial parent as may be necessary for the child to obtain

benefi ts through that coverage.

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28Life & Health

b. Permit the custodial parent or the provider, with the custodial parent’s approval, to submit claims for covered services without the approval of the noncustodial parent.

7. An insurer shall provide coverage for children, from birth through 3 years of age, for or under the family, infant, toddler program administered by the Department of Health, provided eligibility criteria are met, for a maximum benefi t of $3,500 annually for medically necessary early intervention services.

8. Hearing Aid Coverage – Health policies must cover expense for hearing aid and any related service for the full cost of 1 hearing aid per hearing-impaired ear up to $2,200 every 36 months. This coverage lasts until the child reaches age 18 to 20 if still attending high school.

9. Additional Coverage – All individual and group health policies issued in New Mexico must provide the following coverages:a. Childhood Immunization – This includes the initial immunization shots and medically

necessary booster shots. This coverage does not apply to short-term travel, accident-only or limited or specifi ed disease policies. This coverage may be subject to deductibles and coinsurance consistent with those imposed on other benefi ts under the same policy, plan or certifi cate.

b. Circumcision For Newborn Males c. Maternity Transport – Policies providing coverage on an expense-incurred basis shall also

provide coverage for emergency transportation, including air transport, for medically high-risk pregnant women with an impending delivery of a potentially viable infant. Such coverage applies when the transportation is necessary to save the mother and/or the baby’s life.

10. Home Health Care Coverage – In New Mexico, hospital and medical expense policies must provide the option of home health care coverage, which will include:a. RN, LPN, or Home Health Aide services.b. Physical, occupational, respiratory, and speech therapy.c. Medical supplies, drugs, medicines, and laboratory services.

11. Home health care coverage may be limited to:a. Services provided on the written order of a licensed physician, provided the order is renewed at

least every 60 days.b. Direct or contract agreements with a home health agency licensed in the state where home

health services are delivered; andc. Services without which the insured would have to be hospitalized.

12. Coverage provides at least 100 home visits per insured per year, with each home visit including up to 4 hours of home health care services.

13. Managed Health Care Rule – Insurers using managed health care plans are subject to the following rules:a. A summary of benefi ts and exclusions, premium information and provider listing, along with

information on how to access or obtain the evidence of coverage must be provided to each subscriber (covered people on request).

b. An insurer must give each enrollee a statement of his / her rights when delivering the enrollee’s evidence of coverage.

14. An insurer offering comprehensive coverage for basic health care services must provide coverage for the following when medically necessary: a. Physician and diagnostic services.b. Outpatient medical and inpatient hospital services.c. Short-term rehabilitation services and physical therapy.d. Emergency and urgent care.e. Children’s health care and women’s health care.f. A health promotion program.

HEALTH LAWS

29 Life & Health

g. Dental services.h. Mental health services.i. Surgical benefi ts.j. Other services as required by law.

15. An insurer may not limit or exclude prescription drug coverage: a. Because it is not prescribed for its intended use, as long as the use for which it is prescribed is

accepted by the medical community. b. For a drug not specifi cally covered if it serves the same purpose as a covered drug, as long as

the enrollee’s patient history indicates that the prescribed drug will be more effective or will help the enrollee avoid an adverse reaction.

16. Women cannot be charged a higher co-pay for requesting a female physician as her primary care provider.

17. Managed health plans may provide the following supplemental coverages:a. Consultation services.b. Corrective devices such as prosthetics.c. Cosmetic surgery.d. Outpatient drugs.e. Ambulance services.f. Vision care.g. Long term therapy.h. Experimental/Investigational services.

18. Mental Health Paritya. Group health plans shall not impose treatment limitations or fi nancial requirements on mental

health benefi ts if identical limitations or requirements are not imposed on other conditions. Group plans may:1) Require pre-admission screening prior to the authorization of mental health benefi ts whether

inpatient or outpatient; or 2) Apply limitations that restrict mental health benefi ts provided under the plan to those that

are medically necessary. b. Group health plans may not be changed through amendment or renewal to exclude or decrease

the mental health benefi ts existing as of that date. An employer with 2 to 49 employees, and having group health coverage may, if a premium increase of more than 1.5% results from the inclusion of mental health benefi ts: 1) Pay the premium increase.2) Reach agreement with the employees to cost-share the premium increase.3) Negotiate a reduction in coverage, but not below the coverage existing before the renewal,

to reduce the premium increase to no more than 1.5%; or 4) After demonstrating to the Insurance Division’s satisfaction that the premium increase

above 1.5% is due exclusively to the required additional coverage, receive written permission to not increase coverage. Note: Employers having 50 or more employees may take one of the same above actions if inclusion of mental health benefi ts in their group policy results in a premium increase of more than 2.5%.

c. Mental Health Benefi ts – The same as described in the group health plan, or group health insurance offered in connection with the plan, but does not include benefi ts with respect to treatment of substance abuse, chemical dependency or gambling addiction.


30Life & Health

Group Health Insurance Extension of Benefi ts 1. If a policy providing disability benefi t extensions of any type is discontinued, the extensions will not

be discontinued. 2. If a disability income contract providing benefi ts for loss of time from work or specifi c indemnity

during hospital confi nement is discontinued, the benefi ts will still be payable to the individual. 3. Hospital, major medical, comprehensive medical expense coverage, and HMO plans other than

dental and maternity expense, must provide an extension of at least 12 months. Other types of hospital or medical expense coverage should provide an extension of at least 90 days.

4. Any applicable extension of benefi ts or accrued liability is described in the group contract as well as in group insurance certifi cates.

5. A conversion or continuation privilege must be exercised within 30 days. 6. Continuation of group coverage must be allowed for 6 months. 7. An insured minor must be allowed to convert health coverage to an individual policy when he/she is

18 years of age.

