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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 14 - Group Life Insurance (§§ 1401 — 1411) › § 1407 - Age falsely stated

A provision specifying an equitable adjustment of premiums or of benefits or of both to be made in the event the age of a person insured has been misstated, such provision to contain a clear statement of the method of adjustment to be used.
History —Ins. Code, added as § 14.070 on June 6, 1960, No. 64.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 14 - Group Life Insurance (§§ 1401 — 1411) › § 1408 - Provision to facilitate payment

A provision that any sum becoming due by reason of the death of the person insured shall be payable to the beneficiary designated by the person insured, subject to the provisions of the policy in the event there is no designated beneficiary, as to all or any part of such sum, living at the time of the death of the person insured, and subject to any right reserved by the insurer in the policy and set forth in the certificate to pay at its option a part of such sum not exceeding five hundred dollars ($500) to any person appearing to the insurer to be equitably entitled thereto by reason of having incurred funeral or other expenses incident to the last illness or death of the person insured.
History —Ins. Code, added as § 14.080 on June 6, 1960, No. 64.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 14 - Group Life Insurance (§§ 1401 — 1411) › § 1409 - Issuance of certificate

A provision that the insurer will issue to the policyholder for delivery to each person insured an individual certificate setting forth a statement as to the insurance protection to which he is entitled, to whom the insurance benefits are payable, and the rights and conditions set forth in subdivisions (1), (2) and (3) of § 1410 of this title.
History —Ins. Code, added as § 14.090 on June 6, 1960, No. 64.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 14 - Group Life Insurance (§§ 1401 — 1411) › § 1411 - Special form in case of creditors’ and debtors’ insurance

In the case of a policy issued to a creditor to insure debtors of such creditor, the policy shall contain a provision that the insurer will furnish to the policyholder for delivery to each debtor insured under the policy a form which will contain a statement that the life of the debtor is insured under the policy and that any death benefit paid thereunder by reason of his death shall be applied to reduce or extinguish the indebtedness.
History —Ins. Code, added as § 14.110 on June 6, 1960, No. 64.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1601 - Scope

Nothing in this chapter shall apply to or affect:
(1) Any policy of workmen’s compensation insurance or any policy of liability insurance with or without supplementary coverage therein; or
(2) any policy or contract of reinsurance; or
(3) any blanket or group policy of insurance; or
(4) life insurance, endowment or annuity contracts, or contracts supplemental thereto which contain only such provisions relating to accident and sickness insurance as:
(a) Provide additional benefits in case of death or dismemberment or loss of sight by accident, or as
(b) operate to safeguard such contracts against lapse, or to give a special surrender value or special benefit or an annuity in the event that the insured or annuitant shall become totally and permanently disabled, as defined by the contract or supplemental contract. Provided, however, That §§ 1609, 1610 and 1613 of this title shall apply to contracts supplemental to life insurance or endowment or annuity contracts.
History —Ins. Code § 16.010; Mar. 18, 2008, No. 31, § 2, eff. 90 days after Mar. 18, 2008.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1602 - Format of disability policies

No disability policy shall be delivered or issued for delivery to any person in Puerto Rico unless it otherwise complies with this title, and complies with the following:
(1) It shall purport to insure only one person, except as to family expense insurance written pursuant to § 1633 of this title.
(2) The style, arrangement and over-all appearance of the policy shall give no undue prominence to any portion of the text, and every printed portion of the text of the policy and of any endorsements or attached papers shall be plainly printed in light-faced type of a style in general use, the size of which shall be uniform and not less than ten-point with a lower case unspaced alphabet length not less than one hundred and twenty-point (the “text” shall include all printed matter except the name and address of the insurer, name or title of the policy, the brief description if any, and caption and subcaptions).
(3) The exceptions and reductions of indemnity shall be set forth in the policy and, other than those contained in §§ 1605–1628 of this title, inclusive, shall be printed, at the insurer’s option, either included with the benefit provision to which they apply, or under an appropriate caption such as “EXCEPTIONS”, or “EXCEPTIONS AND REDUCTIONS”, except that if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of such exception or reduction shall be included with the benefit provision to which it applies.
(4) Each such form, including riders and endorsements, shall be identified by a form number in the lower left-hand corner of the first page thereof.
(5) It shall contain no provision purporting to make any portion of the insurer’s charter, rules, constitution, or bylaws a part of the policy unless such portion is set forth in full in the policy, except in the case of the incorporation of, or reference to, a statement of rates or classification of risks, or short-rate table filed with the Commissioner.
History —Ins. Code § 16.020.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1603 - Policies issued by domestic insurer for delivery elsewhere

