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2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3326. Incontestability

A. Each group life insurance policy shall contain a provision that the validity of the policy shall not be contested, except for nonpayment of premiums, after it has been in force for two years from its date of issue.
B. The provision shall also state that no statement made by any person insured under the policy relating to his insurability or the insurability of his insured dependents shall be used in contesting the validity of the insurance with respect to which such statement was made:
1. After the insurance has been in force prior to the contest for a period of two years during the lifetime of the person about whom the statement was made; and
2. Unless the statement is contained in a written instrument signed by him.
Code 1950, § 38-429(1); 1952, c. 317, § 38.1-425; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3327. Entire contract; statements deemed representations

A. Each group life insurance policy shall contain a provision that the policy and any application of the policyowner, and any individual applications of the persons insured shall constitute the entire contract between the parties.
B. The provision shall also state that:
1. A copy of any application of the policyowner shall be attached to the policy when issued;
2. All statements made by the policyowner or by the persons insured shall be deemed representations and not warranties; and
3. No written statement made by any person insured shall be used in any contest unless a copy of the statement has been furnished to the person, his beneficiary or his personal representative.
Code 1950, § 38-429(2); 1952, c. 317, § 38.1-426; 1960, c. 273; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3328. Evidence of individual insurability

Each group life insurance policy shall contain a provision setting forth any conditions under which the insurer reserves the right to require a person eligible for insurance to furnish evidence of individual insurability satisfactory to the insurer as a condition to part or all of his coverage.
1960, c. 273, § 38.1-426.1; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3329. Misstatement of age

Each group life insurance policy 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.
Code 1950, § 38-429(3); 1952, c. 317, § 38.1-427; 1960, c. 273; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3330. Payment of benefits

Each group life insurance policy shall contain a provision that any sum payable because of the death of the person insured shall be payable to the beneficiary or beneficiaries designated by the person insured, subject to:
1. The provisions of the policy as to all or any part of such sum if there is no designated beneficiary living at the time of death of the person insured; and
2. Any right reserved by the insurer in the policy and set forth in the certificate to pay a part of the sum, not exceeding $2,000, to any person appearing to the insurer to be equitably entitled thereto because of having incurred funeral or other expenses incident to the death or last illness of the person insured.
1960, c. 273, § 38.1-427.1; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3331. Individual certificates

A. Each group life insurance policy shall contain a provision that the insurer will issue to the policyholder, for delivery to each person insured, an individual 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; and
3. The rights and conditions set forth in §§ 38.2-3332, 38.2-3333 and 38.2-3334.
B. Each policy issued pursuant to § 38.2-3318.1 B, where any part of the premium is paid by the debtors or by the creditor 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 delivery to each debtor insured under the policy a form that will contain a statement that the life of the debtor is insured under the policy and that any death benefit paid under the policy by reason of his death shall be applied to reduce or extinguish the indebtedness.
Code 1950, § 38-429(4); 1952, c. 317, § 38.1-428; 1960, c. 273, § 38.1-428.4; 1986, c. 562; 1998, c. 154.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3332. Right to individual policy upon termination of employment or membership

Each group life insurance policy shall contain a provision that if the insurance, or any portion of it, on a person covered under the policy, other than a minor child insured pursuant to § 38.2-3323, ceases because of termination of employment or of membership in the class or classes eligible for coverage under the policy, the person shall be entitled to have the insurer issue him without evidence of insurability an individual policy of life insurance, without disability or other supplementary benefits, subject to the following:
1. Application for the individual policy shall be made, and the first monthly or other mutually agreeable modal premium paid to the insurer, within thirty-one days after the termination;
2. The individual policy shall at the option of the person be on any one of the forms, except term insurance, then customarily issued by the insurer, subject to the insurer's customary age and amount requirements for the forms;
3. The amount of the individual policy shall not exceed the amount of terminated group life insurance less the amount of any group life insurance that the person is or becomes eligible for within thirty-one days after the termination. Any amount of insurance maturing on or before the date of the termination as an endowment payable to the person insured, whether in one sum, installments or in the form of an annuity, shall not be included in the amount of terminated group life insurance; and
4. The premium on the individual policy shall be at the insurer's then current rate applicable to the form and amount of the individual policy, to the class of risk to which the person then belongs, and to the person's age on the effective date of the individual policy.
1960, c. 273, § 38.1-428.1; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3333. Right to individual policy upon termination of group policy or elimination of class of insured persons