Continuation of Coverage under HIPAA, COBRA and New Mexico Rules1. Every group accident and health insurance policy in this state that provides hospital, surgical, and

medical expense benefi ts must allow continuation of coverage through a converted or separate policy. 2. Each employee and family member aged 18 and over may continue coverage:

a. If the employment is terminated through no fault of the employee.b. The employer chooses to discontinue the coverage.c. Upon the dissolution of the marriage by divorce, annulment, or separation.d. Upon the death of the employee.

3. If the policy is converted by a surviving spouse in the name of the deceased employee, dependent children for whom the employee was responsible may be included in the converted policy.

4. The continued or converted policy premium must be paid within 30 days of the group policy’s termination. Evidence of insurability nor a preexisting condition probation period are required.

5. A period of creditable coverage will not be counted if, there was a period of 95 continuous days and that 95 day period was between the enrollment date and the last date of previous coverage. Waiting periods are not included in the 95 continuous day non-coverage period.

6. Periods of creditable coverage are established through certifi cations when:a. An individual ceases to be covered under the plan or otherwise becomes covered under a

COBRA continuation provision.b. An individual covered under a COBRA continuation provision, ceases to be covered under that

provision; andc. On the request of an individual made not later than 24 months after the date of cessation of the

coverage described in Paragraphs a or b, whichever is later.7. Employees or dependents will be permitted to enroll in a group health plan if or when:

a. The employee or dependent was covered under a group health plan or had health insurance coverage at the time coverage was previously offered but refused.

b. The employee, because of employer requirements, stated in writing at the time coverage was offered, the reason for declining enrollment is because he was already covered under a plan.

c. The coverage was under a COBRA continuation provision and the coverage under that provision was exhausted; or

d. The coverage was not under a COBRA continuation provision and the coverage was terminated as a result of loss of eligibility; and

e. 30 or less days have elapsed since the previous coverage ceased and application for enrollment is made.

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31 Life & Health

Conversion Privilege Subject to the provision of the Health Insurance Portability Act: 1. Every accident and health insurance policy that provides hospital, surgical and medical expense

benefi ts shall provide that: a. If an individual policy, covered family members have the right to continue the policy as

the named insured or through a conversion policy upon the named insured’s death divorce, annulment, dissolution of marriage or legal separation from the spouse.

b. If a group policy: 1) Each member or employee has the right to continue the coverage for a period of 6 months

and thereafter through a conversion policy upon termination of membership or employment. 2) Covered family members of an employee or association member has the right to continue

the coverage through a converted or separate policy upon the member’s or employee’s death, divorce, annulment, dissolution of marriage or legal separation of the spouse.

2. Where a continuation of coverage or conversion is made in the name of the named insured’s, member’s or employee’s spouse, the coverage may, at the spouse’s option include coverage for dependent children for whom the spouse has responsibility for care and support.

3. The right to a continuation of coverage or conversion does not apply if coverage terminates for nonpayment of premium or policy nonrenewal or expiration of the term for which the policy is issued. If a member, employee, or any covered family member is eligible for Medicare or any other similar government health insurance program, the right to a continuation of coverage or conversion shall be limited to coverage under a Medicare supplement policy.

4. Coverage provided through continuance or conversion shall be provided at a reasonable, nondiscriminatory rate and shall provide coverage that most nearly approximates the policy coverage from which conversion is exercised. Continued and converted coverages shall contain renewal provisions that are not less favorable than those contained in the policy from which the conversion is made. However, if a person has reached the age of eligibility for Medicare or other similar government health programs, he/she may exercise the right of conversion only for a Medicare supplement policy.

5. At the inception of coverage, the insurer shall furnish to each covered person aged 18 and over a statement summarizing the policy’s continuation and conversion provisions. The eligible person exercising the continuation or conversion right shall notify the employer or insurer and pay the applicable premium within 30 days. There shall be no lapse of coverage during the period in which conversion is available.

6. Coverage shall be provided through continuation or conversion without additional evidence of insurability and shall not impose any preexisting condition, limitations or other contractual time limitations other than those remaining unexpired under the policy or contract from which continuation or conversion is exercised.

7. Benefi ts otherwise payable under a converted or separate policy may be reduced so they are not in excess of those that would have been payable under the policy from which conversion is exercised. Benefi ts otherwise payable under a converted or separate policy are not payable for a loss claimed under the policy from which conversion is exercised.

8. Any probationary or waiting period in the converted or separate policy is deemed to start on the original policy’s effective date.


32Life & Health

Small Employer Medical Plans Defi nition of Small EmployerSmall employer means any person, fi rm, corporation, limited liability company, partnership, or association actively engaged in business that employed at least 2, but no more than 50 eligible employees, during 50% of the working days of the preceding 2 years. Spouses of employers and dependents of employees can be counted as separate employees.

Rate and Renewability1. A health benefi t plan subject to the Small Group Rate and Renewability Act must be renewable to

all eligible employees and dependents at the option of the small employer, except for the following reasons: a. Nonpayment of required premiums. b. Fraud or misrepresentation. c. Noncompliance with plan provisions. d. The number of individuals covered under the plan is less than the number or percentage of

eligible individuals required by percentage requirements. e. The small employer is no longer actively engaged in the business in which it was engaged on

the effective date of the plan. 2. A small employer carrier may cease to renew all plans under a class of business. 3. A small employer carrier may not change eligibility classifi cations upon renewal or replacement

within 12 months of termination of its own coverage if the change in classifi cation eliminates any individual who was previously insured previous to the change from coverage.

4. There cannot be more than a 20% difference between the lowest and highest rates in any age group where rates are based on gender.

