dcrodriguez/Code-of-Virginia huggingface dataset:
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3512. Notice; waiver.
The acknowledgment by any insurer of the receipt of notice given under any individual accident and sickness insurance policy, the furnishing of forms for filing proofs of loss, the acceptance of such proofs, or the investigation of any claim thereunder shall not operate as a waiver of any of the rights of the insurer in defense of any claim arising under the policy.

1952, c. 317, § 38.1-358; 1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3513. Age limit.
A. If any individual accident and sickness insurance policy contains a provision establishing, as an age limit or otherwise, a date after which the coverage provided by the policy will not be effective, and if the date falls within a period for which a premium is accepted by the insurer or if the insurer accepts a premium after the date, the coverage provided by the policy will continue in force subject to any right of cancellation until the end of the period for which the premium has been accepted.

B. If the age of the insured has been misstated, and if according to the correct age of the insured, the coverage provided by the policy would not have become effective or would have ceased prior to the acceptance of the premium, then the liability of the insurer shall be limited to the refund, upon request, of all premiums paid for the period not covered by the policy.

1952, c. 317, § 38.1-359; 1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3514. When liability not to be denied because of preexisting disease, physical impairment or defect.
No insurer that has delivered or issued for delivery in this Commonwealth an accident and sickness insurance policy pursuant to the provisions of this article shall deny liability on any claim otherwise covered under such policy because of the existence of a disease or physical impairment or defect, congenital or otherwise, at the time of the making of the application for such policy, unless it is shown that the applicant knew or might reasonably have been expected to know of such disease, impairment or defect.

1966, c. 184, § 38.1-361.1; 1986, c. 562.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3514.1. Preexisting conditions provisions.
A. In determining whether a preexisting conditions provision applies to an insured, all coverage shall credit the time the person was covered under previous individual or group policies providing hospital, medical and surgical or major medical coverage on an expense incurred basis if the previous coverage was continuous to a date not more than thirty days prior to the effective date of the new coverage, exclusive of any applicable waiting period under such coverage.

B. As used herein, a "preexisting conditions provision" means a policy provision that limits, denies, or excludes coverage for charges or expenses incurred during a twelve-month period following the insured's effective date of coverage, for a condition that, during a twelve-month period immediately preceding the effective date of coverage, had manifested itself in such a manner as would cause an ordinarily prudent person to seek diagnosis, care, or treatment, or for which medical advice, diagnosis, care, or treatment was recommended or received within twelve months immediately preceding the effective date of coverage or as to pregnancy existing on the effective date of coverage.

C. This section shall not apply to the following insurance policies or contracts:

1. Short-term travel;

2. Accident-only;

3. Limited or specified disease contracts;

4. Long-term care insurance;

5. Short-term nonrenewable policies or contracts of not more than six months' duration which are subject to no medical underwriting or minimal underwriting;

6. Policies subject to Article 4.1 (§ 38.2-3430.1 et seq.) of Chapter 34 of this title;

7. Policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or federal government plans; and

8. Disability income.

1995, c. 522; 1997, c. 291; 1999, c. 1004.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3514.2. Renewability of coverage.
A. Every individual policy, subscription contract or plan delivered, issued for delivery or renewal in this Commonwealth providing benefits to or on behalf of an individual shall provide for the renewability of such coverage at the sole option of the insured, policyholder, subscriber, or enrollee. The insurer, health services plan or health maintenance organization issuing such policy, subscription contract or plan shall be permitted to refuse to renew the policy, subscription contract or plan only for one or more of the following reasons:

1. Nonpayment of the required premiums by the insured, policyholder, subscriber, or enrollee, or such individual's representative;

2. In the event that the policy, subscription contract or plan contains a provision requiring the use of network providers, a documented pattern of abuse or misuse of such provision by the insured, policyholder, subscriber, or enrollee, continuing for a period of no less than two years;

3. Subject to the time limits contained in subdivision 2 of § 38.2-3503 or in regulations adopted by the Commission governing the practices of health maintenance organizations, for fraud or material misrepresentation by the individual, with respect to his application for coverage;

4. Eligibility of an individual insured for Medicare, provided that such coverage may not terminate with respect to other individuals insured under the same policy, subscription contract or plan and who are not eligible for Medicare; and

5. The insured, subscriber, or enrollee has not maintained a legal residence in the service area of the insurer, health services plan or health maintenance organization for a period of at least six months.

