reglab/statecodes huggingface dataset:
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3455. Definitions

As used in this article, unless the context requires otherwise:
"Exchange" means either a (i) federal health benefit exchange established by the Secretary of the U.S. Department of Health and Human Services pursuant to § 1321 of the Patient Protection and Affordable Care Act codified as 42 U.S.C. § 18041(c) in the Commonwealth or (ii) state-based exchange established pursuant to Chapter 65 (§ 38.2-6500 et seq.) and § 1311 (b) of the Patient Protection and Affordable Care Act codified as 42 U.S.C. § 18031.
"Health carrier" has the same meaning assigned to that term in § 38.2-3438.
"Navigator" means an individual or entity described in 42 U.S.C. § 1311(i)(2) that is selected to perform the activities and duties identified in 42 U.S.C. § 18031 (i) in the Commonwealth. "Navigator" does not include an individual or entity licensed as an agent under Chapter 18 (§ 38.2-1800 et seq.) of this title to sell, solicit, or negotiate contracts of insurance or annuity in the Commonwealth.
"Other affordable care options" means the programs provided under the state plan for medical assistance services pursuant to pursuant to Title XIX of the Social Security Act, as amended, and the Family Access to Medical Insurance Security (FAMIS) Plan developed pursuant to Title XXI of the Social Security Act, as amended.
"Qualified dental plan" means a limited scope dental plan that has in effect a certification that the plan meets the criteria for certification described in § 1311(d)(2)(B)(ii) of the Patient Protection and Affordable Care Act, P.L. 111-148, as amended.
"Qualified health plan" means a health benefit plan that has in effect a certification that the plan meets the criteria for certification described in § 1311(c) of the Patient Protection and Affordable Care Act, P.L. 111-148, as amended.
"Secretary" means the Secretary of the U.S. Department of Health and Human Services.
2013, cc. 595, 791; 2014, cc. 752, 769; 2020, cc. 916, 917.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3456. Prohibited activities

A. A navigator shall not:
1. Engage in any activity that would require an insurance agent license under this title;
2. Offer advice about which qualified health plan or qualified dental plan is better or worse for a particular individual or employer;
3. Act as an intermediary between an employer and an insurer that offers a qualified health plan or qualified dental plan offered through an exchange;
4. Violate any unfair trade practice and privacy requirements in §§ 38.2-502, 38.2-503, 38.2-506, 38.2-509, 38.2-512, 38.2-515, 38.2-612.1, 38.2-613, and 38.2-614 to the extent such requirements are applicable to the activities of navigators; or
5. Receive compensation for services or duties as a navigator that are prohibited by federal law, including compensation from a health carrier.
B. An individual or entity shall not claim to be, or otherwise hold himself or itself out as, a navigator or conduct business as a navigator in the Commonwealth without:
1. Having been selected as a navigator in accordance with applicable federal or state law;
2. Having evidence of successful completion of all navigator requirements prescribed by the Secretary or the Exchange; and
3. Having met requirements established pursuant to § 38.2-3457.
C. If an individual or entity has engaged in the Commonwealth in one or more of the prohibited activities identified in this section, a complaint may be filed with the Commission. The Commission, upon investigation and verification of the prohibited activity or activities, may order such individual or entity to cease and desist such prohibited conduct.
2013, cc. 595, 791; 2014, cc. 752, 769; 2020, cc. 916, 917.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3457. Application for registration

A. On or after September 1, 2014, no individual or entity shall act as a navigator in the Commonwealth unless such individual or entity has been certified by the U.S. Department of Health and Human Services or the Exchange and registered with the Commission.
B. An application for registration under this article shall be in the form and containing the information the Commission prescribes. Each applicant shall, at the time of applying for registration, pay a nonrefundable application processing fee in an amount and in a manner prescribed by the Commission. A criminal history record report shall accompany each individual registration application.
C. The Commission shall register the applicant if it finds that the character and general fitness of the applicant are such as to warrant belief that the applicant will act as a navigator fairly, in the public interest, and in accordance with law.
2014, cc. 752, 769; 2020, cc. 916, 917.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3458. Power of Commission to investigate navigators