5. Insurers must provide at least 90 days’ advance notice before terminating coverage of small employer plans. a. An insurer that ceases to renew all plans in a class of business shall not establish a new class of

business for a period of 5 years after such nonrenewal without the Superintendent’s prior approval. b. An insurer shall not transfer or otherwise provide coverage to any employers from the

nonrenewed class of business unless it offers the same transfer or coverage to all affected employers, eligible employees and dependents without regard to case characteristics, claim experience, health status or duration of coverage.

6. ‘Health Status’ does not include genetic information.

Disclosure Each small employer carrier disclose the following in solicitation and sales materials: 1. The extent to which premium rates for a specifi c small employer are established or adjusted due to

the claim experience, health status or duration of coverage. 2. The provisions concerning the carriers’ right to change premium rates and the factors that affect

changes in premium rates.3. A description of the class of business in which the small employer is or will be included. 4. The provisions relating to renewability of coverage.

Preexisting Conditions ExclusionA health benefi t plan may not exclude or limit benefi ts due to a preexisting condition for more than 6 months (18 months for a late enrollee) following the effective date of coverage. A health benefi t plan may not defi ne a preexisting condition more restrictively than a condition for which medical advice, diagnosis, care or treatment was recommended or received during the 6 months immediately preceding the effective date of coverage.

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33 Life & Health

Medicare Supplement InsuranceMinimum Standards1. Medicare Supplement policies must comply with the Superintendent’s standards with respect to

policy provisions related to: a. Renewabilityb. Conditions of eligibilityc. Non-duplication of coveraged. Probationary periodse. Benefi t limitations, exceptions, and reductionsf. Elimination periodsg. Replacementh. Recurrent conditionsi. Defi nitions of terms

2. A Medicare supplement policy must provide that benefi ts designed to cover cost sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible amount and co-payment percentage.

3. Termination of a Medicare supplement policy or certifi cate shall be without prejudice to any continuous loss which commenced while the policy was in force.

4. A Medicare supplement policy must provide that benefi ts and premiums under the policy will be suspended at the request of the policyholder for the period (not to exceed 24 months) in which the policyholder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act. The policyholder must request suspension within 90 days after the date the individual becomes entitled to assistance.

5. Each Medicare supplement policy must be guaranteed renewable.6. If the Medicare supplement policy is terminated by the group policyholder and is not replaced, the

insurer must offer certifi cate holders an individual Medicare supplement policy. 7. If an individual is a certifi cate holder in a group Medicare supplement policy and the individual

terminates membership in the group, the insurer must offer the certifi cate holder the conversion opportunity or continuation of coverage under the group policy

8. Medicare supplement policies must provide coverage for the following preventive health services not covered by Medicare:a. An annual clinical preventive medical history and physical examination.b. Preventive screening tests or preventive services.

9. At-home recovery services provided must be primarily services which assist in activities of daily living.

10. Free Look – A Medicare Supplement must have a 30-day free-look period. 11. An insurer may, with the prior approval of the Superintendent, offer policies or certifi cates with new

or innovative benefi ts (except for an outpatient prescription drug benefi t) in addition to the benefi ts provided in a policy or certifi cate that otherwise complies with the applicable standards.

12. A Medicare Supplement policy shall not pay benefi ts resulting from losses due to sickness on a different basis than losses resulting from accidents.

13. For other than nonpayment of premium, no Medicare Supplement policy or certifi cate shall terminate coverage of a spouse solely because of an event that terminates the insured’s coverage.

14. After December 31, 2005, a Medicare supplement policy with benefi ts for outpatient prescription drugs may not be renewed after the policyholder enrolls in Medicare part D unless:a. The policy is modifi ed to eliminate outpatient prescription coverage for expenses of outpatient

prescription drugs incurred after the effective date of the individual’s coverage under a part D plan; and

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34Life & Health

b. Premiums are adjusted to refl ect the elimination of outpatient prescription drug coverage at the time of Medicare part D enrollment.

15. Medicare supplement policies shall not provide benefi t payments that are based on standards described as “unusual” and “customary” or words of similar import.

16. If a Medicare supplement policy contains any limitations with respect to preexisting conditions, such limitations shall appear as a separate paragraph and be labeled as “preexisting condition limitations.”

Outline of Coverage 1. An Outline of Coverage must be provided to the applicant when an application is made.2. The Outline must include:

a. A description of the principal benefi ts and coverage provided in the policy or certifi cate.b. A statement that provides disclosure of any provision concerning automatic renewal premium

increases based on the age of a policyholder.c. A statement of the renewal provisions, including any reservation by the issuer of a right to

change premiums; andd. A statement that the outline of coverage is a summary of the policy or certifi cate issued or

applied for and that the policy or certifi cate should be consulted to determine governing contractual provisions.

Core Benefi tsAn insurer must offer a policy including only the core benefi ts.

Advertising and Marketing1. Copies of any Medicare supplement advertisement intended for use in this state must be submitted

to the Superintendent for review and approval. The advertisement shall comply with all applicable laws of this state.

2. No representative or marketer of Medicare supplement insurance policies may advertise any Medicare supplement insurance policies in this state unless a copy of such advertising was submitted by the insurer and received the Superintendent’s approval.

3. An insurer must determine that a Medicare Supplement is suitable for a prospective applicant’s needs before soliciting a Medicare Supplement.

4. High pressure tactics and cold-lead advertising are not allowed. 5. Marketing procedures must ensure that comparison of policies by its agents or other producers will

be fair and accurate and that excessive insurance is not sold or issued.6. The fi rst page of the policy must prominently display the following: “Notice to buyer: This policy

may not cover all of your medical expenses.”

Prohibited Policy Provisions 1. Preexisting Conditions – A Medicare supplement policy may not impose a preexisting condition

exclusion period of more than 6 months on any condition for which treatment was recommended or received within 6 months before the coverage’s effective date.