B. This section shall not apply to the following insurance policies, subscription contracts or plans:

1. Short-term travel;

2. Accident-only;

3. Disability income;

4. Limited or specified disease contracts;

5. Long-term care insurance;

6. Short-term nonrenewable policies or contracts of not more than six months' duration which are subject to no medical underwriting or minimal underwriting; and

7. Individual health insurance coverage as defined in subsection B of § 38.2-3431.

1996, c. 550; 1998, c. 24.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3515. Repealed.
Repealed by Acts 2022, c. 180, cl. 2.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3516. Purpose.
The purpose of this article is to authorize the Commission, pursuant to the authority granted in § 38.2-223, to issue rules and regulations to:

1. Establish the minimum standards for filing of policy forms for individual and small group health benefit plans as defined in § 38.2-3438;

2. Establish the minimum standards, terms, and coverages for individual and group accident and sickness policies known as excepted benefits, as defined in § 38.2-3431; and

3. Establish the minimum standards for short-term limited-duration insurance.

The Commission shall ensure that policy standards are simple and understandable and are not misleading or unreasonably confusing and that the sale of such policies provides for full disclosure.

1980, c. 204, § 38.1-362.11; 1986, c. 562; 2022, c. 531.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3517. Definitions.
As used in this article:

"Form" means a policy, rider, endorsement, amendment, application, enrollment form, certificate of insurance, evidence of coverage, group agreement, supplemental agreement, or any other form required to be filed with or approved by the Commission.

"Policy" means an insurance policy, contract, certificate, evidence of coverage, or other agreement of insurance, including any attached rider, endorsement, or application.

1980, c. 204, § 38.1-362.12; 1986, c. 562; 2022, c. 531.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3518. Standards for policy provisions.
A. Pursuant to the authority granted in § 38.2-223, the Commission may issue rules and regulations to establish standards for the sale of individual and group accident and sickness insurance policies. These rules and regulations shall be in addition to and in accordance with applicable laws of the Commonwealth, including Chapter 34 (§ 38.2-3400 et seq.), Article 1 (§ 38.2-3500 et seq.), this article, and Article 3 (§ 38.2-3521.1 et seq.).

B. Pursuant to the authority granted in § 38.2-223, the Commission may issue rules and regulations that specify prohibited policies or policy provisions not otherwise specifically authorized by statute that in the opinion of the Commission are unjust, unfair, or unfairly discriminatory to the policyowner, beneficiary, or any person insured under the policy.

1980, c. 204, § 38.1-362.13; 1981, c. 575; 1986, c. 562; 2022, c. 531.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3519. Minimum standards for excepted benefits.
A. Pursuant to the authority granted in § 38.2-223, the Commission may issue rules and regulations establishing minimum standards for benefits under any of the categories of policies known as excepted benefits.

B. No excepted benefits policy shall be delivered or issued for delivery in the Commonwealth that does not meet the prescribed minimum standards established by the Commission or does not meet the requirements set forth in § 38.2-3501.

C. The Commission may prescribe the method of identification of policies based upon coverages provided.

1980, c. 204, § 38.1-362.14; 1986, c. 562; 2022, c. 531.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3520. Coverage of preexisting conditions.
A. Notwithstanding the provisions of § 38.2-3503, if an insurer elects to use a simplified application form, with or without a specific question as to the applicant's health, but without any detailed questions concerning the insured's health history or medical treatment history, the policy shall cover any loss occurring after twelve months from the effective date of coverage from any preexisting condition not specifically excluded from coverage by terms of the policy. Except as so provided, the policy shall not include wording that would permit a defense based upon preexisting conditions.

