reglab/statecodes huggingface dataset:
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35.1 - Health Carrier Internal Appeal Process and External Review › § 38.2-3557. Scope of chapter

A. This chapter shall apply to all health carriers, except that the provisions of this chapter shall not apply to a policy or certificate that provides coverage only for a specified disease, specified accident or accident-only coverage, credit, disability income, hospital indemnity, long-term care, dental, vision care, or any other limited supplemental benefit or to a Medicare supplement policy of insurance, coverage under a plan through Medicare, Medicaid, or the federal employees health benefits program, self-insured plans, any coverage issued under Chapter 55 of Title 10 of the U.S. Code, and any coverage issued as supplemental to that coverage, any coverage issued as supplemental to liability insurance, workers' compensation or similar insurance, automobile medical payment insurance or any insurance under which benefits are payable with or without regard to fault, whether written on a group blanket or individual basis.
B. Notwithstanding the provisions of this section, self-insured employee welfare benefit plans may request a standard external review from the Commission. "Employee welfare benefit plan" has the meaning set forth in the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1002 (1).
2011, c. 788.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35.1 - Health Carrier Internal Appeal Process and External Review › § 38.2-3558. Health carrier's internal appeal process

Each health carrier shall establish an internal appeal process, including a process for urgent care appeals, to consider a utilization review adverse determination or other adverse benefit determination or decision that is appealed by a covered person, his authorized representative, or his provider. The Commission shall promulgate regulations effectuating the purpose of this section, including timeframes for filing appeals, types of claims that may be appealed including rescissions, notice requirements, rights of the covered person, and reviewer requirements.
2011, c. 788.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35.1 - Health Carrier Internal Appeal Process and External Review › § 38.2-3560. Exhaustion of internal appeal process

A. A request for an external review shall not be made until the covered person has exhausted the health carrier's internal appeal process, provided that a covered person's exhaustion of the health carrier's internal appeal process shall not be required if the adverse determination relates to the treatment of a cancer of the covered person.
B. A covered person shall be considered to have exhausted the health carrier's internal appeal process if the covered person or his authorized representative has filed an appeal requesting a review of an adverse determination, and, except to the extent the covered person or his authorized representative requested or agreed to a delay, has not received a written decision from the health carrier within 30 days following the date the appeal was filed with the health carrier.
C. If a covered person or his authorized representative files a request for an expedited internal appeal of an adverse determination with the health carrier, the covered person or his authorized representative is deemed to have exhausted the internal appeal process and may file a request for an expedited external review of the adverse determination at the same time. Upon receipt of a request for an expedited external review of an adverse determination, the independent review organization conducting the external review shall determine whether the covered person shall be required to complete the health carrier's expedited internal appeal process before it conducts the expedited external review. The independent review organization shall promptly notify the covered person and his authorized representative, if any, of this determination, and either proceed with the expedited external review or wait until completion of the internal expedited appeal process.
D. A request for an external review of an adverse determination may be made before the covered person has exhausted the health carrier's internal appeal process whenever the health carrier agrees to waive the exhaustion requirement. If the exhaustion requirement is waived, the covered person or his authorized representative may file a request in writing for a standard external review.
2011, c. 788; 2019, cc. 826, 840.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35.1 - Health Carrier Internal Appeal Process and External Review › § 38.2-3564. Binding nature of external review decision

A. An external review decision is binding on the health carrier. Failure to comply with the assigned independent review organization's external review decision shall be a knowing and willful violation of this section and subject to one or more of the following: (i) punishment as provided in § 38.2-218, (ii) the suspension or revocation of any license issued by the Commission, or (iii) any order that may be issued by the Commission pursuant to § 38.2-219.
B. An external review decision is binding on the covered person except to the extent the covered person has other remedies available under applicable federal or state law.
C. A covered person or his authorized representative may not file a subsequent request for external review involving the same adverse determination or final adverse determination for which the covered person has already received an external review decision.
2011, c. 788.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35.1 - Health Carrier Internal Appeal Process and External Review › § 38.2-3566. Approval of independent review organizations