If any policy is issued by a domestic insurer for delivery to a person residing in another state or country, and if the insurance commissioner or corresponding public official of such other state or country has advised the Commissioner in Puerto Rico that any such policy is not subject to approval or disapproval by such official, the Commissioner may by ruling require that such policy meet the applicable standards set forth in this chapter and in §§ 1101–1137 of this title.
History —Ins. Code § 16.030.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1604 - Standard provisions required; substitutions; captions

Except as provided in § 1113 of this title, each such policy delivered or issued for delivery to any person in Puerto Rico shall contain the provisions as specified in §§ 1605–1623 of this title inclusive, in the words in which the same appear; except, that the insurer may, at its option, 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. Each such provision shall be preceded by the applicable caption shown or, at the insurer’s option, by such appropriate individual or group caption or subcaption as the Commissioner may approve.
History —Ins. Code § 16.040; Mar. 18, 2008, No. 31, § 3, eff. 90 days after Mar. 18, 2008.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1605 - Entire contract; changes

There shall be 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.
History —Ins. Code § 16.050.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1606 - Time limit on certain defenses

The policy shall contain a provision as follows: Time limit on certain defenses :—
(a) After three (3) years from the date of [issuance] of this policy no misstatements (except fraudulent misstatements) made by the applicant in the application for such policy may 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 three (3)-year period. Fraudulent misstatements may 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 three (3)-year period, only when the act or omission in question has contributed to the loss which is the object of the cause of action.
(The foregoing policy provision shall not be so construed as to affect any legal requirement for voidance of a policy or denial of a claim during such initial three (3)-year period or to limit the application of §§ 1618–1622 of this title in the event of misstatement with respect to age or occupation, or other insurance.)
A policy which the insured has the right to continue in force subject to its terms by the timely payment of premium:
(1) Until at least age 50, or
(2) in the case of a policy issued after age forty-four (44), for at least five (5) years from its date of issue, may contain in lieu of the foregoing, the following provision (from which the clause in parenthesis may be omitted at the insurer’s option) under the caption “INCONTESTABLE: After this policy has been in force for a period of three (3) years during the lifetime of the insured (excluding any period during which the insured is disabled), it shall become incontestable as to the statements contained in the application.”)
(b) No claim for loss incurred or disability (as defined in the policy) commencing after three years from 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 specific description effective on the date of loss had existed prior to the effective date of coverage of this policy.
History —Ins. Code § 16.060; Mar. 18, 2008, No. 31, § 4, eff. 90 days after Mar. 18, 2008.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1607 - Grace period

There shall be a provision as follows:
Grace period.— A grace period ____ (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 which contains a cancellation provision may add, at the end of the above provision: “subject to the right of the insurer to cancel in accordance with the cancellation provision hereof.”
A policy in which the insurer reserves the right to refuse any renewal shall have, at the beginning of the above provision: “Unless not less than ten days prior to the premium due date, the insurer has delivered to the insured or has mailed to his last address as shown by the records of the insurer written notices of its intention not to renew this policy beyond the period for which the premium has been accepted.”).
History —Ins. Code § 16.070.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1608 - Reinstatement