B. The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34.

1980, c. 204, § 38.1-362.15; 1981, c. 575; 1986, c. 562; 2013, c. 751.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3521. Repealed.
Repealed by Acts 1998, c. 154.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3522. Repealed.
Repealed by Acts 1998, c. 154.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3523. Repealed.
Repealed by Acts 1998, c. 154.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3523.1. Review of records.
The Commission may review the records of any insurer to determine that the insurer's policies have been issued in compliance with the requirements set forth in this article. Insurers issuing coverage not complying with the provisions of § 38.2-3521.1 and not complying with the provisions of § 38.2-3522.1 shall be deemed to have committed a knowing and willful violation of this article, and shall be punished as set forth in subsection A of § 38.2-218.

1998, c. 154.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3523.2. Policies issued outside of the Commonwealth of Virginia.
A group accident and sickness insurance policy issued outside of this Commonwealth, providing coverage to residents of this Commonwealth, that does not qualify under § 38.2-3521.1 or § 38.2-3522.1 shall be subject to the statutory requirements of this title and may subject the insurer issuing such policy to the penalties available under this title for violation of such requirements.

1998, c. 154.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3523.3. Requirements for those marketing group accident and sickness insurance.
Insurance marketed to certificate holders of a group which does not qualify under § 38.2-3521.1 or § 38.2-3522.1 must be marketed by a person holding a valid life and health insurance agent license as required by Chapter 18 (§ 38.2-1800 et seq.) of this title.

1998, c. 154; 1999, c. 86.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3523.4. Minimum number of persons covered.
A. A group accident and sickness insurance policy shall on the issue date and at each policy anniversary date, cover at least two persons, other than spouses or minor children, unless such spouse or minor child is determined to be an eligible employee as defined in § 38.2-3431.

B. The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34.

1998, c. 154; 2013, c. 751.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3524. Repealed.
Repealed by Acts 1998, c. 154.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3525. Group accident and sickness insurance coverages of spouses, dependent children or other persons.
A. Coverage under a group accident and sickness insurance policy, except a policy issued pursuant to subsection B of § 38.2-3521.1, may be extended to insure:

1. The spouse and any child who is (i) under the age of 19 years, (ii) who is a dependent and under the age of 25 years, or (iii) who is a dependent and a full-time student under 25 years of age, without regard to whether such child resides in the same household as the insured group member, or any class of spouse and dependent children, of each insured group member who so elects; and

2. Any other class of persons as may mutually be agreed upon by the insurer and the group policyholder.

B. The amount of accident and sickness insurance for the spouse, dependent child or other person shall not exceed the amount of accident and sickness insurance for the insured group member.

C. At the insurer's option and subject to the policyholder's election, the coverage for children of the insured group member may be extended beyond the ages established in subsection A. Any such extension of coverage shall be as mutually agreed upon by the insurer and the group policyholder.

D. Notwithstanding the provisions of § 38.2-3538, one certificate may be issued for each insured group member if a statement concerning any spouse's, dependent child's, or other person's coverage is included in the certificate.

E. When a policy provides coverage for a dependent child who is enrolled based upon the child's status as a full-time student and such child is unable due to a medical condition to continue as a full-time student, coverage under the policy for such child nevertheless shall continue in force provided the child's treating physician certifies to the insurer at the time the child withdraws as a full-time student that the child's absence is medically necessary. Coverage for such child shall continue in force until the earlier of (i) the date that is 12 months from the date the child ceases to be a full-time student or (ii) the date the child no longer qualifies as a dependent child under the terms of the group policy. A child's status as a full-time student shall be determined in accordance with the criteria specified by the institution in which the child is enrolled.

F. The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34.

1986, c. 562; 1993, c. 306; 1998, c. 154; 2004, c. 771; 2005, c. 871; 2007, c. 428; 2008, c. 209; 2011, c. 882.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3526. Standard provisions required; exceptions.
A. No group accident and sickness insurance policy shall be delivered or issued for delivery in this Commonwealth unless it contains the standard provisions prescribed in this article.

B. The provisions of § 38.2-3531, subsection A of §§ 38.2-3533 and 38.2-3538 shall not apply to policies issued pursuant to subsection B of § 38.2-3522.1.