A. Each independent review organization that wishes to be eligible to conduct external reviews shall submit an application to the Commission for approval or reapproval. The Commission may charge a reasonable fee for initial approval and each reapproval.
B. The Commission shall approve independent review organizations that meet the minimum qualifications to conduct external reviews. Such approval is not subject to the Virginia Public Procurement Act (§ 2.2-4300 et seq.).
C. An independent review organization is eligible for approval if it is accredited by a nationally recognized private accrediting entity that the Commission has determined has standards that are equivalent to or at least meet the minimum qualifications for independent review organizations.
D. An approval or reapproval is effective for two years, unless the Commission determines before its expiration that the independent review organization is not satisfying the minimum qualifications or its decisions have been consistently unclear or incomplete. Whenever the Commission determines that an independent review organization has lost its accreditation or does not meet the requirements of this subsection, the Commission shall terminate the approval of the independent review organization and remove it from the list of independent review organizations approved to conduct external reviews.
E. The Commission shall maintain and periodically update a list of approved independent review organizations.
F. The assignment by the Commission of an approved independent review organization shall be done on a random basis, taking into consideration the nature of the health care service or treatment.
2011, c. 788.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35.1 - Health Carrier Internal Appeal Process and External Review › § 38.2-3567. Independent review organizations to be held harmless

No independent review organization or clinical reviewer working on behalf of an independent review organization or an employee, agent, or contractor of an independent review organization shall be liable in damages to any person for any opinions rendered or acts or omissions performed within the scope of the organization's or person's duties under the law during or upon completion of an external review, unless the opinion was rendered or act or omission performed in bad faith or involved gross negligence.
2011, c. 788.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35.1 - Health Carrier Internal Appeal Process and External Review › § 38.2-3568. External review reporting requirements

A. An independent review organization shall maintain written records, in the aggregate by state and by health carrier, on all external review requests and external reviews conducted during each calendar year. Each independent review organization shall submit a report to the Commission. The report shall be submitted to the Commission by April 1 of the following calendar year. The report shall include in the aggregate by state, and for each health carrier: the total number of requests for external review; the number of requests for external review resolved and, of those resolved, the number upholding the adverse determination or final adverse determination, and the number reversing the adverse determination or final adverse determination; the average length of time for resolution; a summary of the types of coverages or cases for which an external review was sought; the number of external reviews that were terminated as the result of a reconsideration by the health carrier; and any other information the Commission may request or require. The independent review organization shall retain required written records for at least three years.
B. Each health carrier shall maintain written records, in the aggregate by state and for each type of health benefit plan offered, on all requests for external review. Each health carrier shall submit a report to the Commission. The report shall be submitted to the Commission by April 1 of the following calendar year. The report shall include in the aggregate by state, and by type of health benefit plan: the total number of requests for external review, the number of requests determined eligible for external review, the number of external reviews completed, and any other information the Commission may request or require. The health carrier shall retain required written record for at least three years.
2011, c. 788.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35.1 - Health Carrier Internal Appeal Process and External Review › § 38.2-3570. Disclosure requirements

Each health carrier shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage it provides to covered persons. The description shall include a statement that informs the covered person of his right to file a request for an external review of an adverse determination or final adverse determination with the Commission. The statement shall explain that external review is available when the adverse determination or final adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care, or effectiveness. The statement shall include the telephone number and address of the Commission. The statement shall inform the covered person that, when filing a request for an external review, the covered person will be required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.
2011, c. 788.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 36 - Medicare Supplement Policies › § 38.2-3600. Medicare supplement policy; definition