Each group life insurance policy shall contain a provision that if the group policy terminates or is amended so as to terminate the insurance of any class of insured persons, every person, other than a minor child insured pursuant to § 38.2-3323, whose insurance terminates and who has been insured for at least five years prior to the termination date shall be entitled to have the insurer issue him an individual life insurance policy. The individual life policy shall be subject to the conditions and limitations set forth in § 38.2-3332. However, the group policy may contain a provision that the amount of the individual policy shall not exceed the smaller of (i) the amount of the person's life insurance protection ceasing because of the termination or amendment of the group policy, less the amount of any life insurance for which he is or becomes eligible under any group policy issued or reinstated by the same or another insurer within 31 days after the termination, or (ii) $10,000.
1960, c. 273, § 38.1-428.2; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3334. Death after termination of group insurance and before issuance of individual policy

Each group life insurance policy shall contain a provision that if a person insured under the group policy dies during the period within which he is entitled to have an individual policy issued to him in accordance with § 38.2-3332 or § 38.2-3333 and before the individual policy has become effective, the amount of life insurance that he would have been entitled to have issued to him under an individual policy shall be payable as a claim under the group policy, whether or not application for the individual policy or the payment of the first premium was made.
1960, c. 273, § 38.1-428.3; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3335. Additional persons becoming eligible

Each group life insurance policy shall contain a provision that any person who subsequently becomes a member of a group or class that is covered under the policy shall be eligible for group life insurance in accordance with the same requirements as any other member of the group or class.
Code 1950, § 38-429(5); 1952, c. 317, § 38.1-429; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3336. Provisions required by other jurisdictions

Group life insurance policies issued by any foreign or alien insurer for delivery in this Commonwealth may contain any provision that is prescribed by the laws of its domiciliary jurisdiction and that is not in conflict with the laws of this Commonwealth. Policies issued by any domestic insurer for delivery in any other jurisdiction may contain any provision required by the laws of that jurisdiction.
Code 1950, § 38-430; 1952, c. 317, § 38.1-430; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3337. Assignment

With mutual agreement among the insured, the policyholder, and the insurer, any person insured under a group life insurance policy may make an irrevocable assignment of the rights and benefits conferred on him by any provision of the policy or by this article. The assignment may be made to any person other than the insured's employer.
Code 1950, §§ 38-429, 38-431; 1952, c. 317, § 38.1-424; 1960, c. 273; 1968, c. 282; 1970, c. 145; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3338. Provisions prohibited

No group life insurance policy shall be delivered or issued for delivery in this Commonwealth if it contains any provision:
1. Limiting the time within which any action at law or in equity may be commenced to less than one year after the cause of action accrues; or
2. To the effect that the agent soliciting the insurance is the agent of the person insured under the policy, or making the acts or representations of the agent binding upon the person insured under the policy.
Code 1950, § 38-386; 1952, c. 317, § 38.1-406; 1956, c. 417; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3339. Exemption of group life insurance policies from legal process

No group life insurance policy, nor its proceeds, shall be liable to attachment, garnishment, or other process, or to be seized, taken, appropriated, or applied by any legal or equitable process or operation of law, to pay any debt or liability of any person insured under the policy, or his beneficiary, or any other person who has a right under the policy, either before or after payment. If the proceeds of a group life insurance policy are not made payable to a named beneficiary, the proceeds shall not constitute a part of the insured person's estate for the payment of his debts.
Code 1950, § 38-432; 1952, c. 317, § 38.1-482; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3340. Definition of industrial life insurance

