CO Code § 10-16-202 (2021)
2021 Colorado Code|Title 10 - Insurance|Article 16 - Health Care Coverage|Part 2 - Sickness and Accident Insurance|§ 10-16-202. Required Provisions in Individual Sickness and Accident Policies

  Except as provided in section 10-16-204, each such policy delivered or issued for delivery to any person in this state shall contain the provisions specified in this section in the words in which the same appear in this section; except that the insurer, at its option, may substitute for one or more of such provisions corresponding provisions of different wording approved by the commissioner which are in each instance not less favorable in any respect to the insured or the beneficiary. Such provisions shall be preceded individually by the caption appearing in this section or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the commissioner may approve.    A provision as follows: “Entire contract--changes: This policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the insurer and unless such approval be endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions.”    Provisions as follows: “Time limit on certain defenses:   Two years after the date of issue of this policy no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or to deny a claim for loss incurred or disability (as defined in the policy) commencing after the expiration of such two-year period. The policy cannot be retroactively terminated except for fraud or intentional misrepresentation. For any termination other than for fraud or intentional misrepresentation, the carrier shall provide notice thirty days in advance of the cancellation of the policy.”    Except for individual disability income insurance policies, no claim for loss incurred or disability, as defined in the policy, commencing one year after the date of issue of this policy shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or a specific description effective on the date of loss had existed prior to the effective date of coverage of this policy.    If this is an individual disability income insurance policy then no claim for loss incurred or disability, as defined in this individual disability income insurance policy, commencing two years after the date of issue of the policy shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or a specific description effective on the date of loss had existed prior to the effective date of coverage of this policy.         Except as required by section 10-16-140, in a policy other than a health benefit plan, a provision as follows: “Grace period: A grace period of ........ (insert a number not less than ‘7' for weekly premium policies, ‘10' for monthly premium policies, and ‘31' for all other policies) days will be granted for the payment of each premium falling due after the first premium, during which grace period the policy shall continue in force.”    A policy in which the insurer reserves the right to refuse any renewal shall have, at the beginning of the provision referred to in paragraph (a) of this subsection (4), “Unless not less than thirty days prior to the premium due date the insurer has delivered to the insured or has mailed to the insured's last address as shown by the records of the insurer written notice of its intention not to renew this policy beyond the period for which the premium has been accepted.”         A provision as follows: “Reinstatement: If any renewal premium is not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any agent duly authorized by the insurer to accept such premium, without requiring in connection therewith an application for reinstatement, shall reinstate the policy. If the insurer or such agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy will be reinstated upon approval of such application by the insurer or, lacking such approval, upon the forty-fifth day following the date of such conditional receipt unless the insurer has previously notified the insured in writing of its disapproval of such application. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than ten days after such date. In all other respects the insured and insurer shall have the same rights thereunder as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions endorsed hereon or attached hereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than sixty days prior to the date of reinstatement.”    The last sentence of the above provision may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums until at least age fifty or, in the case of a policy issued after age forty-four, for at least five years from its date of issue.         Provisions as follows: “Notice of claim: Written notice of claim must be given to the insurer within twenty days after the occurrence or commencement of any loss covered by the policy or as soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or the beneficiary to the insurer at ........ (insert the location of such office as the insurer may designate for the purpose), or to any authorized agent of the insurer, with information sufficient to identify the insured, shall be deemed notice to the insurer.”    In a policy providing a loss-of-time benefit which may be payable for at least two years, an insurer may at its option insert the following between the first and second sentences of the provision set forth in paragraph (a) of subsection (6) of this section: “Subject to the qualifications set forth below, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least two years, the insured shall, at least once in every six months after having given notice of claim, give to the insurer notice of continuance of said disability, except in the event of legal incapacity. The period of six months following any filing of proof by the insured or any payment by the insurer on account of such claim or any denial of liability in whole or in part by the insurer shall be excluded in applying this provision. Delay in the giving of such notice shall not impair the insured's right to any indemnity which would otherwise have accrued during the period of six months preceding the date on which such notice is actually given.”       A provision as follows: “Claim forms: The insurer, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within fifteen days after the giving of such notice, the claimant shall be deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character, and the extent of the loss for which claim is made.”    A provision as follows: “Proofs of loss: Written proof of loss must be furnished to the insurer at its said office in case of claim for loss for which this policy provides any periodic payment contingent upon continuing loss within ninety days after the termination of the period for which the insurer is liable and in case of claim for any other loss within ninety days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, if such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required.”    