A. The Commission shall have the power to examine and investigate the affairs of any person engaged or alleged to be engaged in navigator activities in the Commonwealth to determine whether the individual or entity has engaged or is engaging in any violation of this article.
B. Each registered navigator shall report to the Commission within 30 calendar days the following: (i) any action taken by the U.S. Department of Health and Human Services to decertify the navigator; (ii) upon conviction of a felony, the facts and circumstances surrounding that conviction; and (iii) the disposition of the matter of any administrative action taken against the navigator in another jurisdiction or by another governmental agency in the Commonwealth.
2014, cc. 752, 769.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3459. Grounds for termination, placing on probation, revocation, or suspension of registration

A. If the Commission determines that a registered navigator has violated this article, or any order or regulation adopted thereunder, after notice and opportunity to be heard, the Commission may impose a penalty in accordance with §§ 38.2-218 and 38.2-219 and place on probation, suspend, or revoke any individual's or entity's registration.
B. The registration of any navigator shall terminate immediately when such navigator becomes decertified by the U.S. Department of Health and Human Services or the Exchange, as applicable.
2014, cc. 752, 769; 2020, cc. 916, 917.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3460. Sufficiency of federal requirements; additional standards and qualifications for navigators

The Commission may determine whether the standards and qualifications for navigators provided by 42 U.S.C. § 18031 and any regulations enacted thereunder are sufficient to ensure that navigators can perform the required duties. If the Commission determines that the standards and qualifications are insufficient, the Commission shall adopt regulations establishing additional standards and qualifications to ensure that navigators can perform their required duties.
2014, cc. 752, 769; 2020, cc. 916, 917.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3463. Health care price transparency tools

Beginning with health benefit plans offered or renewed on or after July 1, 2020, each health carrier offering a health benefit plan in the Commonwealth shall comply with the following requirements:
1. A health carrier shall establish an interactive mechanism on its website that enables a covered person to request and obtain from the health carrier the estimated out-of-pocket cost to the covered person for comparable health care services from network providers, as well as quality data for those providers, to the extent available. The interactive mechanism shall allow a covered person seeking information about the cost of a comparable health care service to compare estimated out-of-pocket costs applicable to that covered person's health benefit plan. The out-of-pocket estimate shall provide a good faith estimate of the amount the covered person will be responsible to pay out-of-pocket for a proposed comparable health care service or service that is a medically necessary covered benefit from a health carrier's network provider, including any copayment, deductible, coinsurance, or other out-of-pocket amount for any covered benefit, based on the information available to the health carrier at the time the request is made. A health carrier may contract with a third-party vendor to satisfy the requirements of this subdivision.
2. Nothing in this section shall prohibit a health carrier from imposing cost-sharing requirements disclosed in the covered person's covered benefit plan for unforeseen health care services that arise out of the comparable health care service or for a procedure or service provided to a covered person that was not included in an original estimate provided under subdivision 1.
3. A health carrier shall notify a covered person that an estimate provided under subdivision 1 is an estimate of costs and that the actual amount the covered person will be responsible to pay may vary due to the need for unforeseen services that arise out of the proposed comparable health care service.
2019, cc. 666, 684.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3467. Prohibited conduct by carriers and pharmacy benefits managers