2. The insurer may not: a. Terminate a spouse’s coverage solely for a reason that is the basis for termination of the primary

insured’s coverage. b. Cancel or nonrenew the policy solely on the ground of health status of the individual.

3. An insurer may not cancel or refuse to renew Medicare supplement policy for any reason other than nonpayment of premium or material misrepresentation.

4. No Medicare supplement policy may contain benefi ts that duplicate benefi ts provided by Medicare.

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35 Life & Health

5. Except for permitted preexisting condition clauses, no policy may contain limitations or exclusions on coverage that are more restrictive than those of Medicare.

6. A Medicare supplement policy with benefi ts for outpatient prescription drugs cannot be issued after December 31, 2005.

7. A Medicare policy replacing an existing policy cannot require any waiting, probationary or elimination periods to the extent such time periods were satisfi ed under the previous policy.

Medicare Select1. A Medicare Select policy or certifi cate must be approved by the Superintendent before use. Before

selling a Medicare Select policy, the insurer must obtain the applicant’s signature on a form disclosing the policy’s restrictions.

2. A Medicare select policy or certifi cate shall not restrict payment for covered services provided by non-network provider if:a. The services are for symptoms requiring emergency care or are immediately required for an

unforeseen illness, injury, or a condition; andb. It is not reasonable to obtain service with a network provider.

3. A Medicare select policy or certifi cate will provide payment for full coverage under the policy for covered services that are not available through network providers.

4. At the time of initial purchase, a Medicare Select issuer will provide each Medicare select policy or certifi cate applicant with the opportunity to purchase any Medicare supplement policy or certifi cate otherwise offered by the issuer. An Outline of Coverage which will allow the applicant to compare the coverage and premiums of the Medicare Select policy with other Medicare supplement policies must be provided.

5. After a Medicare Select policy has been in force for 6 months, the insured may request to continue coverage under a supplement policy that does not have a restricted network and will not require evidence of insurability.

Appropriateness of Purchase or Replacement1. In recommending the purchase or replacement of any Medicare supplement policy, an agent shall

make reasonable efforts to determine the purchase or replacement’s appropriateness. 2. Any sale of a Medicare supplement policy that will provide an individual more than one Medicare

supplement policy is prohibited. An insurer shall not issue a Medicare supplement policy to an individual enrolled in Medicare part C unless the coverage effective date is after the Part C termination date.

3. Application forms shall include questions designed to reveal whether the applicant currently has any type of health or supplemental coverage in force. a. Agents shall list any other health insurance policies they have sold to the applicant within the

last 5 years, no longer in force, or any policy still in force. b. In the case of a direct response insurer, a copy of the application signed by the applicant and

acknowledged by the insurer, shall be returned to the applicant at policy delivery. 4. When a sale will involve replacement of an existing Medicare supplement policy, the insured must

be provided a Notice Regarding Replacement, prior to policy delivery. The notice must be signed by the applicant, with one copy retained by him/her and the other retained by the insurer. A direct response insurer shall deliver the notice when the policy is delivered.

Reporting of Multiple PoliciesOn or before March 1 of each year, an insurer shall report the following information for every individual New Mexico resident for which the insurer has more than one Medicare supplement policy in force: 1. The policy and certifi cate number; and 2. The date of issuance.


36Life & Health

New Mexico Long-Term Care Policy Regulations and Required Provisions Advertising1. Every issuer of long-term care insurance in this state must provide a copy of any long-term care

insurance advertisement to the Superintendent for review and approval. All advertisements must be kept on fi le at the insurer’s home offi ce for at least 3 years after the advertisement is fi rst used.

2. Persons who market long-term care insurance in this state may not advertise any policies or certifi cates unless the Superintendent has reviewed and approved the advertisement.

Standard for Marketing1. Marketing procedures must

a. Ensure that any comparison of policies will be fair and accurate; and that excessive insurance is not sold or issued.

b. Provide copies of the disclosure forms to the applicant.c. Inquire and otherwise make every reasonable effort to determine whether a prospective

applicant already has accident and sickness or long-term care insurance, to include their types and amounts.

d. Establish auditable procedures for verifying compliance with this section.e. Provide a written notice at solicitation to the applicant that a senior insurance counseling

program for New Mexico, of which the Superintendent approves, is available. The notice must include the program’s name, address and telephone number.

f. Use the terms noncancellable or level premium for long-term care health insurance policies as appropriate; and

g. Provide an explanation of contingent benefi t upon lapse.2. The fi rst page of the outline of coverage and the policy shall prominently display the following:

“Notice to buyer: This policy may not cover all of the costs associated with long-term care incurred by the buyer during the period of coverage. The buyer is advised to review carefully all policy limitations.”

Prohibited Marketing Practices 1. Twisting – Knowingly making any misleading representation or incomplete or fraudulent

comparison of any insurance policies or insurers to induce any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on or convert any insurance policy or to take out a policy of insurance with another insurer.

2. High Pressure Tactics – Employing any method of marketing having the effect of inducing the purchase of insurance through force, fright, threat, or undue pressure, whether explicit or implied.

3. Cold Lead Advertising – Making use of any method of marketing that fails to disclose in a conspicuous manner that a purpose of the marketing is solicitation of insurance and that contact will be made by an insurance agent or insurance company.

Suitability of Recommended Purchase1. Insurers shall use worksheets to determine:

a. The ability to pay for the proposed coverage and other pertinent fi nancial information related to the purchase of the coverage.

b. The applicant’s goals or needs with respect to long-term care and the advantages and disadvantages of insurance to meet these goals or needs; and

c. A comparison between the values, benefi ts, and costs of the applicant’s existing insurance to applicable values, benefi ts and costs of the recommended purchase or replacement.