1986, c. 562; 1998, c. 154.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3527. Grace period.
Each group accident and sickness insurance policy shall contain a provision that the policyowner is entitled to a grace period of not less than thirty-one days for the payment of any premium due except the first premium. The provision shall also state that during the grace period the accident and sickness coverage shall continue in force unless the policyowner has given the insurer written notice of discontinuance in accordance with the terms of the policy and in advance of the date of discontinuance. The policy may provide that the policyowner shall be liable to the insurer for the payment of a pro rata premium for the time the policy was in force during the grace period.

1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3528. Incontestability.
A. Each group accident and sickness insurance policy shall contain a provision that the validity of the policy shall not be contested, except for nonpayment of premiums, after it has been in force for two years from its date of issue.

B. The provision shall also state that no statement made by any person insured under the policy relating to his insurability or the insurability of his insured dependents shall be used in contesting the validity of the insurance with respect to which such statement was made:

1. After the insurance has been in force prior to the contest for a period of two years during the lifetime of the person about whom the statement was made; and

2. Unless the statement is contained in a written instrument signed by him.

C. This provision shall not preclude the assertion at any time of defenses based on the person's ineligibility for coverage under the policy or upon other provisions in the policy.

1986, c. 562.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3529. Entire contract; statements deemed representations.
A. Each group accident and sickness insurance policy shall contain a provision that the policy, and any application of the policyowner, and any individual applications of the persons insured shall constitute the entire contract between the parties.

B. The provision shall also state that:

1. A copy of any application of the policyowner shall be attached to the policy when issued;

2. All statements made by the policyowner or by the persons insured shall be deemed representations and not warranties; and

3. No written statement made by any person insured shall be used in any contest unless a copy of the statement is furnished to the person or to his beneficiary or personal representative.

1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3530. Evidence of individual insurability.
Each group accident and sickness insurance policy shall contain a provision setting forth any conditions under which the insurer reserves the right to require a person eligible for insurance to furnish evidence of individual insurability satisfactory to the insurer as a condition to part or all of his coverage.

1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3531. Additional exclusions and limitations.
A. Each group accident and sickness insurance policy shall contain a provision specifying all additional exclusions or limitations applicable under the policy for any disease or physical condition of a person, not otherwise excluded from the person's coverage by name or specific description effective on the date of the person's loss, which existed prior to the effective date of the person's coverage under the policy.

B. Any such exclusion or limitation may only apply to a disease or physical condition for which medical advice or treatment was received by the person during the twelve months prior to the effective date of the person's coverage. The exclusion or limitation shall not apply to loss incurred or disability commencing after the earlier of (i) the end of a continuous period of twelve months commencing on or after the effective date of the person's coverage during which the person receives no medical advice or treatment in connection with the disease or physical condition, or (ii) the end of the two-year period commencing on the effective date of the person's coverage.

C. This section shall not apply to group accident and sickness policies providing hospital, medical and surgical or major medical coverage on an expense incurred basis to an employer's employees and their dependents.

1986, c. 562; 1998, c. 24.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3532. Misstatement of age.
Each group accident and sickness insurance policy where the premiums or benefits vary by age shall contain a provision that an equitable adjustment of premiums, benefits or both shall be made if the age of a person insured has been misstated. The provision shall contain a clear statement of the method of adjustment to be used.

1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3533. Individual certificates.
A. Each group accident and sickness insurance policy shall contain a provision that the insurer will issue to the policyholder for delivery to each person insured a certificate setting forth:

1. The insured person's insurance protection, including any limitations, reductions, and exclusions applicable to the coverage provided;

2. To whom the insurance benefits are payable;

3. Any family member's or dependent's coverage; and

4. The rights and conditions set forth in § 38.2-3541.

B. Each group policy issued pursuant to § 38.2-3522.1 B, where any part of the premium is paid by debtors from identifiable charges collected from the insured debtors not required of an uninsured debtor, shall contain a provision that the insurer will furnish to the policyholder for each debtor insured under the policy a form that will contain a statement describing the debtor's coverage and that the benefits payable shall be applied to reduce or extinguish the indebtedness.