"Industrial life insurance" means life insurance provided by an individual insurance contract (i) under which premiums are payable monthly or more frequently, and (ii) with the words "industrial policy" printed upon the policy as a part of the descriptive matter.
Code 1950, § 38-433; 1952, c. 317, § 38.1-482; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3341. Standard provisions required

No industrial life insurance policy shall be delivered or issued for delivery in this Commonwealth, unless it contains in substance the provisions prescribed in this article or provisions that are, in the Commission's opinion, more favorable to policyowners.
Code 1950, §§ 38-434, 38-435; 1952, c. 317, § 38.1-410; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3342. Ten-day right to examine policy

No industrial life insurance policy shall be delivered or issued for delivery in this Commonwealth unless it has printed on it a notice stating in substance that if during a ten-day period from the date the policy is delivered to the policyowner, the policy is surrendered to the insurer or its agent with a written request for cancellation, the policy shall be void from the beginning and the insurer shall refund any premium paid for the policy. Nothing in this section shall prohibit an insurer from extending the right to examine period to more than ten days if the period is specified in the policy.
1977, c. 174, § 38.1-410.1; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3343. Grace period

A. Each industrial life insurance policy shall contain a provision that the insured is entitled to a grace period of twenty-eight days within which the payment of any premium after the first may be made. This grace period shall terminate at noon on the twenty-eighth day after the due date of the defaulted premium. However, for monthly payment policies the insured shall be entitled to a grace period of not less than thirty-one days.
B. Each policy shall also contain a provision that during the grace period the policy shall continue in full force, but if a claim arises under the policy during the grace period and before the overdue premiums are paid, the amount of overdue premiums may be deducted in any settlement under the policy.
Code 1950, § 38-434(1); 1952, c. 317, § 38.1-411; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3344. Policy and application to constitute entire contract; statements deemed representations

A. Each industrial life insurance policy shall contain a provision that the policy, or the policy and the application for the policy, if a copy of the application is endorsed upon or attached to the policy when issued, shall constitute the entire contract between the parties.
B. The provision shall also state that:
1. All statements made by the insured shall, in the absence of fraud, be deemed representations and not warranties; and
2. No such statement shall be used in defense of a claim under the policy unless it is contained in a written application that is endorsed upon or attached to the policy when issued.
Code 1950, § 38-434(2); 1952, c. 317, § 38.1-412; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3345. Incontestability

Each industrial life insurance policy shall contain a provision that the policy shall be incontestable after it has been in force for two years from the date of issue during the lifetime of the insured, except for nonpayment of premiums, and except as to provisions and conditions (i) relating to benefits in the event of certain specific types of disability and (ii) granting additional insurance specifically against death by accident or accidental means.
Code 1950, § 38-434(3); 1952, c. 317, § 38.1-413; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3346. Misstatement of age

Each industrial life insurance policy shall contain a provision that if, before final settlement of the policy, the age of the insured or the age of any other person if considered in determining the premium is found to have been misstated, the amount payable under the policy shall equal the amount that the premium would have purchased at the insured's or other person's correct age, at the time the policy was issued.
Code 1950, § 38-434(4); 1952, c. 317, § 38.1-414; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3347. Nonforfeiture benefits and cash surrender values

Each industrial life insurance policy shall contain a provision for nonforfeiture benefits in accordance with the requirements of §§ 38.2-3202 and 38.2-3208, and a provision for cash surrender values in accordance with the requirements of §§ 38.2-3203 and 38.2-3209.
Code 1950, § 38-434(5), (6); 1952, c. 317, § 38.1-415; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3348. Reinstatement

Each industrial life insurance policy shall contain a provision that the policy, if not surrendered for its cash value or if the period of extended term insurance has not expired, may be reinstated within one year from the date of default in payment of premiums upon:
1. Payment of all overdue premiums and, at the insurer's option, interest on the overdue premiums at an annual rate not exceeding six percent; and
2. Presentation of evidence satisfactory to the insurer of the insurability of the insured.
Code 1950, § 38-434(7); 1952, c. 317, § 38.1-416; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3349. Table of nonforfeiture options