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37 Life & Health

2. The completed personal worksheet must be returned to the insurer prior to considering the applicant for coverage, except the personal worksheet need not be returned for sales of employer group long-term care insurance to employees and their spouses.

3. No insurer or agent may sell or disseminate outside the company any information obtained through the personal worksheet.

Required Disclosure Provisions1. Renewability – Individual long-term care insurance policies must contain a renewability provision

on the fi rst page of the policy disclosing the duration of renewability and the duration of the term of coverage.

2. Riders and Endorsements – All riders or endorsements added to an individual long-term care insurance policy after date of issue or at reinstatement or renewal which reduce or eliminate benefi ts or coverage are subject to signed acceptance by the insured. After the date of policy issue, any rider or endorsement which increases benefi ts or coverage with an increase in premium must be agreed to in writing signed by the insured, except if the increased benefi ts or coverage are requested by the insured or required by law.

3. Payment of Benefi ts – A long-term care insurance policy which provides benefi ts based on usual and customary, or reasonable and customary charges, must include a defi nition of such terms and an explanation of such terms in its accompanying outline of coverage.

4. Limitations – If a long-term care insurance policy contains any limitations with respect to preexisting conditions, such limitations must appear as a separate paragraph of the policy and must be labeled as Preexisting Condition Limitations.

5. Other Limitations or Conditions – A long-term care insurance policy containing any limitations or conditions for eligibility must provide a description of such limitations or conditions in a separate paragraph of the policy and must be labeled as Limitations or Conditions on Eligibility for Benefi ts.

6. Tax Consequences – Life insurance policies which provide an accelerated benefi t for long-term care, must have a disclosure statement at the time of application and at the time the accelerated benefi t payment request is submitted that receipt of these accelerated benefi ts may be taxable, and that assistance should be sought from a personal tax advisor. The disclosure statement shall be prominently displayed on the fi rst page of the policy or rider and any other related documents.

Outline of Coverage and Shopper’s Guide 1. An Outline of Coverage must be provided at the time of initial solicitation. This outline cannot have

any material which is advertising in nature.2. The Outline of Coverage must contain:

a. A description of the principal benefi ts and coverage provided in the policy.b. A statement of the principal exclusions, reductions, and limitations contained in the policy.c. A statement of the terms under which the policy may be continued in force or discontinued.d. A statement that the outline of coverage is a summary only, not a contract of insurance, and that

the policy or group master policy contains governing contractual provisions.e. A description of the terms under which the policy or certifi cate may be returned and premium

refunded.f. A brief description of the relationship of cost of care and benefi ts.g. A statement that the coverage afforded is not Medicare supplement coverage.

3. A Long-Term Care Shopper’s Guide (Buyer’s Guide) must be provided to the applicant prior to the application’s presentation or enrollment form’s presentation, in the case of a producer solicitation.a. In the case of agent solicitations, an agent must deliver the Shopper’s Guide prior to presenting

an application or enrollment form. b. In the case of direct response solicitations, the Shopper’s Guide must be sent with any

application or enrollment form.


38Life & Health

c. Life insurance policies or riders containing accelerated long-term care benefi ts are not required to furnish the Shopper’s Guide, but shall furnish the Policy Summary.

Right to ReturnA long-term care insurance policy, except an employer group policy, shall have a notice prominently printed on the fi rst page stating in substance that the policyholder has the right to return the policy, within 30 days of its delivery and to have the premium fully refunded within 30 days of the return of the policy if the policyholder or certifi cate holder is not satisfi ed for any reason.

Replacement 1. If the policy being replaced is a life insurance policy, the insurer shall comply with the replacement

requirements of life and annuity contracts. 2. If a life insurance policy that accelerates benefi ts for long-term care is replaced by a similar policy,

the replacing insurer shall comply with both the long-term care and life insurance replacement requirement.

3. If a group long-term care policy is replaced by another group long-term care policy issued to the same policyholder, the succeeding insurer must offer coverage to all persons covered under the previous group policy on its date of termination, subject to the following:a. Coverage under the new policy shall not result in any exclusion for preexisting conditions that

would have been covered under the prior group policy.b. Coverage under the new policy shall not vary or otherwise depend on the individual’s health or

disability status, claim experience or use of long-term care services.

Policy Standards1. A long-term care policy may not provide post-confi nement, post-acute care or recuperative benefi ts

unless such benefi ts are clearly labeled or entitled Limitations or Conditions on Eligibility for Benefi ts.

2. A certifi cate issued pursuant to a group policy must include: a. A description of the principal benefi ts and coverage. b. A statement of the principal exclusions, reductions and limitations.

3. Group long-term care insurance must provide insureds with a basis for continuation or conversion of coverage.

4. No long-term care insurance policy shall:a. Be canceled, nonrenewed or otherwise terminated on the grounds of the age or the deterioration

of the mental or physical health of the insured individual or certifi cate holder.b. Contain a provision establishing a new waiting period in the event existing coverage is

converted to or replaced by a new or other form within the same company, except with respect to an increase in benefi ts voluntarily selected by the insured individual or group policyholder.

c. Provide coverage for skilled nursing care only.d. Provide signifi cantly more coverage for skilled care in a facility than coverage for lower levels

of care.e. Condition eligibility for any benefi ts on a prior hospitalization or institutionalization

requirement.f. Condition eligibility of non-institutional benefi ts on the prior receipt of institutional care

involving a stay of more than 30 days. 5. At the time of policy delivery, a Policy Summary shall be delivered for an individual life insurance

policy which provides long-term care benefi ts within the policy or by rider. In the case of direct response solicitations, the insurer shall deliver the policy summary upon the applicant’s request, but regardless of request shall make such delivery no later than at the time of policy delivery.