1986, c. 562; 1998, c. 154.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3534. Notice of claim.
Each group accident and sickness insurance policy shall contain a provision that written notice of a claim shall be given to the insurer within twenty days after the occurrence or commencement of any loss covered by the policy. Failure to give notice within that time shall not invalidate or reduce any claim if it can be shown that notice was given as soon as reasonably possible.

1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3535. Claim forms.
Each group accident and sickness insurance policy shall contain a provision that the insurer will furnish forms for filing proof of loss to the person making a claim or to the policyholder for delivery to that person. If the forms are not furnished within fifteen days after the insurer received notice of any claim under the policy, the person making the claim shall be deemed to have complied with the requirements of the policy as to proof of loss upon submitting within the time fixed in the policy of filing proof of loss, written proof covering the occurrence, character, and extent of the loss for which a claim is made.

1986, c. 562.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3536. Proofs of loss.
A. Each group accident and sickness insurance policy shall contain a provision that written proof of the loss shall be furnished to the insurer within ninety days after the date of the loss. In the case of a claim for loss of time for disability, each group accident and sickness insurance policy shall contain a provision that written proof of the loss shall be furnished to the insurer within ninety days after the commencement of the period for which the insurer is liable. Subsequent written proof of the continuance of the disability shall be furnished to the insurer at reasonable intervals required by the insurer.

B. Failure to furnish such proof within the prescribed time shall not invalidate or reduce any claim if it was not reasonably possible to furnish the proof within that time and the proof is furnished as soon as reasonably possible. In no event, except in the absence of legal capacity of the claimant, shall such proof be furnished later than one year from the time proof is otherwise required.

1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3537. Time of payment of claims.
Each group accident and sickness insurance policy shall contain a provision that all benefits payable under the policy other than benefits for loss of time shall be payable within sixty days after receipt of proof of loss. The provision shall also state that, subject to proof of loss, all accrued benefits payable under the policy for loss of time shall be paid at least monthly during the continuance of the period for which the insurer is liable, and that any balance remaining unpaid at the termination of such period will be paid as soon as possible.

1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3538. Payment of benefits.
Each group accident and sickness insurance policy shall contain a provision that benefits for loss of life of the person insured shall be payable to the beneficiary designated by the person insured. However, if the policy contains conditions pertaining to family status, the beneficiary may be the family member specified by the policy terms. In either case, payment of those benefits is subject to the provisions of the policy in the event no such designated or specified beneficiary is living at the death of the person insured. The policy may also provide that if any benefit is payable to the estate of a person, or to a person who is a minor or otherwise not competent to give a valid release, the insurer may pay the benefit, up to an amount not exceeding $5,000, to any relative by blood or connection by marriage of the person who is deemed by the insurer to be equitably entitled to the benefit. The policy may also provide that all or any portion of any benefits provided for health care services may be paid to the health care services provider. All other benefits of the policy shall be payable to the person insured.

1986, c. 562; 1991, c. 87.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3539. Physical examinations and autopsy.
Each group accident and sickness insurance policy shall contain a provision that the insurer shall have the right (i) to examine the person for whom a claim is made when and as often as it may reasonably require during the pendency of claim under the policy and (ii) to make an autopsy where it is not prohibited by law.

1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3540. Legal actions.
Each group accident and sickness insurance policy shall contain a provision that no action at law or in equity shall be brought to recover on the policy within sixty days after proof of loss has been filed in accordance with the policy requirements and that no such action shall be brought after the expiration of three years from the time that proof of loss was required to be filed.

1986, c. 562.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3540.2. Employee wellness program.
A. Each group accident and sickness insurance policy and health care plan may provide a premium discount to every employer instituting and maintaining an employee wellness program satisfying such criteria as each insurer may establish. An employer instituting and maintaining an employee wellness program in accordance with the insurer's criteria may require that any employee wishing to enroll in such program undergo a health assessment as a condition of enrollment.