Each industrial life insurance policy shall contain a table showing the nonforfeiture options available under the policy each year upon default in the payment of premiums during at least the first twenty years of the policy, or during the premium-paying period if less than twenty years. There shall also be a provision that the insurer will furnish, upon request, an extension of the table beyond the years shown in the policy.
Code 1950, § 38-434(8); 1952, c. 317, § 38.1-417; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3350. Settlement

Each industrial life insurance policy shall contain a provision that when a death claim arises under the policy, settlement shall be made within two months after receipt of due proof of death.
Code 1950, § 38-434(9); 1952, c. 317, § 38.1-418; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3351. Title

Each industrial life insurance policy shall have a title on its face that briefly and accurately describes the nature and form of the policy.
Code 1950, § 38-434(10); 1952, c. 317, § 38.1-419; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3352. Provisions not required in certain policies

The provisions of this article do not apply to policies issued or granted in exercise of the nonforfeiture provisions of § 38.2-3347.
Code 1950, § 38-438; 1952, c. 317, § 38.1-420; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3353. Provisions required by other jurisdictions

Industrial life insurance policies issued by any foreign or alien insurer for delivery in this Commonwealth may contain any provision that is prescribed by the laws of its domiciliary jurisdiction and is not in conflict with the laws of this Commonwealth. Policies issued by any domestic insurer for delivery in any other jurisdiction may contain any provision required by the laws of that jurisdiction.
Code 1950, § 38-436; 1952, c. 317, § 38.1-421; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 33 - Life Insurance Policies › § 38.2-3354. Prohibited provisions

No industrial life insurance policy shall be delivered or issued for delivery in this Commonwealth if it contains any of the following provisions:
1. Limiting the time within which any action at law or in equity may be commenced to less than one year after the cause of action accrues;
2. For any mode of settlement at maturity of less value than the amount insured by the policy plus any dividend additions to the policy, less (i) any indebtedness to the insurer on or secured by the policy and (ii) any premium that may by the terms of the policy be deducted. This subdivision shall not apply to any nonforfeiture provision that employs the cash value less any indebtedness, to purchase paid up or extended insurance, and shall not prohibit the issuance of policies providing for a limitation in the amount payable under certain specified conditions; or
3. To the effect that the agent soliciting the insurance is the agent of the person insured under the policy, or making the acts or representations of the agent binding upon the person insured under the policy.
Code 1950, § 38-437; 1952, c. 317, § 38.1-422; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3400. Application of chapter

A. This chapter and Chapter 35 (§ 38.2-3500 et seq.) of this title apply to insurance policies or contracts of the class described in § 38.2-109 delivered or issued for delivery in this Commonwealth except as provided in subsection B of this section.
B. Nothing in this chapter shall apply to or affect:
1. Any workers' compensation insurance policy;
2. Any liability insurance policy with or without supplementary expense coverage, including any motor vehicle liability insurance policy, providing weekly indemnity or other specific benefits to persons who are injured and specific death benefits to dependents, beneficiaries or personal representatives of persons who are killed, irrespective of the legal liability of the insured or any other person;
3. Any policy or contract of reinsurance;
4. Life insurance or annuities;
5. Any industrial sick benefit insurance; or
6. Any credit accident and sickness insurance policy.
Code 1950, § 38-225; 1950, p. 1016; 1952, c. 317, §§ 38.1-347, 38.1-360; 1956, c. 678; 1974, c. 95; 1975, c. 281; 1976, c. 355; 1977, c. 606; 1978, c. 496; 1979, cc. 13, 97; 1980, c. 719; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3401. Forms of insurance authorized

A. Accident and sickness insurance shall be issued only in the following forms:
1. Individual accident and sickness policies; or
2. Group accident and sickness policies.
B. Pursuant to the authority granted by § 38.2-223, the Commission may promulgate such regulations as may be necessary or appropriate to govern insurers' practices with regard to Acquired Immunodeficiency Syndrome (AIDS) or the presence of the Human Immunodeficiency Virus (HIV), including advertising practices, underwriting practices, policy provisions, claim practices, or other practices with regard to individual or group accident and sickness insurance policies delivered or issued for delivery in the Commonwealth of Virginia and certificates or evidences of coverage, issued under any contract delivered or issued for delivery in the Commonwealth of Virginia.
1986, c. 562; 1989, c. 653.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3402. Certification to accompany application