A. No carrier on its own or through its contracted pharmacy benefits manager or representative of a pharmacy benefits manager shall:
1. Cause or knowingly permit the use of any advertisement, promotion, solicitation, representation, proposal, or offer that is untrue;
2. Charge a pharmacist or pharmacy a fee related to the adjudication of a claim other than a reasonable fee for an initial claim submission;
3. Reimburse a pharmacy or pharmacist an amount less than the amount that the pharmacy benefits manager reimburses a pharmacy benefits manager affiliate for providing the same pharmacist services, calculated on a per-unit basis using the same generic product identifier or generic code number and reflecting all drug manufacturer's rebates, direct and indirect administrative fees, and costs and any remuneration;
4. Penalize or retaliate against a pharmacist or pharmacy for exercising rights provided pursuant to the provisions of this article;
5. Impose requirements, exclusions, reimbursement terms, or other conditions on a covered entity or contract pharmacy that differ from those applied to entities or pharmacies that are not covered entities or contract pharmacies on the basis that the entity or pharmacy is a covered entity or contract pharmacy or that the entity or pharmacy dispenses 340B-covered drugs. Nothing in this subdivision shall (i) apply to drugs with an annual estimated per-patient cost exceeding $250,000 or (ii) prohibit the identification of a 340B reimbursement request; or
6. Interfere with a covered individual's right to choose a pharmacy or provider, based on the pharmacy or provider's status as a covered entity or contract pharmacy.
B. No carrier, on its own or through its contracted pharmacy benefits manager or representative of a pharmacy benefits manager, shall restrict participation of a pharmacy in a pharmacy network for provider accreditation standards or certification requirements if a pharmacist meets such accreditation standards or certification standards.
C. No carrier, on its own or through its contracted pharmacy benefits manager or representative of a pharmacy benefits manager, shall include any mail order pharmacy or pharmacy benefits manager affiliate in calculating or determining network adequacy under any law or contract in the Commonwealth.
D. No carrier, on its own or through its contracted pharmacy benefits manager or representative of a pharmacy benefits manager, shall conduct spread pricing in the Commonwealth.
E. Each carrier on its own or through its contracted pharmacy benefits manager or representative of a pharmacy benefits manager shall comply with the provisions of this section in addition to complying with the provisions of § 38.2-3407.15:1.
2020, cc. 219, 1288; 2022, c. 319.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3468. Examination of books and records; reports; access to records

A. Each carrier, on its own or through its contract for pharmacy benefits, shall ensure that the Commissioner may examine or audit the books and records of a pharmacy benefits manager providing claims processing services or other prescription drug or device services for a carrier that are relevant to determining if the pharmacy benefits manager is in compliance with this article. The carrier shall be responsible for the charges incurred in the examination, including the expenses of the Commissioner or his designee and the expenses and compensation of his examiners and assistants.
B. Each carrier, on its own or through its contract for pharmacy benefits, shall report the following information to the Commissioner for each health benefit plan:
1. The aggregate amount of rebates received by the pharmacy benefits manager;
2. The aggregate amount of rebates distributed to the appropriate health benefit plan;
3. The aggregate amount of rebates passed on to the enrollees of each health benefit plan at the point of sale that reduced the enrollees' applicable deductible, copayment, coinsurance, or other cost-sharing amount;
4. Upon the request of the Commission, the individual and aggregate amount paid by the health benefit plan to the pharmacy benefits manager for services itemized by pharmacy, by product, and by goods and services; and
5. Upon the request of the Commission, the individual and aggregate amount a pharmacy benefits manager paid for services itemized by pharmacy, by product, and by goods and services.
The report required by this subsection shall be filed on a quarterly basis through March 31, 2023. The final quarterly report shall include information for the period ending December 31, 2022. Thereafter, by March 31 of each year, the report shall be filed on a calendar year basis. The 2023 calendar year report shall be filed by March 31, 2024.
C. All working papers, documents, reports, and copies thereof, produced by, obtained by or disclosed to the Commission or any other person in the course of an examination made under this article and any analysis of such information or documents shall be given confidential treatment, are not subject to subpoena, and may not be made public by the Commission or any other person. Access may also be granted to (i) a regulatory official of any state or country; (ii) the National Association of Insurance Commissioners (NAIC), its affiliate, or its subsidiary; or (iii) a law-enforcement authority of any state or country, provided that those officials are required under their law to maintain its confidentiality. Any such disclosure by the Commission shall not constitute a waiver of confidentiality of such papers, documents, reports or copies thereof. Any parties receiving such papers must agree in writing prior to receiving the information to provide to it the same confidential treatment as required by this section.
2020, cc. 219, 1288; 2022, c. 283.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3469. (Effective October 1, 2020) Enforcement; regulations

A. The Commission shall enforce this article.
B. Pursuant to the authority granted by § 38.2-223, the Commission may promulgate such rules and regulations as it may deem necessary to implement this article.
2020, cc. 219, 1288.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 34 - Provisions Relating to Accident and Sickness Insurance › § 38.2-3470. (Effective October 1, 2020) Scope of article

This article shall not apply with respect to claims under (i) an employee welfare benefit plan as defined in section 3 (1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1002(1), that is self-insured or self-funded; (ii) coverages issued pursuant to Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (Medicaid); or (iii) prescription drug coverages issued pursuant to Part D of Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq. (Medicare Part D).
2020, cc. 219, 1288.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3500. Form of policy

