Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 35 - Accident and Health Insurance › Rule 191-35.4 - Required Provisions

Current through Register Vol. 47, No. 3, July 24, 2024
No blanket policy as herein defined shall be issued or
				  delivered in this state unless a copy of the policy and brochure if required,
				  has been approved by the commissioner of insurance in accordance with the
				  provisions set forth in rule 35.7(509). All policies of blanket accident or
				  sickness insurance or combination thereof issued in this state shall contain in
				  substance the following provisions:
(1) A provision that the policy including
				endorsements and a copy of the application, if any, of the policyholder and the
				persons insured shall constitute the entire contract between the parties, and
				that any statement made by the policyholder or by a person insured shall in the
				absence of fraud, be deemed a representation and not a warranty. No such
				statement shall be used in defense of a claim under the policy, unless it is
				contained in a written application. If a copy of such application is not
				delivered to the person insured the insurer shall be precluded from introducing
				such application as evidence in any action involving any statements contained
				therein.
(2) A provision that
				written notice of sickness or of injury must be given to the insurer within 20
				days of the date when such sickness or injury occurred. Failure to give notice
				within such time shall not invalidate nor reduce any claim if it shall be shown
				not to have been reasonably possible to give such notice and that notice was
				given as soon as was reasonably possible.
(3) A provision that the insurer will furnish
				either to the claimant or to the policyholder for delivery to the claimant such
				forms as are usually furnished by it for filing proof of loss. If such forms
				are not furnished before the expiration of 15 days after giving such notice,
				the claimant shall be deemed to have complied with the requirements of the
				policy as to proof of loss upon submitting within the time fixed in the policy
				for filing proof of loss, written proof covering the occurrence, the character
				and the extent of the loss for which claim is made.
(4) A provision that in the case of claim for
				loss of time for disability, written proof of such loss must be furnished to
				the insurer within 90 days after the commencement of the period for which the
				insurer is liable, and that subsequent written proofs of the continuance of
				such disability must be furnished to the insurer at such intervals as the
				insurer may reasonably require, and that in the case of claim for any other
				loss, written proof of such loss must be furnished to the insurer within 90
				days after the date of such loss. Failure to furnish such proof within such
				time shall not invalidate nor reduce any claim if it shall be shown not to have
				been reasonably possible to furnish such proof and that such proof was
				furnished as soon as was reasonably possible.
(5) A provision that all benefits payable
				under the policy other than benefits for loss of time will be payable
				immediately upon receipt of due written proof of such loss, and that, subject
				to due proof of loss, all accrued benefits payable under the policy for loss of
				time will be paid not less frequently than monthly during the continuance of
				the period for which the insurer is liable, and that any balance remaining
				unpaid at the termination of such period will be paid immediately upon receipt
				of such proof
(6) A provision that
				the insurer at its own expense, shall have the right and opportunity to examine
				the person of the insured when and so often as it may reasonably require during
				the pendency of claim under the policy and also the right and opportunity to
				make an autopsy where it is not prohibited by law.
(7) A provision that no action at law or in
				equity shall be brought to recover under the policy prior to the expiration of
				60 days after written proof of loss has been furnished in accordance with the
				requirements of the policy and that no such action shall be brought after the
				expiration of three years after the time written proof of loss is required to
				be furnished.