B. The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34.

2010, c. 272; 2013, c. 751.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3541. Continuation on termination of eligibility.
A. Each group hospital policy, group medical and surgical policy, or group major medical policy delivered or issued for delivery in the Commonwealth or renewed, reissued, or extended if already issued, shall contain a provision for continuation of coverage under the group policy if the insurance on a person covered under such a policy ceases because of the termination of the person's eligibility for coverage, prior to that person becoming eligible for Medicare or Medicaid benefits. This provision shall not be applicable if the group policyholder is required by federal law to provide for continuation of coverage under its group health plan pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).

B. The insured's present coverage shall continue under the policy for a period of 12 months immediately following the date of the termination of the person's eligibility, without evidence of insurability, subject to the following requirements:

1. The application and payment for the extended coverage is made to the group policyholder within 31 days after issuance of the written notice required in subsection C, but in no event beyond the 60-day period following the date of the termination of the person's eligibility;

2. Each premium for such extended coverage is timely paid to the group policyholder on a monthly basis during the 12-month period;

3. The premium for continuing the group coverage shall be at the insurer's current rate applicable to the group policy plus any applicable administrative fee not to exceed two percent of the current rate;

4. Continuation shall only be available to an employee or member who has been continuously insured under the group policy during the entire three-month period immediately preceding termination of eligibility; and

5. Continuation shall not be available to an individual whose eligibility for coverage under the group policy ceased because the individual was discharged from employment by the group policyholder for gross misconduct. As used in this subdivision, "gross misconduct" means any conduct connected with the individual's work that would constitute misconduct under § 60.2-618, including deliberately and willfully engaging in conduct evincing a complete disregard for the employer's workplace standards and policies.

C. The group policyholder shall provide each employee or other person covered under such a policy written notice of the availability of continuation of coverage and the procedures and timeframes for obtaining continuation of the group policy. Such notice shall be provided within 14 days of the policyholder's knowledge of the employee's or other covered person's loss of eligibility under the policy.

1979, c. 97, § 38.1-348.11; 1982, c. 625; 1984, c. 300; 1986, c. 562; 1988, c. 551; 2010, c. 503; 2014, c. 814; 2018, c. 471.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3541.1. Repealed.
Repealed by Acts 2014, c. 814, cl. 2
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3542. Notice to employees upon termination of coverage; penalty for failure to remit funds.
A. Any employer who (i) assumes part or all of the cost of providing group accident and sickness insurance or a group health services plan or group health care plan for his employees under a group insurance policy or subscription contract or other evidence of coverage; (ii) provides a facility for deducting the full amount of the premium from employees' salaries and remitting such premium to the insurer, health services plan, or health maintenance organization; or (iii) provides for health and medical care or reimbursement of medical expenses for his employees as a self-insurer, shall give written notice to participating employees in the event of termination or upon the receipt of notice of termination of any such policy, contract, coverage, or self-insurance not later than fifteen days after the termination of a self-insured plan or receipt of the notice of termination required by subsection C of this section.

B. Any employer who collects from his employees or covers any part of the cost of any of the policies, contracts, or coverages specified in subsection A of this section and who knowingly fails to remit to the insurer or plan such funds required to maintain coverage in accordance with the policy or contract provisions under which the employees are covered shall be guilty of a Class 1 misdemeanor and shall be subject to civil suit for any medical expenses the employee may become liable for as a result of the employer letting such coverage be terminated.

C. In the event the coverages specified in subsection A of this section are terminated due to nonpayment of premium by the employer, no such coverages shall be terminated by an insurer, health services plan, health maintenance organization or health insurance issuer as defined in § 38.2-3431 with respect to a covered individual unless and until the employer has been provided with a written or printed notice of termination, including a specific date, not less than fifteen days from the date of such notice, by which coverage will terminate if overdue premium is not paid. Coverage shall not be permitted to terminate for at least fifteen days after such notice has been mailed. Each insurer, health services plan, or health maintenance organization shall make reimbursement on all valid claims for services incurred prior to the date coverage is terminated.