A. No individual accident and sickness insurance policy shall be delivered or issued for delivery to any person in this Commonwealth unless:
1. The entire consideration for the policy is expressed in the policy;
2. The time at which the insurance takes effect and terminates is expressed in the policy;
3. The policy insures only one person, except that it may insure eligible family members, originally or by subsequent amendment, upon the application of an adult member of a family who shall be deemed the policyowner;
4. The exceptions and reductions are set forth in the policy and, except those that are set forth in §§ 38.2-3503 through 38.2-3508, are printed with the benefit provisions to which they apply, or under an appropriate caption, but if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of the exception or reduction shall be included with that benefit provision;
5. Each form, including riders and endorsements, is identified by a form number in the lower left-hand corner of the first page of the form;
6. It contains no provision making any portion of the charter, rules, constitution, or bylaws of the insurer a part of the policy unless that portion is set forth in the policy, except in the case of the incorporation of, or reference to, a statement of rates or classification of risks, or short-rate table filed with the Commission; and
7. It contains a statement about the provisions of subsections A and B of § 32.1-325.2 regarding the status of the Department of Medical Assistance Services as the payor of last resort.
B. If any policy is issued by an insurer domiciled in this Commonwealth for delivery to a person residing in another state, and if the insurance supervisory official of the other state advises the Commission that any such policy is not subject to approval or disapproval by such official, the Commission may by ruling require that such policy meet the standards set forth in this chapter.
C. "Eligible family member" means the (i) spouse, (ii) dependent children, without regard to whether such children reside in the same household as the policyowner, (iii) children under a specified age not greater than 19 years, and (iv) any person dependent on the policyowner.
D. 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.
1952, c. 317, § 38.1-348; 1986, cc. 550, 562; 1993, c. 306; 1994, c. 316; 2011, c. 882.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3501. Policy forms; powers of Commission

A. Individual accident and sickness insurance policy forms and the rate manuals showing rules and classification of risks applicable to individual accident and sickness insurance policy forms shall be subject to the provisions of § 38.2-316. The Commission, subject to § 38.2-316, may disapprove or withdraw approval of any such policy form if it finds that the benefits provided in the policy form are or are likely to be unreasonable in relation to the premium charged. If the Commission disapproves a policy form or withdraws approval of a form, an insurer may proceed as indicated in § 38.2-1926.
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.
1979, c. 726, § 38.1-362.8; 1986, c. 562; 2013, c. 751.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3502. Notice to be printed on policy; return of policy to insurer

A. Any individual accident and sickness insurance policy delivered or issued for delivery in this Commonwealth shall have printed on it a notice stating substantially:
"THIS POLICY MAY NOT APPLY WHEN YOU HAVE A CLAIM! PLEASE READ! This policy was issued based on the information entered in your application, a copy of which is attached to the policy. If you know of any misstatement in your application, or if any information concerning the medical history of any insured person has been omitted, you should advise the Company immediately regarding the incorrect or omitted information; otherwise, your policy may not be a valid contract.
RIGHT TO RETURN POLICY WITHIN 10 DAYS. If for any reason you are not satisfied with your policy, you may return this policy to the Company within ten days of the date you received it and the premium you paid will be promptly refunded."
B. If a policyowner returns the policy within ten days from the date of receipt, coverage under that policy shall become void from its inception upon the mailing or delivery of the policy to the insurer or its agent.
C. If the first paragraph of the notice required in subsection A of this section is inapplicable or partially inapplicable to a particular form of policy, the insurer may modify or omit the notice with the Commission's approval.
D. Nothing in this section shall prohibit an insurer from extending the right to examine period to more than ten days if the period is stated in the policy.
1966, c. 342, § 38.1-348.4; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3505. Inapplicable or inconsistent provisions

If any provision of this article is inapplicable to or inconsistent with the coverage provided by a particular form of policy, the insurer, with the Commission's approval, shall omit or modify the inapplicable or inconsistent provision to make that provision consistent with the coverage provided by the policy.
1952, c. 317, § 38.1-351; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3506. Order of certain policy provisions