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39 Life & Health

6. For group policies, the individual shall include: a. A description of the principal benefi ts and coverage provided in the policy.b. A statement of the principal exclusions, reductions and limitations contained in the policy; andc. A statement that the group master policy determines governing contractual provisions.

7. Any time a life insurance vehicle is paying for LTC benefi ts by the acceleration of the death benefi t, a monthly report shall be provided to the policyholder. Such report shall include:a. Any long-term care benefi ts paid out during the month.b. Explanation of any changes in the policy, e.g., death benefi ts or cash values, due to long-term

care benefi ts being paid out; andc. The amount of long-term care benefi ts existing or remaining.

Benefi t Triggers1. Benefi ts may be paid when it’s determined that an insured is defi cient in performing at least 3

activities of daily living or has cognitive impairment. 2. Activities of Daily Living – Activities of daily living shall include at least the following:

a. Bathingb. Continencec. Dressingd. Eatinge. Toiletingf. Transferring

3. Insurers may use activities of daily living to trigger covered benefi ts in addition to those specifi ed above as long as they are defi ned in the policy. An insurer may also use additional provisions for the determination of when benefi ts are payable. However, such provisions shall not restrict, and are not in lieu of, the requirements contained in paragraphs 1 and 2 above.

4. A defi ciency shall not be more restrictive than: a. Requiring the hands-on assistance of another person to perform the prescribed activities of daily

living; or b. If the defi ciency is due to the presence of a cognitive impairment and supervision is needed in

order to protect the insured or others.5. Assessments of activities of daily living and cognitive impairment shall be performed by licensed

or certifi ed professionals, such as physicians, nurses or social workers. LTC policies shall include a clear description of the process for appealing and resolving benefi t determinations.

Preexisting Conditions1. No LTC insurance policy, certifi cate or rider, including a group LTC policy or certifi cate shall use

a defi nition of preexisting condition that is more restrictive than “A condition for which medical advice or treatment was recommended by or received from a health care provider within 6 months before the policy’s effective date of coverage.”

2. No LTC insurance policy, certifi cate or rider, including a group LTC policy, certifi cate or rider, shall exclude coverage for a loss or confi nement which is the result of a preexisting condition unless such loss or confi nement begins within 6 months following the effective date of coverage.

3. The defi nition of preexisting condition does not prohibit an insurer from using an application form designed to elicit the complete health history of an applicant and base its underwriting in accordance with its underwriting standards.

4. A preexisting condition need not be covered within 6 months following the effective date of coverage of the insured person. Coverages or benefi ts may not be excluded, limited or reduced for specifi cally named or described preexisting diseases or physical conditions beyond 6 months following the policy effective date of coverage.


40Life & Health

Nonforfeiture Benefi t Offer1. If the insured receives a premium rate or premium rate schedule increase in the future, he/she will

be notifi ed of the new premium amount and will be able to exercise a least one of the following options: a. Pay the increased premium and continue your policy in force as is. b. Reduce your policy benefi ts to a level that your premiums will not increase. c. Exercise your nonforfeiture option if purchased. d. Exercise your contingent nonforfeiture rights.

2. Contingent Nonforfeiture – If the premium rate goes up in the future and a nonforfeiture option was not purchased, the insured may be eligible for contingent nonforfeiture. Some LTC coverage will be kept if: a. The increased premium exceeds the original premium by a specifi ed percentage; and b. The policy is allowed to lapse (not pay more premiums) within 120 days of the increase.

3. The amount of coverage kept will equal the total amount of premiums paid since the policy was fi rst issued. If any benefi ts have already been received so that the remaining maximum benefi t amount is less than the total amount of premiums paid, the amount of coverage will be that remaining amount.

4. Except for this reduced lifetime maximum benefi t amount, all other policy benefi ts will remain at the levels attained at the time of the lapse and will not increase. Should this option be chosen, the policy, with this reduced maximum benefi t amount, will be considered paid-up with no further premiums due.Example: You bought the policy at age 65 and paid the $1,000 annual premium for 10 years, so you have paid a total of $10,000 in premium. In the 11th year, you received a rate increase of 50%, or $500 for a new annual premium of $1,500, and you decide to let the policy lapse (not pay any more premiums). Your paid-up policy benefi ts are $10,000 (provided you have at least $10,000 of benefi ts remaining under your policy.)

Infl ation Protection1. An insurer offering LTC policies must offer an LTC policy providing protection against infl ation. 2. The protection must be at least as favorable as 1 of the following:

a. Benefi ts are compounded annually at a rate of at least 5%. b. The insured may increase benefi ts so long as the option to increase benefi ts has not been

declined. c. There is not a maximum coverage limit.

3. Rejection of an offer of infl ation protection must be signed by the applicant in order to be valid.

Unintentional Lapse and Reinstatement 1. A LTC policy must allow an insured to designate an additional person to receive notice of

nonpayment of premium to protect against unintentional lapse. 2. An insured must refuse in writing they do not want to designate an additional person for notice of

nonpayment of premium.3. The designee has no liability for services rendered under the policy.4. The designee can be changed only once every 2 years.5. Reinstatement

a. A long-term care policy must include a provision providing for coverage reinstatement from lapse if the insurer is provided proof that the policy or certifi cate holder became cognitively impaired or lost functional capacity before the grace period policy expired.

b. This option must be available to the insured if requested within 5 months after termination and allow for the collection of past due premium, where appropriate.

HEALTH LAWS

41 Life & Health

c. The standard of proof for cognitive impairment or loss of functional capacity in the policy cannot be more stringent than the benefi t eligibility criteria on cognitive impairment or the loss of functional capacity.