1982, c. 586, § 38.1-356.01; 1986, cc. 251, 562; 1990, c. 301; 1999, c. 276.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3543. Provisions required by other jurisdictions.
A. Group accident and sickness insurance policies of a foreign or alien insurer, delivered or issued for delivery in this Commonwealth, may contain any provision that is not less favorable to the insured or the beneficiary than the provisions required by this article and that is prescribed by the laws of its domiciliary jurisdiction.

B. Any group accident and sickness insurance policy of a domestic insurer may, when delivered or issued for delivery in any other jurisdiction, contain any provision permitted or required by the laws of that jurisdiction.

1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3543.1. Regulations.
The Commission may establish rules and regulations for coordination of benefits, as well as to establish standards to be met in connection with the marketing and contracting for group accident and sickness insurance in this Commonwealth. Pursuant to the authority granted by § 38.2-223, the Commission may promulgate such rules and regulations as it may deem necessary to establish standards with regard to coordination of benefits provisions.

1994, c. 316; 1998, c. 154.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3543.2. Applicability of laws.
In the event of conflict between the provisions of this article and other provisions of this title, the provisions of this article shall be controlling.

1998, c. 154.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3544. Definition of industrial sick benefit insurance.
Industrial sick benefit insurance means life insurance combined with accident and sickness insurance under which:

1. Premiums, dues or assessments are payable weekly;

2. A ten dollar maximum weekly indemnity is paid to members or policyowners in the event of sickness or accident;

3. A $250 maximum death benefit is provided, and the named beneficiary is confined to the spouse of the insured, a relative of the insured by blood, marriage or adoption, a person bound in a pledge of marriage to the insured, or any person dependent on the insured; and

4. The issuing insurer is not required by its charter, bylaws, or by statute to maintain the legal reserve for death benefits.

Code 1950, §§ 38-350, 38-351, 38-352; 1952, c. 317, § 38.1-483; 1986, c. 562.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3545. Further restrictions as to beneficiaries.
Within the permitted classes of beneficiaries prescribed in § 38.2-3544, the issuing insurer may designate the classes of beneficiaries. No change of beneficiary shall be made by assignment, will, or otherwise to any person outside the designated classes without the consent of the insurer. If no person within the classes of beneficiaries prescribed in § 38.2-3544 survives the insured, the insurer may discharge its liability by payment of the proceeds of the policy to any person appearing to the insurer to be equitably entitled to the proceeds because of having incurred expense for the maintenance, medical attention or burial of the insured.

Code 1950, § 38-352; 1952, c. 317, § 38.1-484; 1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3546. Cancellation of sick benefit portion of policy.
Every policy of industrial sick benefit insurance issued in this Commonwealth after June 18, 1922, shall contain a provision that:

1. The sick benefit portion of the policy may be cancelled by either the insurer or the insured and the life portion continued by a payment of twenty percent of the original premium;

2. If the cancellation is by the insurer, it shall be without prejudice to any claim arising on account of disability commencing prior to the date on which the cancellation takes effect; and

3. Written notice of the cancellation and payment for the unearned portion of the premium shall be delivered to the insured or mailed to him at his last known address.

Code 1950, § 38-359; 1952, c. 317, § 38.1-485; 1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3547. Excessive insurance; remedy.
A. Any person holding industrial sick benefit insurance policies of several insurers, that, in the aggregate, provide sick benefits in excess of 150 percent of his weekly salary, wages or earnings, shall not be permitted to recover the excess, nor shall the insurer be compelled to pay the excess, unless the existence of all previous policies was admitted by the insured in all applications for insurance in excess of such sum. If by misstatements, or by the failure to admit the existence of previous policies, the insured has obtained such excess additional policies, and has received benefits under such policies in excess of the amount specified above the excess paid may be deducted from the death benefit provided for in the policies.

B. This section shall not apply in any case where the application for the excess policy did not contain any question in regard to the amount of insurance already carried by the applicant, nor where the application blank was printed in less than ten-point type.