The provisions that are the subject of §§ 38.2-3503 and 38.2-3504, or any corresponding provisions that are used instead of them in accordance with these sections, shall be printed in the consecutive order of the provisions in such sections. However, any such provision may appear as a unit in any part of the policy, with other provisions to which it may be logically related, provided the resulting policy shall not be in whole or in part unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to whom the policy is offered, delivered or issued.
1952, c. 317, § 38.1-352; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3507. Third-party ownership

The word "insured," as used in this article, shall not be construed to prevent a person with a proper insurable interest from applying for and owning a policy covering another person or from being entitled to any indemnities, benefits and rights provided under the policy.
1952, c. 317, § 38.1-353; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3508. Requirements of other jurisdictions

A. Any individual accident and sickness insurance policy delivered or issued for delivery to any person in this Commonwealth by a foreign or alien insurer may contain any provision that is prescribed or required by the insurer's domiciliary jurisdiction and that is not less favorable than the provisions of this article to the insured or the beneficiary.
B. Any individual accident and sickness insurance policy delivered or issued for delivery by a domestic insurer in any other jurisdiction may contain any provision permitted or required by the laws of the other jurisdiction.
Code 1950, § 38-224; 1952, c. 317, § 38.1-354; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3509. Denial or reduction of benefits because of existence of other like insurance

A. No individual accident and sickness insurance policy, nor any subscription contract as provided for in Chapter 42 (§ 38.2-4200 et seq.) of this title, delivered or issued for delivery in this Commonwealth shall contain any provision for the denial or reduction of benefits because of the existence of other like insurance except to the extent that the aggregate benefits, with respect to the covered medical expenses incurred under the policy or plan and all other like insurance with other insurers, exceed all covered medical expenses incurred.
B. The term "other like insurance" may include group insurance or coverage provided by hospital or medical service organizations, union welfare plans, employer or employee benefit organizations, or workers' compensation insurance.
1970, c. 378, § 38.1-355; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3510. Conforming to statute

No individual accident and sickness insurance policy provision that is not subject to this article shall make an individual accident and sickness insurance policy, or any portion of the policy, less favorable in any respect to the insured or the beneficiary than the provisions that are subject to this article.
Code 1950, § 38-223; 1952, c. 317, § 38.1-356; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3511. Application

A. The insured shall not be bound by any statement made in an application for an individual accident and sickness policy unless a copy of the application is attached to or endorsed on the policy when issued as a part of the policy. If any such policy delivered or issued for delivery in this Commonwealth is reinstated or renewed, and the insured, beneficiary or assignee of the policy makes a written request to the insurer for a copy of the reinstatement or renewal application, if any, the insurer shall within fifteen days after the receipt of the request, deliver or mail to the person making the request, a copy of the application. If a copy is not so delivered or mailed, the insurer shall be precluded from introducing the application as evidence in any action or proceeding based upon or involving the policy or its reinstatement or renewal.
B. No alteration of any written application for any such policy shall be made by any person other than the applicant without his written consent, except that insertions may be made by the insurer, for administrative purposes only, in a manner indicating clearly that such insertions are not to be ascribed to the applicant.
C. The falsity of any statement in the application for any policy covered by this article may not bar the right to recovery under the policy unless the false statement materially affected either the acceptance of the risk or the hazard assumed by the insurer.
1952, c. 317, § 38.1-357; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3512. Notice; waiver

The acknowledgment by any insurer of the receipt of notice given under any individual accident and sickness insurance policy, the furnishing of forms for filing proofs of loss, the acceptance of such proofs, or the investigation of any claim thereunder shall not operate as a waiver of any of the rights of the insurer in defense of any claim arising under the policy.
1952, c. 317, § 38.1-358; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3513. Age limit

A. If any individual accident and sickness insurance policy contains a provision establishing, as an age limit or otherwise, a date after which the coverage provided by the policy will not be effective, and if the date falls within a period for which a premium is accepted by the insurer or if the insurer accepts a premium after the date, the coverage provided by the policy will continue in force subject to any right of cancellation until the end of the period for which the premium has been accepted.
B. If the age of the insured has been misstated, and if according to the correct age of the insured, the coverage provided by the policy would not have become effective or would have ceased prior to the acceptance of the premium, then the liability of the insurer shall be limited to the refund, upon request, of all premiums paid for the period not covered by the policy.
1952, c. 317, § 38.1-359; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3514. When liability not to be denied because of preexisting disease, physical impairment or defect