A. Each application for an individual accident and sickness insurance policy shall contain a certification, signed by both the applicant and the agent soliciting the insurance, to the effect that: "The undersigned applicant and agent certify that the applicant has read, or had read to him, the completed application and that the applicant realizes that any false statement or misrepresentation in the application may result in loss of coverage under the policy." If the application is to be used in a solicitation where no agent is involved, the certification may delete the reference to and signature of the agent soliciting the insurance.
B. Subsection A of this section shall also apply to an application by an individual for coverage under a group policy where individual underwriting is done.
C. If the certification is wholly or partially inapplicable to a particular form of policy, the insurer may modify or omit the certification with the approval of the Commission.
1966, c. 342, § 38.1-348.2; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3403. Fraudulent procurement of policy

A. No person shall knowingly secure, attempt to secure or cause to be secured an individual accident and sickness insurance policy on any person not in an insurable condition by means of misrepresentations or false or fraudulent statements.
B. An insurance agent who violates this section shall be subject to the penalties under § 38.2-1831 in addition to the penalties of § 38.2-218.
1966, c. 342, § 38.1-348.3; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3404. Commission may establish rules and regulations for simplified and readable accident and sickness insurance policies

A. Pursuant to the authority granted in § 38.2-223, the Commission may issue rules and regulations establishing standards for simplified and readable accident and sickness insurance policy forms. Any such rules and regulations shall apply to any policy forms of accident and sickness insurance as defined in § 38.2-109, except credit accident and sickness insurance, issued on a nongroup basis or to groups with ten or fewer members.
B. The rules and regulations issued hereunder may permit an insurer to issue policies containing policy provisions that deviate in language from the policy provisions required by §§ 38.2-3500 through 38.2-3506 where applicable, provided the provisions in each instance are not less favorable to the insured or the beneficiary.
C. No insurer shall deliver or issue for delivery an accident and sickness insurance policy in this Commonwealth unless the Commission has determined that the policy form satisfies the readability standards established by the rules and regulations and is in compliance with other statutory requirements.
1979, c. 47, § 38.1-354.1; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3405.1. Commonwealth's right to certain accident and sickness benefits

A. The Department of Medical Assistance Services shall be entitled to direct reimbursement under any accident and sickness insurance policy, health services plan, or health maintenance organization contract for covered services or items to the extent that payment has been made by the Department of Medical Assistance Services on behalf of an individual covered under such policy, plan, or contract for such services or items.
B. No insurer, health services plan, or health maintenance organization shall impose upon the Department of Medical Assistance Services or any state agency, which has been assigned or has otherwise acquired the rights of an individual eligible for medical assistance ("Medicaid") and covered for health benefits by the insurance policy, health services plan, or health maintenance organization contract, any requirements that are different from requirements applicable to an agent or assignee of any other individual so covered.
1994, c. 213.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3406. Accident and sickness benefits not subject to legal process

The installment payments to the holder of any accident and sickness insurance policy or certificate 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 or certificate.
Code 1950, § 38-227; 1952, c. 317, § 38.1-346; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3406.2. Capped benefits under insurance policies and contracts

A. Nothing in this chapter or Chapters 35 (§ 38.2-3500 et seq.) or 42 (§ 38.2-4200 et seq.) shall prohibit the offering, sale, or issuance of accident and sickness insurance policies or subscription contracts that cap or limit the total annual or lifetime benefits provided under an accident and sickness insurance policy or subscription contracts at specified dollar amounts.
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.
2009, cc. 796, 877; 2011, c. 882.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3407.1. Interest on accident and sickness claim proceeds