Code 1950, § 38-360; 1952, c. 317, § 38.1-486; 1986, c. 562.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3548. Agents subject to other insurance laws.
Each person representing any insurer in the sale of industrial sick benefit insurance shall be subject to the laws governing agents of insurers.

Code 1950, § 38-361; 1952, c. 317, § 38.1-487; 1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3549. Benefits not subject to legal process.
The payments in weekly or monthly installments to the holder of any policy of industrial sick benefit insurance shall not be subject to the lien of any attachment, garnishment proceeding, writ of fieri facias, or to levy or distress in any manner, for any debt due by the holder of the policy.

Code 1950, § 38-227; 1952, c. 317, § 38.1-488; 1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3550. Effective date.
No industrial sick benefit insurance policy as defined in § 38.2-3544 shall be delivered or issued for delivery in this Commonwealth after June 30, 1987.

1986, c. 562.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3553. Membership in a small employer health group cooperative.
A. A small employer health group cooperative:

1. Shall not limit, restrict, or condition a small employer's membership in the small employer health group cooperative on any health status-related factor relating to an individual, including an employee of a small employer or a dependent of an employee; and

2. Shall make group health policies offered through the small employer health group cooperative available to all eligible employees of its employer-members and their eligible dependents, regardless of any health status-related factor relating to individuals eligible for coverage through a member.

B. Notwithstanding subdivision 2 of subsection A, nothing in this article shall be construed as requiring (i) an issuer to provide coverage outside its service area or (ii) a small employer health group cooperative to make such coverage available to employer-members located outside the service area of the issuer.

C. A small employer health group cooperative shall not make group health policies offered through the cooperative available other than to the eligible employees of its employer-members and their eligible dependents.

2006, c. 427.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3554. Provisions relating to health insurance issuers.
A. No group health policy shall be offered to a small employer group health cooperative that will cover a resident of the Commonwealth unless the Commission finds that:

1. The issuance of such group health policy is not contrary to Virginia's public policy and is in the best interest of the citizens of the Commonwealth;

2. The issuance of the group health policy would result in economies of acquisition or administration; and

3. The benefits are reasonable in relation to the premiums charged.

B. Issuers filing policy forms seeking approval under the provisions of this subsection shall provide with the forms a certification, signed by the officer of the company with the responsibility for forms compliance, in which the company certifies that each such policy form will be issued only when the requirements set forth in subdivisions 1 through 3 of subsection A have been satisfied.

C. If a small employer health group cooperative has elected, under subdivision B 1 a of § 38.2-3552, to be deemed the policyholder of a group health policy covering the eligible employees and eligible dependents of its employer-members within the service area of an issuer and has furnished the authorization required under subdivision B 2 of § 38.2-3552, the issuer of such policy shall deem the small employer health group cooperative to be the policyholder in all respects permissible under applicable state and federal laws and regulations.

D. If a small employer health group cooperative has elected, under subdivision B 1 b of § 38.2-3552, to be deemed only a sponsoring entity facilitating the acquisition of separate group health policies for its employer-members within the service area of an issuer, the issuer shall issue a separate policy to each such employer-member of the cooperative. Each such policy shall conform to the benefit and premium specifications and other policy terms mutually agreed upon by the issuer and the small employer health group cooperative in accordance with subsection B of § 38.2-3552.

E. An issuer providing a group health policy or policies to or through a small employer health group cooperative shall make such policy or policies available to every eligible employee of an employer-member within its service area who applies for such policy or policies, and their eligible dependents, subject to an individual employee's right to reject coverage in writing. No coverage may be offered only to certain eligible employees or their eligible dependents, and no eligible employees or their eligible dependents may be excluded or charged additional premiums, because of health status-related factors.

F. The premiums for the policy or policies issued to or through a small employer health group cooperative shall be paid from funds contributed by the small employer health group cooperative, its employer-members, or both; or from funds contributed by the covered persons, or from both the covered persons and the employer-members or small employer health group cooperative.

2006, c. 427.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3555. Authority of the Commission.
Pursuant to the authority granted by § 38.2-223, the Commission may promulgate such rules and regulations as it may deem necessary to implement this article.

2006, c. 427.