No insurer that has delivered or issued for delivery in this Commonwealth an accident and sickness insurance policy pursuant to the provisions of this article shall deny liability on any claim otherwise covered under such policy because of the existence of a disease or physical impairment or defect, congenital or otherwise, at the time of the making of the application for such policy, unless it is shown that the applicant knew or might reasonably have been expected to know of such disease, impairment or defect.
1966, c. 184, § 38.1-361.1; 1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3514.1. Preexisting conditions provisions

A. In determining whether a preexisting conditions provision applies to an insured, all coverage shall credit the time the person was covered under previous individual or group policies providing hospital, medical and surgical or major medical coverage on an expense incurred basis if the previous coverage was continuous to a date not more than thirty days prior to the effective date of the new coverage, exclusive of any applicable waiting period under such coverage.
B. As used herein, a "preexisting conditions provision" means a policy provision that limits, denies, or excludes coverage for charges or expenses incurred during a twelve-month period following the insured's effective date of coverage, for a condition that, during a twelve-month period immediately preceding the effective date of coverage, had manifested itself in such a manner as would cause an ordinarily prudent person to seek diagnosis, care, or treatment, or for which medical advice, diagnosis, care, or treatment was recommended or received within twelve months immediately preceding the effective date of coverage or as to pregnancy existing on the effective date of coverage.
C. This section shall not apply to the following insurance policies or contracts:
1. Short-term travel;
2. Accident-only;
3. Limited or specified disease contracts;
4. Long-term care insurance;
5. Short-term nonrenewable policies or contracts of not more than six months' duration which are subject to no medical underwriting or minimal underwriting;
6. Policies subject to Article 4.1 (§ 38.2-3430.1 et seq.) of Chapter 34 of this title;
7. Policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or federal government plans; and
8. Disability income.
1995, c. 522; 1997, c. 291; 1999, c. 1004.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3514.2. Renewability of coverage

A. Every individual policy, subscription contract or plan delivered, issued for delivery or renewal in this Commonwealth providing benefits to or on behalf of an individual shall provide for the renewability of such coverage at the sole option of the insured, policyholder, subscriber, or enrollee. The insurer, health services plan or health maintenance organization issuing such policy, subscription contract or plan shall be permitted to refuse to renew the policy, subscription contract or plan only for one or more of the following reasons:
1. Nonpayment of the required premiums by the insured, policyholder, subscriber, or enrollee, or such individual's representative;
2. In the event that the policy, subscription contract or plan contains a provision requiring the use of network providers, a documented pattern of abuse or misuse of such provision by the insured, policyholder, subscriber, or enrollee, continuing for a period of no less than two years;
3. Subject to the time limits contained in subdivision 2 of § 38.2-3503 or in regulations adopted by the Commission governing the practices of health maintenance organizations, for fraud or material misrepresentation by the individual, with respect to his application for coverage;
4. Eligibility of an individual insured for Medicare, provided that such coverage may not terminate with respect to other individuals insured under the same policy, subscription contract or plan and who are not eligible for Medicare; and
5. The insured, subscriber, or enrollee has not maintained a legal residence in the service area of the insurer, health services plan or health maintenance organization for a period of at least six months.
B. This section shall not apply to the following insurance policies, subscription contracts or plans:
1. Short-term travel;
2. Accident-only;
3. Disability income;
4. Limited or specified disease contracts;
5. Long-term care insurance;
6. Short-term nonrenewable policies or contracts of not more than six months' duration which are subject to no medical underwriting or minimal underwriting; and
7. Individual health insurance coverage as defined in subsection B of § 38.2-3431.
1996, c. 550; 1998, c. 24.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3516. Purpose

The purpose of this article is to authorize the Commission, pursuant to the authority granted in § 38.2-223, to issue rules and regulations to:
1. Establish the minimum standards for filing of policy forms for individual and small group health benefit plans as defined in § 38.2-3438;
2. Establish the minimum standards, terms, and coverages for individual and group accident and sickness policies known as excepted benefits, as defined in § 38.2-3431; and
3. Establish the minimum standards for short-term limited-duration insurance.
The Commission shall ensure that policy standards are simple and understandable and are not misleading or unreasonably confusing and that the sale of such policies provides for full disclosure.
1980, c. 204, § 38.1-362.11; 1986, c. 562; 2022, c. 531.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3517. Definitions

