West Virginia Code of State Rules
Agency 114 - Insurance Commission
Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER
Series 114-12 - Individual Accident And Sickness Insurance Minimum Standards
Section 114-12-6 - Required Disclosure Provisions

Universal Citation: 114 WV Code of State Rules 114-12-6

Current through Register Vol. XLI, No. 38, September 20, 2024

6.1. Each policy or certificate subject to this rule shall include a renewal, continuation or nonrenewal provision. The language or specifications of the provision shall be consistent with the type of policy or certificate to be issued. The provision shall be appropriately captioned, shall appear on the first page of the policy or certificate, and shall clearly state the duration, where limited, of renewability and the duration of the term of coverage for which the policy or certificate is issued and for which it may be renewed.

6.2. Except for riders or endorsements by which the insurer effectuates a request made in writing by the policyholder or certificateholder, or exercises a specifically reserved right under the policy, all riders or endorsements added to a policy after date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require signed acceptance by the policyholder or certificateholder, as appropriate. After date of policy issue, any rider or endorsement which increases benefits or coverage with concomitant increase in premium during the policy term shall be agreed to in writing signed by the policyholder or certificateholder, as appropriate, except if the increased coverage or benefits are required by law.

6.3. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charge shall be set forth in the policy.

6.4. A policy which provides for the payment of benefits based on standards described as "usual and customary,@ "reasonable and customary,@ or words of similar import, shall include a definition of such terms within both the policy and its accompanying outline of coverage.

6.5. Any provisions limiting or excluding coverage of preexisting conditions shall appear in a separate paragraph on the first page of the policy, which shall be labeled "Preexisting Condition Limitations," and shall be included in the outline of coverage.

a. An insurer offering accident and sickness insurance coverage, other than excepted benefits, in the individual market may not, with respect to an eligible individual desiring to enroll in accident and sickness insurance coverage, impose any preexisting condition exclusion with respect to such coverage.

6.6. All accident-only policies shall contain as an overlay on the first page of the policy, in contrasting color, a prominent statement as follows: "This is an accident-only policy, and it does not pay benefits for loss from sickness."

6.7. Any accident-only policy providing benefits which vary according to the type of accidental cause shall prominently set forth in the outline of coverage the circumstances under which benefits are payable which are less than the maximum amount payable under the policy.

6.8. All policies, except single-premium nonrenewable policies, shall have a notice prominently printed on the first page of the policy or attached thereto stating in substance that the policyholder has the right to return the policy within ten (10) days of its delivery and to have the premium refunded if, after examination of the policy, the policyholder is not satisfied for any reason.

6.9. If age is to be used as a determining factor for reducing the maximum aggregate benefits made available in the policy as originally issued, that fact shall be prominently set forth in the outline of coverage.

6.10. If a policy contains a conversion privilege, it shall comply, in substance, with the following: The caption of the provision shall be "Conversion Privilege,@ or words of similar import. The provision shall indicate the persons eligible for conversion; the circumstances applicable to the conversion privilege, including any limitations on the conversion; and the person by whom the conversion privilege may be exercised. The provision shall specify the benefits to be provided on conversion, or may state that the converted coverage will be as provided on a policy form then being used by the insurer for that purpose.

6.11. Outlines of coverage delivered in connection with policies defined in this rule as hospital confinement indemnity (Subsection 5.4), specified disease (Subsection 5.8), specified accident (Subsection 5.9) or limited benefits health insurance coverages (Subsection 5.10) to persons eligible for Medicare shall contain, in addition to the requirements of subsections 6.17 and 6.21 of this rule, the following language which shall be printed on or attached to the first page of the outline of coverage: "This policy is not a Medicare Supplement policy. If you are eligible for Medicare, review the Medicare Supplement Buyer's Guide available from the insurer."

6.12. All specified disease policies shall contain on the first page of the policy or attached thereto, in either contrasting color or in boldface type at least equal to the size of type used for policy captions, a prominent statement as follows: "Caution: This is a limited benefits policy. Read it carefully with the Outline of Coverage."