There shall be a provision as follows:
Reinstatement.— If any renewal premium be not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any producer duly authorized by the insurer to accept such premium, without requiring in connection therewith an application for reinstatement, shall reinstate the policy: provided, however, that if the insurer or such producer 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 (1) until at least age 50 or, (2) in the case of a policy issued after age 44, for at least five years from its date of issue).
History —Ins. Code § 16.080; Jan. 19, 2006, No. 10, § 9, eff. 120 days after Jan. 19, 2006.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1609 - Notice of claim

There shall be a provision as follows:
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), 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 above provision:
“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, he 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.”)
History —Ins. Code § 16.090.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1610 - Claim forms

There shall be 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, and the character and extent of the loss for which claim is made.
History —Ins. Code § 16.100.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1611 - Proofs of loss

There shall be 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, provided 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.
History —Ins. Code § 16.110.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1612 - Time of payment of claims

There shall be a provision as follows:
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.
History —Ins. Code § 16.120.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1613 - Payment of claims

(1) There shall be 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 payments 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.
(2) The following provisions, or either of them, may be included with the foregoing provision 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 a valid release, the insurer may pay such indemnity, up to an amount not exceeding $____ (insert an amount which shall not exceed $1,000), 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.”
“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 —Ins. Code § 16.130.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1614 - Physical examinations and autopsy

There shall be 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.
History —Ins. Code § 16.140.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1615 - Civil actions

There shall be a provision as follows:
Civil action.— 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.
History —Ins. Code § 16.150.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1616 - Change of beneficiary

There shall be 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 the 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.)
History —Ins. Code § 16.160.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1617 - Optional standard provisions

Except as provided in § 1113 of this title, no such policy delivered or issued for delivery to any person in Puerto Rico may contain provisions respecting the matters set forth in §§ 1618–1628 of this title, inclusive, unless such provisions are in the words in which the same appear in the applicable section; except, that the insurer may, at its option, use in lieu of any such provision a corresponding provision of different wording approved by the Commissioner which is not less favorable in any respect to the insured or the beneficiary. Any such provision contained in the policy shall be preceded individually by the appropriate caption or, at the insurer’s option, by such appropriate individual or group caption or subcaption as the Commissioner may approve.
History —Ins. Code § 16.170, renumbered as § 16.200 and amended on Mar. 18, 2008, No. 31, § 5, eff. 90 days after Mar. 18, 2008.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1618 - Change of occupation

There may be a provision as follows:
Change of occupation.— If the insured be injured or contracts sickness after having changed his occupation to one classified by the insurer as more hazardous than that stated in this policy or while doing for compensation anything pertaining to an occupation so classified, the insurer shall pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for such more hazardous occupation. If the insured changes his occupation to one classified by the insurer as less hazardous than that stated in this policy, the insurer, upon receipt of proof of such change of occupation, will reduce the premium rate accordingly, and will return the excess pro rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent. In applying this provision, the classification of occupational risk and the premium rates shall be such as have been last filed by the insurer prior to the occurrence of the loss for which the insurer is liable or prior to date of proof of change in occupation, with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued; but if such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the insurer in such state prior to the occurrence of the loss or prior to the date of proof of change in occupation.
History —Ins. Code § 16.180, renumbered as § 16.210 on Mar. 18, 2008, No. 31, § 1, eff. 90 days after Mar. 18, 2008.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1619 - Misstatement of age

There may be a provision as follows:
Misstatement of age.— If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age.
History —Ins. Code § 16.190, renumbered as § 16.220 on Mar. 18, 2008, No. 31, § 1, eff. 90 days after Mar. 18, 2008.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1620 - Other insurance in this insurer