As used in this article:
"Form" means a policy, rider, endorsement, amendment, application, enrollment form, certificate of insurance, evidence of coverage, group agreement, supplemental agreement, or any other form required to be filed with or approved by the Commission.
"Policy" means an insurance policy, contract, certificate, evidence of coverage, or other agreement of insurance, including any attached rider, endorsement, or application.
1980, c. 204, § 38.1-362.12; 1986, c. 562; 2022, c. 531.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3518. Standards for policy provisions

A. Pursuant to the authority granted in § 38.2-223, the Commission may issue rules and regulations to establish standards for the sale of individual and group accident and sickness insurance policies. These rules and regulations shall be in addition to and in accordance with applicable laws of the Commonwealth, including Chapter 34 (§ 38.2-3400 et seq.), Article 1 (§ 38.2-3500 et seq.), this article, and Article 3 (§ 38.2-3521.1 et seq.).
B. Pursuant to the authority granted in § 38.2-223, the Commission may issue rules and regulations that specify prohibited policies or policy provisions not otherwise specifically authorized by statute that in the opinion of the Commission are unjust, unfair, or unfairly discriminatory to the policyowner, beneficiary, or any person insured under the policy.
1980, c. 204, § 38.1-362.13; 1981, c. 575; 1986, c. 562; 2022, c. 531.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3519. Minimum standards for excepted benefits

A. Pursuant to the authority granted in § 38.2-223, the Commission may issue rules and regulations establishing minimum standards for benefits under any of the categories of policies known as excepted benefits.
B. No excepted benefits policy shall be delivered or issued for delivery in the Commonwealth that does not meet the prescribed minimum standards established by the Commission or does not meet the requirements set forth in § 38.2-3501.
C. The Commission may prescribe the method of identification of policies based upon coverages provided.
1980, c. 204, § 38.1-362.14; 1986, c. 562; 2022, c. 531.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3520. Coverage of preexisting conditions

A. Notwithstanding the provisions of § 38.2-3503, if an insurer elects to use a simplified application form, with or without a specific question as to the applicant's health, but without any detailed questions concerning the insured's health history or medical treatment history, the policy shall cover any loss occurring after twelve months from the effective date of coverage from any preexisting condition not specifically excluded from coverage by terms of the policy. Except as so provided, the policy shall not include wording that would permit a defense based upon preexisting conditions.
B. The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34.
1980, c. 204, § 38.1-362.15; 1981, c. 575; 1986, c. 562; 2013, c. 751.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3523.1. Review of records

The Commission may review the records of any insurer to determine that the insurer's policies have been issued in compliance with the requirements set forth in this article. Insurers issuing coverage not complying with the provisions of § 38.2-3521.1 and not complying with the provisions of § 38.2-3522.1 shall be deemed to have committed a knowing and willful violation of this article, and shall be punished as set forth in subsection A of § 38.2-218.
1998, c. 154.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3523.2. Policies issued outside of the Commonwealth of Virginia

A group accident and sickness insurance policy issued outside of this Commonwealth, providing coverage to residents of this Commonwealth, that does not qualify under § 38.2-3521.1 or § 38.2-3522.1 shall be subject to the statutory requirements of this title and may subject the insurer issuing such policy to the penalties available under this title for violation of such requirements.
1998, c. 154.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3523.3. Requirements for those marketing group accident and sickness insurance

Insurance marketed to certificate holders of a group which does not qualify under § 38.2-3521.1 or § 38.2-3522.1 must be marketed by a person holding a valid life and health insurance agent license as required by Chapter 18 (§ 38.2-1800 et seq.) of this title.
1998, c. 154; 1999, c. 86.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3523.4. Minimum number of persons covered

A. A group accident and sickness insurance policy shall on the issue date and at each policy anniversary date, cover at least two persons, other than spouses or minor children, unless such spouse or minor child is determined to be an eligible employee as defined in § 38.2-3431.
B. The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34.
1998, c. 154; 2013, c. 751.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3525. Group accident and sickness insurance coverages of spouses, dependent children or other persons