PenaltiesIn addition to any other penalties provided by the laws of this state, any insurer and any agent found to have violated any requirement of this state relating to the regulation of long-term care insurance shall be subject to a fi ne of up to 3 times the amount of any commissions paid for each policy involved in the violation or up to $10,000, whichever is greater.

New Mexico Comprehensive Health Insurance Pool and Health Insurance AllianceComprehensive Health Insurance Pool 1. The Comprehensive Health Insurance Pool provides medical insurance for eligible applicants. Each

health insurer must be a member of the Pool. 2. The Pool must give a member insurer at least 30 days’ notice of an assessment, and a member

insurer must pay Pool assessments within 30 days. 3. In order to be appointed by the Pool, an agent must be insured under an Errors and Omissions policy

with a professional liability limit of $500,000 or more.

Purpose and Membership1. The purpose of the Health Insurance Alliance Act is to provide increased access to voluntary health

insurance coverage for small employer groups in New Mexico. 2. An additional purpose of the Health Insurance Alliance Act is to provide for access to voluntary

health insurance coverage for individuals in the individual market who have met eligibility criteria established by the Act.

3. All health insurers must be members of the Health Insurance Alliance as a condition for transacting insurance in the state.

Defi nitions1. Alliance means the New Mexico Health Insurance Alliance. 2. Approved health plan means any arrangement for the provisions of health insurance offered

through and approved by the Alliance. 3. Eligible individual means an individual who:

a. As of the date of application for coverage under an approved health plan, has an aggregate of 18 or more months of creditable coverage; or

b. Is entitled to continuation coverage. 4. Eligible individual does not include an individual who:

a. Has or is eligible for coverage under a group health plan.b. Is eligible for coverage under Medicare or a state plan.c. Has health insurance coverage terminated for nonpayment of premium or fraud; or d. Has been offered the option of coverage under a COBRA continuation provision, or under a

similar state program, and did not exhaust the coverage available under the offered program.

Eligibility1. A small employer is eligible for an approved health plan if on the effective date of coverage or

renewal:a. At least 50% of its employees elect to be covered under the approved health plan.b. The small employer has not terminated coverage with an approved health plan within three

years of the date of application for coverage except to change to another approved health plan.


42Life & Health

c. The small employer does not offer other general group health insurance coverage to its employees.

2. An individual is eligible for an approved health plan if on the effective date of coverage or renewal the individual meets the defi nition of an eligible individual.

3. An approved health plan offered to a small employer may contain a preexisting condition exclusion only if:a. The exclusion relates to a condition for which medical advice, diagnosis, care or treatment was

recommended or received within the 6-month period ending on the enrollment date.b. The exclusion extends for a period of not more than six months, after the enrollment date; andc. The period of the exclusion is reduced by the aggregate of the periods of creditable coverage

applicable to the participant or benefi ciary as of the enrollment date.4. An approved health plan issued to an eligible individual cannot contain any preexisting condition

exclusion under the following conditions:a. Individuals covered under creditable coverage to the end of the 30 day period beginning with

the date of birth.b. A child who is adopted or placed for adoption before their 18th birthday is covered under

creditable coverage as of the last day of the 30-day period beginning on and following the date of the adoption or placement for adoption; or

c. Pregnancy.5. An individual is not eligible for coverage by the Alliance under an approved health plan issued to a

small employer if the individual:a. Is eligible for Medicare.b. Has voluntarily terminated health insurance issued through the Alliance within the past 12

months unless it was due to a change in employment; orc. Is an inmate of a public institution.

6. The Alliance shall provide for a 60-day open enrollment period. Individuals enrolled during the open enrollment period shall not be subject to any preexisting conditions limitation.

Deductibles and Coinsurance1. An approved health plan offered through an alliance can impose a deductible on a per-person

calendar year basis. The board can authorize deductibles in other amounts and equivalent cost benefi t structures.

2. A mandatory coinsurance requirement for an approved health plan can be imposed as a percentage of eligible expenses in excess of a deductible.

3. The Alliance board determines the maximum aggregate out-of-pocket payments for eligible expenses by covered individuals.

HEALTH LAWS

43 Life & Health

RETENTION QUESTIONS

44Life & Health

LIFE AND HEALTH

1. A licensing candidate must be at least _____ _____ of age to be licensed.2. An insurance producer may not act as an agent of an insurer unless the producer becomes an appointed

agent of that insurer. (T or F)3. An insurance solicitor is employed by an insurance agent. (T or F)4. A nonresident license may be issued to an individual who is licensed as an agent in the agent’s _____ of

domicile.5. A temporary license can be issued to the _____-_____ _____ _____ of the estate of a deceased agent to

provide services to existing policyholders.6. An agent must notify the Superintendent within _____ days of a change of address.7. Agents must complete _____ hours of continuing education courses during each compliance year.8. The Superintendent ________ and _________ the duties imposed by the Insurance Code.9. An agent must remit premiums within _____ days after receipt. 10. When an agent returns a portion of his/her commission to an insured, it is an example of _____.11. The Superintendent may examine the fi nancial condition of any insurer whenever he/she deems it _____.

LIFE ONLY

12. When replacing a life insurance policy, the applicant must receive a signed Notice of Replacement at time of (application/policy delivery) from the replacing agent. (Choose one.)

13. If it is known or should be known by the agent that an existing life policy is going to be lapsed, forfeited, surrendered or terminated in favor of a new policy, the agent must submit a Notice Regarding _____.

HEALTH ONLY

14. Individual and group disability insurance policies which provides coverage for dependent children of the insured, must provide coverage for newborn children for _____ days from and after the moment of birth.

15. To be considered a small employer when applying for group health coverage, an employer must have no more than _____ eligible employees.