A provision as follows: “Time of payment of claims: Indemnities payable under this policy for any loss other than loss for which this policy provides any periodic payment will be paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment will be paid ........ (insert period for payment which must not be less frequently than monthly) and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof.”      A provision as follows: “Payment of claims: Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to the estate of the insured. Any other accrued indemnities unpaid at the insured's death may, at the option of the insurer, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the insured.”    The following provisions, or either of them, may be included with the provision set forth in paragraph (a) of this subsection (10) at the option of the insurer: “If any indemnity of this policy shall be payable to the estate of the insured, or to an insured or beneficiary who is a minor or otherwise not competent to give valid release, the insurer may pay such indemnity, up to an amount not exceeding $ ........ (insert an amount which shall not exceed $1000), to any relative by blood or connection by marriage of the insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any payment made by the insurer in good faith pursuant to this provision shall fully discharge the insurer to the extent of such payment.”       A provision as follows: “Physical examinations and autopsy: The insurer at its own expense shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law.”    A provision as follows: “Legal actions: No action at law or in equity shall be brought to recover on this policy prior to the expiration of sixty days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished.”      A provision as follows: “Change of beneficiary: Unless the insured makes an irrevocable designation of beneficiary, the right to change of beneficiary is reserved to the insured and the consent of the beneficiary or beneficiaries shall not be requisite to surrender or assignment of this policy or to any change of beneficiary or beneficiaries, or to any other changes in this policy.”    The first clause of this provision, relating to the irrevocable designation of beneficiary, may be omitted at the insurer's option.        “(The foregoing policy provision does not affect any legal requirement for avoidance of a policy or denial of a claim during such initial two-year period, nor limit the application of section 10-16-203 in the event of misstatement with respect to age or occupation or other insurance.)”   (A policy that the insured has the right to continue in force subject to its terms by the timely payment of premium until at least age fifty, or in the case of a policy issued after age forty-four, for at least five years after its date of issue, may contain, in lieu of the foregoing, the following provision, from which the clause in parentheses may be omitted at the insurer's option, under the caption “Incontestable”:   “After this policy has been in force for a period of two years during the lifetime of the insured (excluding any period during which the insured is disabled), it becomes incontestable as to the statements contained in the application.”)   “Subject to any written direction of the insured in the application or otherwise, all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical, or surgical services may, at the insurer's option and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the service be rendered by a particular hospital or person.”    History. Source: L. 92: Entire article R&RE, p. 1660, § 1, effective July 1. L. 94: (3) amended, p. 1918, § 11, effective July 1. L. 95: (3)(b) amended and (3)(c) added, p. 726, § 2, effective May 23. L. 2013: (3) and (4)(a) amended,(HB 13-1266), ch. 217, p. 978, § 29, effective May 13.    Editor's note:   This section is similar to former § 10-8-104 as it existed prior to 1992.   ANNOTATION   Annotator's note. Since § 10-16-202 is similar to § 10-8-104 as it existed prior to the 1992 repeal of part 1 of article 8 of this title, relevant cases construing that provision have been included in the annotations to this section.   An insured adopts the application when he executes it even though he may not have read the application. Commercial Ins. Co. v. Smith, 417 F.2d 1330 (10th Cir. 1969).   Even so, this does not shift the burden of proving fraud which was the critical issue. The company has the affirmative burden in avoiding a policy. The insured contends he did not know the seriousness of the eye disease. The issue of scienter was presented and the jury decided in favor of the insured. Therefore, the insurer failed to prove fraud clearly, cogently, convincingly, and beyond a reasonable doubt. Commercial Ins. Co. v. Smith, 417 F.2d 1330 (10th Cir. 1969).   For “fraudulent misstatements” must have elements of common-law fraud. The insurance company's contention is that the insured knew, at the time he answered the application, of the serious nature of his eye condition and therefore the company is entitled to rescind the insurance contract. The contention concerns a construction of the meaning of the statutory phrase “except fraudulent misstatements”. Under this statute, the trial court correctly submitted the case to the jury on instructions that the appellant must establish the legal elements of common-law fraud which includes scienter or intent to defraud, instead of instructions setting out the equitable defense of fraud, as to which scienter or intent to defraud is not a necessary element. Commercial Ins. Co. v. Smith, 417 F.2d 1330 (10th Cir. 1969).   Initial effective date of policy governs rider if parties intend this. The second part of the policy which increased the benefits was added as a rider within two years of the claim. The language consolidates the rider and the policy initially issued by the words “Attached to and forming part of policy”. The parties intended one policy, with the initial effective date to govern the two year contestability clause. This conclusion is more clear when the brevity of the rider application is noted. Commercial Ins. Co. v. Smith, 417 F.2d 1330 (10th Cir. 1969).   The reinstatement of sickness and accident policies is governed by this section, and the provisions of this section are dispositive of arguments related to the limitations of which insurers are required to notify insureds. Jarnigan v. Banker's Life and Casualty Co., 824 P.2d 11 (Colo. App. 1991).   The language in subsection (3)(b) regarding “preexisting conditions” supercedes that of § 10-16-118 (1)(a)(II) with respect to individual health coverage plans. Thus, the definition of “preexisting conditions” in such plans does not include specified conditions the coverage for which is explicitly limited, denied, or excluded. Usick v. Am. Family Mut. Ins. Co., 131 P.3d 1195 (Colo. App. 2006).