A. If an action to recover the claim proceeds due under an individual or group accident and sickness policy results in a judgment against an insurer, interest on the judgment at the legal rate of interest shall be paid from the date of presentation to the insurer of proof of loss to the date judgment is entered.
B. If no action is brought, interest upon the claim proceeds paid to the policyholder, insured, claimant, or assignee entitled thereto shall be computed daily at the legal rate of interest from the date of fifteen working days from the insurer's receipt of proof of loss to the date of claim payment.
C. This section shall not apply to individual policies issued prior to July 1, 1990, but shall apply to any renewals or reissues of group accident and sickness policies occurring after that date.
D. This section shall not apply to claims for which payment has been or will be made directly to health care providers pursuant to a negotiated reimbursement arrangement requiring uniform or periodic interim payments to be applied against the insurer's obligation on such claims.
E. For purposes of this section, "proof of loss" means all necessary documentation reasonably required by the insurer to make a determination of benefit coverage.
F. This section shall not apply to claims proceeds payable to an out-of-state provider of pharmacy services for pharmacy services rendered outside of the Commonwealth. Notwithstanding the foregoing sentence, this section shall apply to claims proceeds payable to such an out-of-state provider if the state where such services are rendered fails to provide for the payment of interest on the claims proceeds. If this section is applicable to claims proceeds payable to such an out-of-state provider as a result of the failure of such other state to provide for the payment of interest on the claims proceeds, then, notwithstanding the provisions of subsection B, interest upon the claim proceeds paid to the policyholder, insured, claimant, or assignee entitled thereto shall be computed daily at the legal rate of interest from the thirtieth day following the insurer's receipt of proof of loss to the date of claim payment.
1990, c. 531; 1992, c. 23; 1996, c. 75; 2009, c. 226.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3407.2. Coverage for medical child support

A. No insurer, health services plan, or health maintenance organization shall refuse to enroll a child under a parent's coverage because (i) the child was born out of wedlock; (ii) the child is not claimed as a dependent on the parent's federal income tax return; or (iii) the child does not reside with the parent or in the insurer's, health services plan's, or health maintenance organization's service area.
B. Upon receipt of proof that a parent eligible for family coverage under an accident and sickness policy, health services plan, or health maintenance organization contract has been required by a court or administrative order to provide health coverage for a child, the insurer, health services plan, or health maintenance organization shall:
1. Permit such parent to enroll under such family coverage any such child who is otherwise eligible for such coverage, without regard to any enrollment season restrictions;
2. If such parent is enrolled but fails to make application to obtain coverage for such child, enroll such child upon application by the child's other parent or by the Department of Social Services; and
3. Not disenroll or otherwise eliminate coverage of such child unless the insurer, health services plan, or health maintenance organization is provided satisfactory written evidence that:
a. Such court or administrative order is no longer in effect;
b. Such child is or will be enrolled in comparable health coverage through another insurer, health services plan, or health maintenance organization which will take effect not later than the effective date of termination of the child's coverage under the policy or contract issued by the insurer, health services plan, or health maintenance organization; or
c. Family health coverage has been eliminated under the insurance policy, health services plan, or health maintenance organization contract.
C. Any insurer, health services plan, or health maintenance organization providing coverage to the child of a noncustodial parent shall (i) provide to the custodial parent, upon request, any information that is necessary to obtain benefits for such child under such coverage; (ii) permit the custodial parent, or the provider of health services if approved by the custodial parent, to submit claims for services without the approval of the noncustodial parent; and (iii) make payment on claims submitted pursuant to clause (ii) directly to such custodial parent, provider, or the Department of Medical Assistance Services.
1994, c. 213.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3407.3. Calculation of cost-sharing provisions