16. Each Medicare Supplement policy must be noncancellable. (T or F)17. A Medicare supplement policy may not defi ne a preexisting condition more restrictively than as a

condition for which medical advice was given or treatment was recommended by or received from a physician within _____ months before the effective date of coverage.

Record Answers Below1. 18 years2. True3. True4. State5. Court-appointed personal representative6. 207. 158. Enforces and executes9. 15

10. Rebating11. Appropriate12. Application13. Replacement14. 3115. 5016. False17. 6

Retention Question Answer Key

45 Life & Health

LIFE AND HEALTH

1. 18 years2. True3. True4. State5. Court-appointed personal representative6. 207. 158. Enforces and executes9. 1510. Rebating11. Appropriate

LIFE ONLY

12. Application13. Replacement

HEALTH ONLY

14. 3115. 5016. False17. 6

46Life & Health

Key Word IndexAAgent Appointment 9Agent Regulation 9

Controlled Business 10Prohibited Premiums or Charges 9Sharing of Commissions 9

Agent Termination 9

BBoycott, Intimidation or Coercion 10Business Entity 5

CCease and Desist Orders 7Change of Address 6Claim/Claimant 3, 8, 11, 12, 14, 21, 22,

26, 27, 28, 32, 33, 39Coinsurance 29, 43Company Regulation 8

Agent Appointment 9Agent Termination 9Certifi cate of Authority 8Complaint Record 8Unfair Claims Settlement Practices 8

Complaint Record 8Consumer Information Privacy Act 12Continuing Education 6Controlled Business 10

DDeductible(s) 29, 34, 43Defamation 10Disability 5, 21, 27, 28, 31, 39Disciplinary Actions 6

Cease and Desist Orders 7Penalties and Fines 7Suspension, Revocation or Refusal to

Renew License 6

EExamination of Books and Records 11

FFalse Advertising 10False Information 12, 14Fiduciary Duties 9Fingerprint Cards 3

GGenetic Testing 26Group Health Insurance 31

Continuation of Coverage under HIPAA, COBRA and New Mexico Rules 31

Conversion Privilege 32Extension of Benefi ts 31

Guaranteed Renewable 26, 34

HHealth Insurance Regulation

Advertising 25Life & Health Guaranty Association

17Unfair Discrimination 26

Home Health Care 29

IIndividual Disability Insurance 28

Loss of Time Benefi t Adjustment 28Individual Health Policy Provisions 26Individual Life Policy Provisions 22

Entire Contract 22Exclusions 22Grace Period 22Incontestability 22Misstatement of Age 22Payment of Premiums 22Reinstatement 22

Individual Underwriting 26Information Privacy 12Insurable Interest 17Insurance Fraud Act 11

LLicensing Process 3Life & Health Guaranty Association 17Life Insurance Group Policies 20

Continuation of Coverage 21Conversion Rights 21Plan Sponsors 20

Life Insurance Policy Provisions 22Settlement of Death Benefi t 22

Life Insurance RegulationBuyer’s Guide 19Illustrations 17Insurable Interest 17

Life & Health Guaranty Association 17

Policy Replacement 19Policy Summary 19Variable Products 17

Loss of Time Benefi t Adjustment 28

MMaintenance and Duration 5

Change of Address 6Continuing Education 6Expiration and Renewal 5

Medical Plans 28Medicare Select 36Medicare Supplement Insurance 34

Free Look 34Outline of Coverage 35Prohibited Policy Provisions 35

Misrepresentations 11Monthly Wage 28

NNew Mexico Comprehensive Health

Insurance Pool and Health Insurance Alliance 42

New Mexico Long-Term Care Policy Regulations and Required Provi-sions 37

Advertising 37Benefi t Triggers 40Infl ation Protection 41Nonforfeiture Benefi t Off er 41Outline of Coverage 38Penalties 42Policy Standards 39Preexisting Conditions 40Prohibited Marketing Practices 37Replacement 39Required Disclosure Provisions 38Right to Return 39Shopper’s Guide 38Standard for Marketing 37Suitability 37Unintentional Lapse and Reinstate-

ment 41New Mexico Medical Plan Eligibility

Requirements and Benefi t Off ers (Individual and Group) 28

Adopted Children 28

47 Life & Health

Key Word IndexChild Enrollment; Noncustodial

Parents 28Continued Coverage of Handicapped

Children 28Home Health Care Coverage 29Managed Health Care Rule 29Mental Health Parity 30Newborn Children 28

OOptional Health Provisions 27

Cancellation 27Change of Occupation 27Misstatement of Age 27Other Insurance With Diff erent

Insurer 27Other Insurance With Same Insurer

27Unpaid Premium 27

PProhibited Premiums or Charges 9Proof of Loss 8, 26Provisions Prohibited in Individual Life

Insurance 22

RRebating 10Refund 38Reinsurance 13Required Health Policy Provisions 26

Grace Period 27Time Limit on Certain Defenses 26

Required Health ProvisionsChange of Benefi ciary 27Claim Procedures 27Legal Actions 27Physical Examination and Autopsy

27Reinstatement 27

SSmall Employer Medical Plans 33

Defi nition of Small Employer 33Rate and Renewability 33

State Regulation 7Superintendent’s General Duties and

Powers 7

TTwisting 10Types of Licensees 4

Agent 4Broker 4Consultant 4Nonresident 5Solicitor 4Temporary License 5

UUnfair Claims Settlement Practices 8Unfair Discrimination 10Unfair Trade Practices 10

Boycott, Intimidation or Coercion 10Defamation 10False Advertising 10Misrepresentations 11Rebating 10Twisting 10Unfair Discrimination 10

VViolate/Violation 6, 7, 8, 11, 14, 26, 42

WWaiting Period 31, 32, 39

48Life & Health

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