6.13. Outline of coverage requirements generally as required in this section are as follows:

a. No policy or certificate subject to this rule may be delivered or issued for delivery in this State unless an appropriate outline of coverage, as prescribed in subsections 6.14 through 6.22 of this rule, is completed as to the policy and:
1. In the case of a direct response insurance product is delivered with the policy; or

2. In all other cases is delivered to the applicant at the time application is made and acknowledgment of receipt or certification of delivery of the outline of coverage is provided to the insurer.

b. If an outline of coverage was delivered at the time of application and the policy is issued on a basis which would require revision of the outline, a substitute outline of coverage properly describing the policy shall accompany the policy when it is delivered and contain the following statement in no less than twelve (12) point type, immediately above the insurer's name: "Notice: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application, and the policy originally applied for has not been issued."

c. The appropriate outline of coverage for policies providing hospital coverage which only meets the standards of subsection 5.2 of this rule shall be that outline contained in subsection 6.14 of this rule. The appropriate outline of coverage for policies providing coverage which meets the standards of both subsections 5.2 and 5.3 of this rule shall be the outline contained in subsection 6.16 of this rule. The appropriate outline of coverage for policies providing coverage which meets the standards of both subsections 5.2 and 5.5 or subsections 5.3 and 5.5 or subsections 5.2, 5.3 and 5.5 of this rule shall be the outline contained in subsection 6.18 of this rule.

d. Appropriate changes in terminology shall be made in the outline of coverage in the case of subscriber contracts of hospital, medical, dental or health service corporations. In any other case where the prescribed outline of coverage is inappropriate for the coverage provided by the policy, an alternate outline of coverage shall be submitted to the Commissioner for prior approval. Should the Commissioner consider it appropriate to approve policies or contracts containing less than the prescribed minimum standards for benefits as provided in this rule, the outline of coverage issued in connection with any such policy or contract shall be approved prior to use and shall prominently state that the coverages therein described do not meet the minimum standards for benefits established for that category of coverage.

6.14. Basic Hospital Expense Coverage (Outline of Coverage). -- An outline of coverage, in the form prescribed in appendix A, shall be issued in connection with policies meeting the standards of subsection 5.2 of this rule. The items included in the outline of coverage shall appear in the sequence prescribed.

6.15. Basic Medical-Surgical Expense Coverage (Outline of Coverage). -- An outline of coverage, in the form prescribed in appendix B, shall be issued in connection with policies meeting the standards of subsection 5.3 of this rule. The items included in the outline of coverage shall appear in the sequence prescribed.

6.16. Basic Hospital and Medical-Surgical Expense Coverage (Outline of Coverage). -- An outline of coverage, in the form prescribed in appendix C, shall be issued in connection with policies meeting the standards of subsections 5.2 and 5.3 of this rule. The items included in the outline of coverage shall appear in the sequence prescribed.

6.17. Hospital Confinement Indemnity Coverage (Outline of Coverage). -- An outline of coverage, in the form prescribed in appendix D, shall be issued in connection with policies meeting the standards of subsection 5.4 of this rule. The items included in the outline of coverage shall appear in the sequence prescribed.

6.18. Major Medical Expense Coverage (Outline of Coverage). -- An outline of coverage, in the form prescribed in appendix E, shall be issued in connection with policies meeting the standards of subsection 5.5 of this rule. The items included in the outline of coverage shall appear in the sequence prescribed.

6.19. Disability Income Protection Coverage (Outline of Coverage). -- An outline of coverage, in the form prescribed in appendix F, shall be issued in connection with policies meeting the standards of subsection 5.6 of this rule. The items included in the outline of coverage shall appear in the sequence prescribed.

6.20. Accident-Only Coverage (Outline of Coverage). -- An outline of coverage, in the form prescribed in appendix G, shall be issued in connection with policies meeting the standards of subsection 5.7 of this rule. The items included in the outline of coverage shall appear in the sequence prescribed.

6.21. Specified Disease or Specified Accident Coverage (Outline of Coverage). -- An outline of coverage, in the form prescribed in appendix H, shall be issued in connection with policies meeting the standards of subsections 5.8 or 5.9 of this rule. The coverage shall be identified by the appropriate bracketed title. The items included in the outline of coverage shall appear in the sequence prescribed.

6.22. Limited Benefits Health Coverage (Outline of Coverage). -- An outline of coverage, in the form prescribed in appendix I, shall be issued in connection with policies which do not meet the minimum standards of subsections 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8 and 5.9 of this rule. The items included in the outline of coverage shall appear in the sequence prescribed.

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