There may be a provision as follows:
If an accident or sickness or accident and sickness policy or policies previously issued by the insurer to the insured be in force concurrently herewith, making the aggregate indemnity for ____ (insert type of coverage or coverages) in excess of $ ____ (insert maximum limit of indemnity or indemnities), the excess insurance shall be void and all premiums paid for such excess shall be returned to the insured or to his estate.
Or, in lieu thereof:
Insurance effective at any one time on the insured under a like policy or policies in this insurer is limited to the one such policy elected by the insured, his beneficiary or his estate, as the case may be, and the insurer will return all premiums paid for all other such policies.
History —Ins. Code § 16.200, renumbered as § 16.230 on Mar. 18, 2008, No. 31, § 1, eff. 90 days after Mar. 18, 2008.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1621 - Insurance with other insurers (provision of service or expense basis)

(1) There may be a provision as follows:
Insurance with other insurers.— If there be other valid coverage, not with this insurer, providing benefits for the same loss on a provision of service basis or on an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability under any expense incurred coverage of this policy shall be for such proportion of the loss as the amount which would otherwise have been payable hereunder plus the total of the like amounts under all such other valid coverages for the same loss of which this insurer had notice bears to the total like amounts under all valid coverages for such loss, and for the return of such portion of the premium paid as shall exceed the pro rata portion for the amount so determined. For the purpose of applying this provision when other coverage is on a provision of service basis, the “like amount” of such other coverage shall be taken as the amount which the services rendered would have cost in the absence of such coverage.
(2) If the foregoing policy provision is included in a policy which also contains the policy provision set out in § 1622 of this title, there shall be added to the caption of the foregoing provision the phrase “... EXPENSE INCURRED BENEFITS”. The insurer may, at its option, include in this provision a definition of “other valid coverage”, approved as to form by the Commissioner, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of Puerto Rico or any state of the United States or any province of Canada, and by hospital or medical service organizations, and to any other coverage the inclusion of which may be approved by the Commissioner. In the absence of such definition, such term shall not include group insurance, automobile medical payments insurance, or coverage provided by hospital or medical service organizations or by union welfare plans or employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute (including any workman’s compensation or employer’s liability statute), whether provided by a governmental agency or otherwise, shall in all cases be deemed to be “other valid coverage” of which the insurer has had notice. In applying the foregoing policy provision, no third party liability coverage shall be included as “other valid coverage”.
History —Ins. Code § 16.210, renumbered as § 16.170 and amended on Mar. 18, 2008, No. 31, § 6, eff. 90 days after Mar. 18, 2008.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1622 - Insurance with other insurers

(1) There may be a provision as follows:
Insurance with other insurers.— If there be other valid coverage, not with this insurer, providing benefits for the same loss on other than an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability for such benefits under this policy shall be for such proportion of the indemnities otherwise provided hereunder for such loss as the like indemnities of which the insurer had notice (including the indemnities under this policy) bear to the total amount of all like indemnities for such loss, and for the return of such portion of the premium paid as shall exceed the pro rata portion for the indemnities thus determined.
(2) If the foregoing policy provision is included in a policy which also contains the policy provision set out in § 1621 of this title, there shall be added to the caption of the foregoing provision the phrase “... OTHER BENEFITS”. The insurer may, at its option, include in this provision a definition of “other valid coverage”, approved as to form by the Commissioner, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of Puerto Rico or any state of the United States or any province of Canada, and to any other coverage the inclusion of which may be approved by the Commissioner. In the absence of such definition, such term shall not include group insurance, or benefits provided by union welfare plans or by employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute (including any workmen’s compensation or employer’s liability statute), whether provided by a governmental agency or otherwise, shall in all cases be deemed to be “other valid coverage” of which the insurer has had notice. In applying the foregoing policy provision, no third party liability coverage shall be included as “other valid coverage”.
History —Ins. Code § 16.220, renumbered as § 16.180 and amended on Mar. 18, 2008, No. 31, § 7, eff. 90 days after Mar. 18, 2008.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1623 - Relation of earnings to insurance

