State RegulationsNY specificDifficulty 2/5
Which statement about the other benefits provision required by N.Y. Ins. Law §3216(d)(2)(E) in individual accident and health policies is correct?
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Answer & full 3-part explanation (select an option above, or peek)
Why D is correct
Under N.Y. Ins. Law §3216(d)(2)(E), the other benefits provision addresses other valid coverage, not with this insurer, that provides benefits for the same loss on other than an expense-incurred basis, such as duplicate indemnity or loss-of-income benefits. When such unnotified coverage exists, the insurer pays only a proportionate share of the indemnities and refunds the excess premium. Expense-incurred medical benefits are coordinated under different rules.
Why the other options are wrong
- A) The provision expressly applies to benefits on other than an expense-incurred basis; expense benefits are handled by coordination rules instead.
- B) The provision is required in individual accident and health policies; it is not a group-policy provision.
- C) The insured may keep other coverage; the provision merely proportionates indemnity benefits and refunds excess premium when duplicate indemnity coverage exists.
Memory hook
Other benefits = duplicate indemnity (non-expense) benefits, shared proportionately.