A. Coverage under a group accident and sickness insurance policy, except a policy issued pursuant to subsection B of § 38.2-3521.1, may be extended to insure:
1. The spouse and any child who is (i) under the age of 19 years, (ii) who is a dependent and under the age of 25 years, or (iii) who is a dependent and a full-time student under 25 years of age, without regard to whether such child resides in the same household as the insured group member, or any class of spouse and dependent children, of each insured group member who so elects; and
2. Any other class of persons as may mutually be agreed upon by the insurer and the group policyholder.
B. The amount of accident and sickness insurance for the spouse, dependent child or other person shall not exceed the amount of accident and sickness insurance for the insured group member.
C. At the insurer's option and subject to the policyholder's election, the coverage for children of the insured group member may be extended beyond the ages established in subsection A. Any such extension of coverage shall be as mutually agreed upon by the insurer and the group policyholder.
D. Notwithstanding the provisions of § 38.2-3538, one certificate may be issued for each insured group member if a statement concerning any spouse's, dependent child's, or other person's coverage is included in the certificate.
E. When a policy provides coverage for a dependent child who is enrolled based upon the child's status as a full-time student and such child is unable due to a medical condition to continue as a full-time student, coverage under the policy for such child nevertheless shall continue in force provided the child's treating physician certifies to the insurer at the time the child withdraws as a full-time student that the child's absence is medically necessary. Coverage for such child shall continue in force until the earlier of (i) the date that is 12 months from the date the child ceases to be a full-time student or (ii) the date the child no longer qualifies as a dependent child under the terms of the group policy. A child's status as a full-time student shall be determined in accordance with the criteria specified by the institution in which the child is enrolled.
F. The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34.
1986, c. 562; 1993, c. 306; 1998, c. 154; 2004, c. 771; 2005, c. 871; 2007, c. 428; 2008, c. 209; 2011, c. 882.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3526. Standard provisions required; exceptions

A. No group accident and sickness insurance policy shall be delivered or issued for delivery in this Commonwealth unless it contains the standard provisions prescribed in this article.
B. The provisions of § 38.2-3531, subsection A of §§ 38.2-3533 and 38.2-3538 shall not apply to policies issued pursuant to subsection B of § 38.2-3522.1.
1986, c. 562; 1998, c. 154.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3527. Grace period

Each group accident and sickness insurance policy shall contain a provision that the policyowner is entitled to a grace period of not less than thirty-one days for the payment of any premium due except the first premium. The provision shall also state that during the grace period the accident and sickness coverage shall continue in force unless the policyowner has given the insurer written notice of discontinuance in accordance with the terms of the policy and in advance of the date of discontinuance. The policy may provide that the policyowner shall be liable to the insurer for the payment of a pro rata premium for the time the policy was in force during the grace period.
1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3528. Incontestability

A. Each group accident and sickness insurance policy shall contain a provision that the validity of the policy shall not be contested, except for nonpayment of premiums, after it has been in force for two years from its date of issue.
B. The provision shall also state that no statement made by any person insured under the policy relating to his insurability or the insurability of his insured dependents shall be used in contesting the validity of the insurance with respect to which such statement was made:
1. After the insurance has been in force prior to the contest for a period of two years during the lifetime of the person about whom the statement was made; and
2. Unless the statement is contained in a written instrument signed by him.
C. This provision shall not preclude the assertion at any time of defenses based on the person's ineligibility for coverage under the policy or upon other provisions in the policy.
1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3529. Entire contract; statements deemed representations

A. Each group accident and sickness insurance policy shall contain a provision that the policy, and any application of the policyowner, and any individual applications of the persons insured shall constitute the entire contract between the parties.
B. The provision shall also state that:
1. A copy of any application of the policyowner shall be attached to the policy when issued;
2. All statements made by the policyowner or by the persons insured shall be deemed representations and not warranties; and
3. No written statement made by any person insured shall be used in any contest unless a copy of the statement is furnished to the person or to his beneficiary or personal representative.
1986, c. 562.
2023 Code of Virginia › Title 38.2 - Insurance › Chapter 35 - Accident and Sickness Insurance Policies › § 38.2-3530. Evidence of individual insurability

Each group accident and sickness insurance policy shall contain a provision setting forth any conditions under which the insurer reserves the right to require a person eligible for insurance to furnish evidence of individual insurability satisfactory to the insurer as a condition to part or all of his coverage.
1986, c. 562.