(a) There may be a provision as follows:
Relation of earnings to insurance.— If the total monthly amount of loss-of-time benefits promised for the same loss under all valid loss of time coverage upon the insured, whether payable on a weekly or monthly basis, shall exceed the monthly earnings of the insured at the time disability commenced, or his average monthly earnings for the period of two years immediately preceding a disability for which claim is made, whichever is the greater, the insurer will be liable only for such proportionate amount of such benefits under this policy as the amount of such monthly earnings or such average monthly earning of the insured bears to the total amount of monthly benefits for the same loss under all such coverage upon the insured at the time such disability commences and for the return of such part of the premiums paid during such two years as shall exceed the pro rata amount of the premiums for the benefits actually paid hereunder; but this shall not operate to reduce the total monthly amount of benefits payable under all such coverage upon the insured below the sum of two hundred dollars or the sum of the monthly benefits specified in such coverages, whichever is the lesser, nor shall it operate to reduce benefits other than those payable for loss of time.
(b) The foregoing policy provision may be inserted only in a policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums
(1) Until at least age 50, or
(2) in the case of a policy issued after age 44, for at least five years from its date of issue. The insurer may, at its option, include in this provision a definition of “valid loss of time coverage,” approved as to form by the Commissioner, which definition shall be limited in subject matter to coverage provided by governmental agencies or by organizations subject to regulation by insurance law or by insurance authorities of Puerto Rico or any state of the United States or any province of Canada, or to any other coverage the inclusion of which may be approved by the Commissioner, or any combination of such coverages. In the absence of such definition, such term shall not include any coverage provided for such insured pursuant to any compulsory benefit statute (including any workmen’s compensation or employer’s liability statute), or benefits provided by union welfare plans or by employer or employee benefit organizations.
History —Ins. Code § 16.230, renumbered as § 16.190 on Mar. 18, 2008, No. 31, § 1, eff. 90 days after Mar. 18, 2008.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1624 - Unpaid premium

There may be a provision as follows:
Unpaid premiums.— Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom.
History —Ins. Code § 16.240.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1625 - Cancellation

There may be a provision as follows:
Cancellation.— The insurer may cancel this policy at any time by written notice delivered to the insured, or mailed to his last address as shown by the records of the insurer, stating when, not less than ten days thereafter, such cancellation shall be effective; and after the policy has been continued beyond its original term, the insured may cancel this policy at any time by written notice delivered or mailed to the insurer, effective upon receipt or on such later date as may be specified in such notice. In the event of cancellation, the insurer will return promptly the unearned portion of any premium paid. If the insured cancels, the earned premium shall be computed by the use of the short-rate table last filed with the state official having supervision of insurance in the state where the insured resided when the policy was issued. If the insurer cancels, the earned premium shall be computed pro rata. Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation.
History —Ins. Code § 16.250.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1626 - Conformity with state statutes

There may be a provision as follows:
Conformity with state statutes.— Any provision of this policy which, on its effective date, is in conflict with the statutes of the state in which the insured resides on such date is hereby amended to conform to the minimum requirements of such statutes.
History —Ins. Code § 16.260.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1627 - Illegal occupation

There may be a provision as follows:
Illegal occupation.— The insurer shall not be liable for any loss to which a contributing cause was the insured’s commission of or attempt to commit a felony or to which a contributing cause was the insured’s being engaged in an illegal occupation.
History —Ins. Code § 16.270.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1628 - Intoxicants and narcotics

There may be a provision as follows:
Intoxicants and narcotics.— The insurer shall not be liable for any loss sustained or contracted in consequence of the insured’s being intoxicated or under the influence of any narcotic unless administered on medical prescription.
History —Ins. Code § 16.280.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1629 - Order of certain policy provisions

The provisions which are the subject of §§ 1605–1628 of this title, inclusive, or any corresponding provisions which are used in lieu thereof in accordance with such sections, shall be printed in the consecutive order of the provisions in such sections or, at the insurer’s option, any such provision may appear as a unit in any part of the policy, with other provisions to which it may be logically related, provided the resulting policy shall not be in whole or in part unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to whom the policy is offered, delivered or issued.
History —Ins. Code § 16.290.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1630 - Third party ownership