A. An insurer, health services plan, or health maintenance organization that issues an accident and sickness insurance policy or contract pursuant to which the insured, subscriber or enrollee is required to pay a specified percentage of the cost of covered services, shall calculate such amount payable based upon an amount not to exceed the total amount actually paid or payable to the provider of such services for the services provided to the insured, subscriber, or enrollee. When there is no amount actually paid or payable to the provider by the insurer, health services plan, or health maintenance organization for the services provided, the insurer, health services plan, or health maintenance organization shall use such insurer's, health services plan's, or health maintenance organization's pre-established allowed amount to calculate the amount payable by the insured for such services. When an insured, subscriber, or enrollee receives covered services outside the insurer's, health services plan's, or health maintenance organization's provider network, and such entity utilizes another insurer's, health services plan's, or health maintenance organization's provider network located outside the Commonwealth, such entity may satisfy the obligation of this section by using the cost of services as reported by the out-of-state insurer, health services plan, or health maintenance organization when calculating the insured's, subscriber's, or enrollee's percentage of the cost of covered services.
B. Any insurer, health services plan, or health maintenance organization failing to administer its contracts as set forth herein shall be deemed to have committed a knowing and willful violation of this section, and shall be punished as set forth in subsection A of § 38.2-218. Each claim payment found to have been calculated in noncompliance with this section shall be deemed a separate and distinct violation, and shall further be deemed a violation subject to subdivision D 1 c of § 38.2-218, permitting the Commission to require restitution in addition to any other penalties.
1994, c. 320; 1997, c. 56; 1998, c. 49; 2017, c. 588.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3407.3:1. Premium payment arrearages; order of crediting payments

Each (i) insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, (ii) corporation providing individual or group accident and sickness subscription contracts, and (iii) health maintenance organization providing a health care plan for health care services, shall when accepting premium payments in arrears, credit any such payments first to the longest-outstanding arrearage, and then in succession to the most recent arrearage or payment due.
1999, c. 321.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3407.4. Explanation of benefits

A. Each insurer issuing an accident and sickness insurance policy, a corporation issuing subscription contracts, and each health maintenance organization shall file for approval explanation of benefits forms. These explanation of benefit forms shall be subject to the requirements of § 38.2-316 or § 38.2-4306 as applicable.
B. The explanation of benefits shall accurately and clearly set forth the benefits payable under the contract.
C. The Commission may issue regulations to establish (i) standards for the accuracy and clarity of the information presented in an explanation of benefits and (ii) alternative methods of delivery of the explanation of benefits that permit (a) a subscriber who is legally authorized to consent to care for a covered person or recipient, (b) a covered person or recipient who is legally authorized to consent to that covered person's or recipient's own care, or (c) another party who has the exclusive legal authorization to consent to care for the covered person or recipient to receive the explanation of benefits by an alternative method, provided that each such alternative method is in compliance with the provisions of 45 C.F.R. § 164.522 regarding the right to request privacy protection for protected health information.
D. The term "explanation of benefits" as used in this section shall include any form provided by an insurer, health services plan, or health maintenance organization which explains the amounts covered under a policy or plan or shows the amounts payable by a covered person to a health care provider.
1994, c. 320; 2020, cc. 715, 716.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3407.5:1. Coverage for prescription contraceptives

A. Each (i) insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense incurred basis; (ii) corporation providing individual or group accident and sickness subscription contracts; and (iii) health maintenance organization providing a health care plan for health care services, whose policy, contract or plan, including any certificate or evidence of coverage issued in connection with such policy, contract or plan, includes coverage for prescription drugs on an outpatient basis, shall offer and make available coverage thereunder for any prescribed drug or device approved by the United States Food and Drug Administration for use as a contraceptive.
B. No insurer, corporation or health maintenance organization shall impose upon any person receiving prescription contraceptive benefits pursuant to this section any (i) copayment, coinsurance payment or fee that is not equally imposed upon all individuals in the same benefit category, class, coinsurance level or copayment level receiving benefits for prescription drugs, or (ii) reduction in allowable reimbursement for prescription drug benefits.
C. The provisions of subsection A shall not be construed to:
1. Require coverage for prescription coverage benefits in any contract, policy or plan that does not otherwise provide coverage for prescription drugs;
2. Preclude the use of closed formularies, provided, however, that such formularies shall include oral, implant and injectable contraceptive drugs, intrauterine devices and prescription barrier methods; or
3. Require coverage for experimental contraceptive drugs not approved by the United States Food and Drug Administration.
D. The provisions of this section shall not apply to short-term travel, accident-only, limited or specified disease policies, or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or federal governmental plans, or to short-term nonrenewable policies of not more than six months' duration.
E. The provisions of this section shall be applicable to contracts, policies or plans delivered, issued for delivery or renewed in this Commonwealth on and after July 1, 1997.
1997, c. 748.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3407.6. Exclusion of podiatrist not permitted under certain circumstances

