California Code of Regulations
Title 10 - Investment
Chapter 5 - Insurance Commissioner
Subchapter 2 - Policy Forms and Other Documents
Article 2a - Group Disability Policies
Subarticle 2 - Compulsory Uniform Provisions
Section 2232.18 - Time Limit on Certain Defenses

Universal Citation: 10 CA Code of Regs 2232.18

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) After this policy has been in force for a period of three years, no statements of the employer contained in the application, and no statement relating to insurability made by any employee eligible for coverage under the policy shall be used to deny a claim or in contesting the validity of the insurance with respect to which such statement was made after the insurance has been in force prior to the contest for a period of three years during the lifetime of the person with respect to whom any such statement was made.

(b) After three years from the date of issue of this policy, no misstatement of the employer, except a fraudulent misstatement, made in the employer's application shall be used to void the policy; and after three years from the effective date of the coverage with respect to which any claim is made no misstatement of any employee eligible for coverage under the policy, except a fraudulent misstatement, made in an application under the policy shall be used to deny a claim for loss incurred or disability (as defined in the policy) commencing after expiration of such three years.

(c) No claim for loss incurred or disability (as defined in the policy) commencing after three years from the effective date of the insurance coverage with respect to which the claim is made shall be reduced or denied on the ground that a disease or physical condition, not excluded from coverage by name or specific description effective on the date of loss, had existed prior to the effective date of the coverage with respect to which the claim is made:

Instructions

1. If the insurer uses Form A or Form B of the "Entire Contract; Changes" uniform provision, it may, at its option, include paragraph (a) in the policy (eliminating, if Form A is used, references to statements of employees), and the insurer shall use such paragraph, with the language appropriately adjusted, as aforesaid, in any policy which is noncancellable and guaranteed renewable for five years or more and for which the premium rate is guaranteed for five years or more. If said paragraph (a) is used, the insurer shall not use paragraph (b), and shall omit the portion of the first paragraph of Form C, if used, of the "Entire Contract; Changes" uniform provision following the phrase "unless it is contained in a written application."

2. In case the insurer uses Form A or Form C of the "Entire Contract; Changes" uniform provision, and unless paragraph (a) of this uniform provision is included in the policy in accordance with Instruction 1, the insurer shall include paragraph (b) therein, except that if the alternative language at the end of the first paragraph of Form C of the "Entire Contract; Changes" uniform provision is used and not omitted therefrom in accordance with Instruction 7 for the use of that form of such uniform provision, then the insurer may omit both paragraph (a) and (b) hereof. If Form A of the "Entire Contract; Changes" uniform provision is used, there shall be omitted from paragraph (a) or (b) hereof, whichever is used in the policy, all portions referring to statements of the employees.

3. The insurer shall omit paragraph (c) from any policy which does not exclude coverage for pre-existing diseases or conditions. The insurer shall use said paragraph (c) in any policy which contains any exclusion of pre-existing diseases or conditions. The term "pre-existing disease or conditions, means any diseases or conditions" means any disease or condition, other than pregnancy, of any employee or other person covered by the policy which existed on, or had its inception before the effective date of the insurance coverage of such person under the policy. (Ins. C. 10350.2 Cf. Ins. C. 10206 and 10270.6.)

1. Change without regulatory effect amending subsection (b) filed 7-14-2021 pursuant to section 100, title 1, California Code of Regulations (Register 2021, No. 29). Filing deadline specified in Government Code section 11349.3(a) extended 60 calendar days pursuant to Executive Order N-40-20.

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