The word “insured,” as used in this chapter, shall not be construed as preventing a person other than the insured with a proper insurable interest from making application for and owning a policy covering the insured or from being entitled under such a policy to any indemnities, benefits and rights provided therein.
History —Ins. Code § 16.300.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1631 - Requirements of other jurisdictions

(1) Any policy of a foreign insurer, when delivered or issued for delivery to any person in Puerto Rico, may contain any provision which is not less favorable to the insured or to the beneficiary than the provisions of this chapter and which is prescribed or required by the laws of the state or country under which the insurer is organized.
(2) Any policy of a domestic insurer may, when issued for delivery in any other state or country, contain any provision permitted or required by the laws of such other state or country.
History —Ins. Code § 16.310.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1632 - Age limit

If any such 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 such date falls within a period for which premium is accepted by the insurer, or if the insurer accepts a premium after such 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 premium has been accepted. In the event 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 such premium or premiums 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.
History —Ins. Code § 16.320.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1633 - Family expenses disability insurance

Family expenses disability insurance, is that provided under a policy issued to an insured member of the family, who will be deemed as the policyholder, covering any two or more eligible members of a family, including husband, wife, dependent children or any children of a specified age which shall not exceed nineteen years, and any other person dependent upon the policy holder; Provided, That the term “children” includes foster children. For the purposes of this section, “foster children” shall be minor children that, although they are not natural or adopted children of the insured principal, have lived since infancy under the same roof with the latter, in a normal parent/child relationship and that are, and shall continue to be, totally dependent on the family of said insured to receive support, as this term is defined in § 561 of Title 31. Any authorized disability insurer may issue family expenses disability insurance.
History —Ins. Code § 16.330; Aug. 31, 2000, No. 251, § 1.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1634 - Franchise plan disability insurance

(1) Disability insurance on a franchise plan is that issued to:
(a) Five or more employees of a common employer, or
(b) ten or more members of any bona fide association or labor union, which association or union was formed and exists for purposes other than that of obtaining insurance, and under which such employees or members, with or without their dependents, are issued individual policies which may vary as to amounts and kinds of coverage as applied for, under an arrangement whereby the premiums on the policies are to be paid to the insurer periodically by the employer, with or without payroll deductions, or by the association, or by some designated employee or officer of the association acting on behalf of the employer or association members.
(2) The term “employer” includes also the employer’s officers and the employer or partners if the employer is an individual or a partnership.
(3) An insurer may charge different rates, provide different benefits, or employ different underwriting procedure for individuals insured under a franchise plan, if such rates, benefits, or procedures as used do not unfairly discriminate as between individuals or plans having substantially like insuring, risk, and exposure factors, or expense elements, and do not unfairly discriminate as between individuals insured under franchise plans and individuals otherwise insured under similar policies, taking into consideration the insuring, risk and exposure factors, and expense elements.
History —Ins. Code § 16.340.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1635 - Incontestability after reinstatement

The reinstatement of any policy of noncancellable disability insurance, or of any disability policy containing a provision for incontestability, or a provision of similar nature, delivered or issued for delivery in Puerto Rico while this Code is in effect, shall be contestable only on account of fraud or misrepresentation of facts material to the reinstatement and only for the same period following reinstatement as is provided in the policy with respect to the contestability thereof after the original issuance of the policy.
History —Ins. Code § 16.350.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 1 - Insurance Generally (§§ 101 — 4513) › Chapter 16 - Disability Insurance (§§ 1601 — 1636) › § 1636 - Effective date of standard provision and certain other sections—Two (2)-year periods

A policy, rider or endorsement, which could have been lawfully used or delivered or issued for delivery to any person in Puerto Rico immediately before the effective date of this Code, may be used or delivered or issued for delivery to any such person within two (2) years after such date.
History —Ins. Code § 16.360.