"Medicare supplement policy" means an individual or group accident and sickness insurance policy or certificate, or a health maintenance organization subscription contract or evidence of coverage, issued or issued for delivery in this Commonwealth which is (i) designed primarily to supplement Medicare by providing benefits for payment of hospital, medical or surgical expenses, or (ii) advertised, marketed or otherwise purported to be a supplement to Medicare.
For group policies, the term does not include a policy or contract of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or a combination of employees and labor organizations, for employees, former employees, or a combination of employees and labor organizations or for members or former members, or combination thereof, of the labor organizations.
1979, c. 726, § 38.1-362.7; 1986, c. 562; 1992, c. 225; 1996, c. 11.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 36 - Medicare Supplement Policies › § 38.2-3601. Medicare supplement policies; minimum return for group policies generally

Group Medicare supplement policies shall be expected to return to policyholders in the form of aggregate benefits at least seventy-five percent of the aggregate amount of premiums collected.
1981, c. 575, § 38.1-362.8:1; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 36 - Medicare Supplement Policies › § 38.2-3603. Same; minimum return for individual policies

Medicare supplement policies sold on an individual basis shall be expected to return to policyowners in the form of aggregate benefits at least sixty-five percent of the aggregate amount of premiums collected.
1981, c. 575, § 38.1-362.8:3; 1986, c. 562; 1991, c. 120.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 36 - Medicare Supplement Policies › § 38.2-3604. Free look notice required

Notwithstanding the provisions of § 38.2-3502, Medicare supplement policies shall have printed on the policy a notice stating substantially: "RIGHT TO RETURN POLICY WITHIN THIRTY DAYS. If for any reason you are not satisfied with your policy you may return this policy to the company within thirty days of the date you received it and the premium paid will be promptly refunded."
A policy returned pursuant to the notice shall be void upon the mailing or delivery of the policy to the insurer.
Nothing in this section shall prohibit an insurer from extending the right to examine period to more than thirty days if the period is specified in the policy.
1980, c. 204, § 38.1-362.13; 1981, c. 575; 1986, c. 562; 1989, c. 151.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 36 - Medicare Supplement Policies › § 38.2-3605. Coverage of preexisting conditions; Medicare supplement policies

Notwithstanding subdivision 2 (b) of § 38.2-3503 or the provisions of § 38.2-3514.1, an insurer that issues a Medicare supplement policy shall not deny a claim for losses incurred more than six months from the effective date of coverage on the grounds that a condition existed prior to the effective date of coverage regardless of the application form used. Except as so provided, the policy or contract shall not include wording that would permit a defense based upon preexisting conditions.
1980, c. 204, § 38.1-362.15; 1981, c. 575; 1986, c. 562; 1995, c. 522.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 36 - Medicare Supplement Policies › § 38.2-3606. Outline of coverage

Pursuant to the authority granted in § 38.2-223, the Commission may issue rules and regulations that may (i) require that an outline of coverage for Medicare supplement policies be delivered to the insured at the time the application is made and (ii) prescribe the format and content of the outline of coverage.
1980, c. 204, § 38.1-362.16; 1986, c. 562; 1996, c. 11.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 36 - Medicare Supplement Policies › § 38.2-3607. Group or individual Medicare supplement policies; minimum standards

A. The provisions of §§ 38.2-3418.1, 38.2-3604, 38.2-3605, 38.2-3606 and 38.2-3516 through 38.2-3520 shall be applicable to group Medicare supplement policies. The term "policy" as used in this article shall include a certificate issued under a group Medicare supplement policy which has been delivered or issued for delivery in this Commonwealth.
B. The provisions of § 38.2-3418.1 shall be applicable to individual Medicare supplement policies.
C. No Medicare supplement policy or certificate in force in this Commonwealth shall contain benefits that duplicate benefits provided by Medicare.
1981, c. 575, § 38.1-362.17; 1986, c. 562; 1989, c. 646; 1996, c. 11.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 36 - Medicare Supplement Policies › § 38.2-3608. Regulations establishing minimum standards

