Current through August 26, 2024
(1) PURPOSE. This
rule implements and interprets applicable statutes for the purpose of
establishing procedures and requirements to expedite the review and approval of
group accident and sickness policies permitted by s.
600.03(23),
Stats., and s.
Ins 6.75(1) (c) or
(2) (c).
(3)RATE FILINGS. Schedules of premium rates
shall be filed in accordance with the requirements of ch. 601, Stats., and s.
631.20,
Stats. The schedules of premium rates shall bear the insurer's name and shall
identify the coverages to which such rates are applicable.
(4)CERTIFICATES.
(a) Each certificate issued to an employee or
member of an insured group in connection with a group insurance policy shall
include a statement in summary form of the provisions of the group policy
relative to:
1. The essential features of the
insurance coverage,
2. To whom
benefits are payable,
3. Notice or
proof of loss,
4. The time for
paying benefits, and
5. The time
within which suit may be brought.
(5)COVERAGE REQUIREMENTS.
(a) Policies issued in accordance with s.
600.03(23),
Stats., shall offer to insure all eligible members of the group or association
except any as to whom evidence of insurability is not satisfactory to the
insurer. Cancellation of coverage of individual members of the group or
association who have not withdrawn participation nor received maximum benefits
is not permitted, except that the insurer may terminate or refuse renewal of an
individual member who attains a specified age, retires or who ceases to
actively engage in the duties of a profession or occupation on a full-time
basis or ceases to be an active member of the association or labor union or an
employee of the employer, or otherwise ceases to be an eligible
member.
(b) Surgical benefit
provisions or schedules shall provide that the benefit for any covered surgical
procedure not specifically listed in the schedule and not excluded by the
provisions of the policy shall be determined by the company on a basis
consistent with the benefit provided for a comparable listed
procedure.
(c) A policy which
contains any provision under which the claimant may elect one benefit in lieu
of another shall not limit to a specified period the time within which election
may be made.
(6)ELIGIBLE
GROUPS. In accordance with s.
600.03(23),
Stats.:
(a) The members of the board of
directors of a corporation are eligible to be covered under a group accident
and sickness policy issued to such corporation,
(b) The individual members of member
organizations of an association, as defined in s.
600.03(23),
Stats., are eligible to be covered under a group accident and sickness policy
issued to such association insuring employees of such association and employees
of member organizations of such association, and
(c) The individuals supplying raw materials
to a single processing plant and the employees of such processing plant are
eligible to be covered under a group accident and sickness policy issued to
such processing plant.