No podiatrist shall be excluded from participating in any preferred provider plan pursuant to this chapter or Chapter 42 (§ 38.2-4200 et seq.) of this title or health maintenance organization pursuant to Chapter 43 (§ 38.2-4300 et seq.) of this title solely because such preferred provider plan or health maintenance organization requires that participating health care providers have active medical staff privileges or admitting medical staff privileges at specified hospitals, provided that the podiatrist has a delineation of privileges that enables such podiatrist to perform the type of services that are covered by the preferred provider plan or health maintenance organization at the designated hospital or hospitals. The Commission shall have no jurisdiction to adjudicate controversies arising out of this section.
1994, c. 522.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3407.6:1. Denial of benefits for certain prescription drugs prohibited

A. Each (i) insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, (ii) corporation providing individual or group accident and sickness subscription contracts, and (iii) health maintenance organization providing a health care plan for health care services, whose policy, contract or plan, including any certificate or evidence of coverage issued in connection with such policy, contract or plan, includes coverage for prescription drugs, whether on an inpatient basis, an outpatient basis, or both, shall provide in each such policy, contract, plan, certificate, and evidence of coverage that such benefits shall not be denied for any drug approved by the United States Food and Drug Administration for use in the treatment of cancer pain on the basis that the dosage is in excess of the recommended dosage of the pain-relieving agent, if the prescription in excess of the recommended dosage has been prescribed in compliance with §§ 54.1-2971.01, 54.1-3303 and 54.1-3408.1 for a patient with intractable cancer pain.
B. The provisions of this section shall not apply to short-term travel, or accident-only policies, or to short-term nonrenewable policies of not more than six months' duration.
C. The provisions of this section are applicable to contracts, policies or plans delivered, issued for delivery or renewed in this Commonwealth on and after July 1, 1999.
1999, c. 857.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3407.9. Reimbursement for emergency medical services vehicle transportation services

A. If an accident and sickness insurance policy provides coverage for services provided by an emergency medical services vehicle, any person providing such services to a person covered under such policy shall receive reimbursement for such services directly from the issuer of such policy, when the issuer of such policy is presented with an assignment of benefits by the person providing such services.
B. No (i) insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, (ii) corporation providing individual or group accident and sickness subscription contracts, or (iii) health maintenance organization providing a health care plan for health care services shall establish or promote an emergency medical response and transportation system that encourages or directs access by a person covered under such policy, contract or plan in competition with or in substitution of an emergency 911 system or other state, county or municipal emergency medical system for services provided by an emergency medical services vehicle. An entity subject to this subsection may use transportation outside an emergency 911 system or other state, county or municipal emergency medical system for services that are not services provided by an emergency medical services vehicle.
C. For the purposes of this section, "services provided by an emergency medical services vehicle" means the transportation of any person requiring resuscitation or emergency relief or where human life is endangered, by means of any emergency medical services vehicle designed or used principally for such purposes. No (i) insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, (ii) corporation providing individual or group accident and sickness subscription contracts, or (iii) health maintenance organization providing a health care plan for health care services shall require a person covered under such policy, contract or plan to obtain prior authorization before accessing an emergency 911 system or other state, county or municipal emergency medical system for services provided by an emergency medical services vehicle.
1995, c. 420; 2000, c. 630; 2015, cc. 502, 503.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3407.9:02. Requirement for prescription drug coverage

No (i) insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, (ii) corporation providing individual or group accident and sickness subscription contracts, or (iii) health maintenance organization providing a health care plan for health care services, whose policy, contract or plan, including any certificate or evidence of coverage issued in connection with such policy, contract or plan, includes coverage for prescription drugs shall exclude coverage for any prescription drug solely on the basis of the length of time since the drug obtained FDA approval.
2000, c. 508.