A. The Commission may issue regulations to establish minimum standards for payment of claims under Medicare supplement policies and for marketing practices, compensation arrangements, requirements for loss ratio refunds or credits, Medicare select policies and certificates, and reporting practices of insurers providing such policies.
B. The Commission may revise or amend such regulations and may increase the scope of the regulations only to the extent necessary to maintain federal approval of the Commonwealth's program for regulation of Medicare supplement insurance pursuant to the requirements established by the United States Department of Health and Human Services.
C. The Commission shall annually advise the standing committees of the General Assembly having jurisdiction over insurance matters of revisions and amendments made pursuant to subsection B.
1989, c. 151; 1990, c. 268; 1992, c. 225; 1996, c. 11.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 36 - Medicare Supplement Policies › § 38.2-3609. Insurer to file copy of advertisement with Commission

Every insurer, health service plan or health maintenance organization providing Medicare supplement insurance or benefits in this Commonwealth shall file with the Commission a copy of any Medicare supplement advertisement intended for use in this Commonwealth whether through written, radio or television medium.
1989, c. 151.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 37.1 - Credit Life Insurance and Credit Accident and Sickness Insurance › § 38.2-3717. Scope

All life insurance and all accident and sickness insurance issued or sold in connection with loans or other credit transactions shall be subject to the provisions of this chapter except:
1. Such insurance issued in connection with a loan or other credit transaction of more than ten years duration;
2. Such insurance written in connection with a credit transaction that is:
a. Secured by a first mortgage or deed of trust; and
b. Made to finance the purchase of real property or the construction of a dwelling thereon, or to refinance a prior credit transaction made for such a purpose;
3. Where the issuance of such insurance is an isolated transaction on the part of the insurer not related to an agreement or a plan for insuring debtors of the creditor.
1960, c. 67, § 38.1-482.1; 1972, c. 527, § 38.2-3700; 1982, c. 223; 1986, c. 562; 1990, c. 236; 1992, c. 586.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 37.1 - Credit Life Insurance and Credit Accident and Sickness Insurance › § 38.2-3718. Definitions

For the purposes of this chapter:
"Commission" means the State Corporation Commission.
"Creditor" means the lender of money or vendor or lessor of goods, services, or property, rights or privileges, for which payment is arranged through a credit transaction, or any successor to the right, title or interest of any such lender, vendor, or lessor and an affiliate, associate or subsidiary of any of them or any other person in any way associated with them.
"Credit transaction" means any transaction by the terms of which the repayment of money loaned or loan commitment made, or payment for goods, services or properties sold or leased is to be made at a future date or dates.
"Critical period coverage" means a death benefit or an accident and sickness insurance benefit in which the benefit is equal to a specified number of monthly payments or the remaining payments on the loan, whichever is less.
"Debtor" means a borrower of money or a purchaser or lessee of goods, services, property, rights or privileges for which payment is arranged through a credit transaction.
"Form" means any policy, contract, rider, endorsement, amendment, certificate, application, enrollment request, or notice of proposed insurance pertaining to credit life insurance or credit accident and sickness insurance. For the purpose of administering §§ 38.2-3726, 38.2-3727 and 38.2-3730, (i) the earned premiums and incurred claims of all credit accident and sickness insurance forms issued in this Commonwealth with the same waiting period will be combined to determine the loss ratio in this Commonwealth regardless of differences in the contractual terms of each form and, (ii) the earned premiums and incurred claims of all credit life insurance forms issued in this Commonwealth will be combined to determine the loss ratio in this Commonwealth regardless of differences in the contractual terms or coverage types.
"Indebtedness" means the total amount payable by a debtor to a creditor in connection with a loan or other credit transaction.
"Open-end credit" means credit extended under an agreement in which:
1. The creditor reasonably contemplates repeated transactions;
2. The creditor imposes a finance charge from time to time on an outstanding unpaid balance; and
3. The amount of credit that may be extended to the debtor during the term of the agreement (up to any limit set by the creditor) is generally made available to the extent that any outstanding balance is repaid.
"Truncated coverage" means a credit life insurance benefit or a credit accident and sickness insurance benefit with a term of insurance coverage that is less than the term of the loan.
1960, c. 67, § 38.1-482.2; 1982, c. 223, § 38.2-3701; 1986, c. 562; 1992, c. 586.