reglab/statecodes huggingface dataset:
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Appendix 4

Current through June 24, 2024
LONG-TERM CARE INSURANCE SUITABILITY LETTER
Dear [Applicant]:
Your recent application for [long-term care insurance]
				[insurance for care in a nursing home] [insurance for care at home or other
				community setting] included a "personal worksheet," which asked questions about
				your finances and your reasons for buying this coverage. For your protection,
				state law requires us to consider this information when we review your
				application, to avoid selling a policy to those who may not need
				coverage.
[Your answers indicate that insurance coverage you applied for
				may not meet your financial needs. We suggest that you review the information
				provided along with your application, including the booklet "Guide to Long-Term
				Care" and the page titled "Things You Should Know Before Buying Long-Term Care
				Insurance." The Wisconsin Office of the Commissioner of Insurance also has
				information about long-term care insurance and may be able to refer you to a
				county Benefit specialist or a Senior Health Insurance Information specialist
				free of charge who can help you decide whether to buy this policy.]
[You chose not to provide any financial information for us to
				review.]
Note: Choose the paragraph and bracketed sentences in that
				paragraph that apply.
We have suspended our final review of your application. If,
				after careful consideration, you still believe this policy is what you want,
				check the appropriate box below and return this letter to us within the next 60
				days. We will then continue reviewing your application and issue a policy if
				you meet our medical standards.
If we do not hear from you within the next 60 days, we will
				close your file and not issue you a policy. You should understand that you will
				not have any coverage until we hear back from you, approve your application,
				and issue you a policy.
Please check one box and return in the enclosed
				envelope.
[] Yes, [although my worksheet indicates that nursing home only
				or home health care insurance only insurance may not be a suitable purchase,] I
				wish to purchase this coverage. Please resume review of my application.
Note: Delete the phrase in brackets if the applicant did not
				answer the questions about income.
[] No, I have decided not to buy a policy at this time.
_______________________________ __________________
(Applicant's Signature) (Date)
Please return to [insurer] at [address] by [date].
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Appendix 7

Current through June 24, 2024
NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND
				SICKNESS OR LONG-TERM CARE INSURANCE
[Insurance company's name and address]
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE
				FUTURE.
According to [your application] [information you have
				furnished], you intend to lapse or otherwise terminate existing accident and
				sickness or long-term care insurance and replace it with the long-term care
				insurance policy delivered herewith issued by [company name] Insurance Company.
				Your new policy provides thirty (30) days within which you may decide, without
				cost, whether you desire to keep the policy. For your own information and
				protection, you should be aware of and seriously consider certain factors that
				may affect the insurance protection available to you under the new
				policy.
You should review this new coverage carefully, comparing it
				with all accident and sickness or long-term care insurance coverage you now
				have, and terminate your present policy only if, after due consideration, you
				find that purchase of this long-term care coverage is a wise decision.
1. Health conditions that you may presently have (preexisting
				conditions), may not be immediately or fully covered under the new policy. This
				could result in denial or delay in payment of benefits under the new policy,
				whereas a similar claim might have been payable under your present
				policy.
2. State law provides that your replacement policy or
				certificate may not contain new preexisting conditions or probationary periods.
				Your insurer will waive any time periods applicable to preexisting conditions
				or probationary periods in the new policy (or coverage) for similar benefits to
				the extent such time was spent (depleted) under the original policy.
3. If you are replacing existing long-term care insurance
				coverage, you may wish to secure the advice of your present insurer or its
				agent regarding the proposed replacement of your present policy. This is not
				only your right, but it is also in your best interest to make sure you
				understand all the relevant factors involved in replacing your present
				coverage.
4. [To be included only if the application is attached to the
				policy.] If, after due consideration, you still wish to terminate your present
				policy and replace it with new coverage, read the copy of the application
				attached to your new policy and be sure that all questions are answered fully
				and correctly. Omissions or misstatements in the application could cause an
				otherwise valid claim to be denied. Carefully check the application and write
				to [company name and address] within thirty (30) days if any information is not
				correct and complete, or if any past medical history has been left out of the
				application.
[Company Name]
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Appendix 8

Current through June 24, 2024
RESCISSION REPORTING FORM FOR LONG-TERM CARE
				POLICIES
FOR THE STATE OF _______________
FOR THE REPORTING YEAR [ ]
Company Name:
				________________________________________________________________
Address:
				________________________________________________________________
________________________________________________________________
Phone Number: _____________________
Due: March 1 annually
INSTRUCTIONS:
The purpose of this form is to report all rescissions of
				long-term care insurance policies or certificates. Those rescissions
				voluntarily effectuated by an insured are not required to be included in this
				report. Please furnish one form per rescission.
Policy Form #
Policy and Certificate #
Name of Insured
Date of Policy Issuance
Date/s Claim/s Submitted
Date of Rescission
Detailed reason for rescission:
				____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
__________________________________
Signature
__________________________________
Name and Title (please type)
__________________________________
Date
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Appendix 9

Current through June 24, 2024
CLAIMS DENIAL REPORTING FORM
LONG-TERM CARE INSURANCE
For the State of ______________________________________
For the Reporting Year of ________________
Company Name: _______________________________________
Due: June 30 annually
Company Address:
_____________________________________________________________
_____________________________________________________________
Company NAIC Number:
				_____________________________________
Contact Person: _____________________________Phone Number:
				______________________
Line of Business: Individual Group
INSTRUCTIONS
The purpose of this form is to report all long-term care claim
				denials under in force long-term care insurance policies. "Denied" means a
				claim that is not paid for any reason other than for claims not paid for
				failure to meet the waiting period or because of an applicable preexisting
				condition.
State Data
Nationwide Data1
1
Total Number of Long-Term Care Claims Reported
2
Total Number of Long-Term Care Claims Denied/Not
							 Paid
3
Number of Claims Not Paid due to Preexisting
							 Condition Exclusion
4
Number of Claims Not Paid due to Waiting
							 (Elimination) Period Not Met
5
Net Number of Long-Term Care Claims Denied for
							 Reporting Purposes (Line 2 Minus Line 3 Minus Line 4)
6
Percentage of Long-Term Care Claims Denied of Those
							 Reported (Line 5 Divided By Line 1)
7
Number of Long-Term Care Claim Denied due to:
8
Long-Term Care Services Not Covered under the
							 Policy2
9
Provider/Facility Not Qualified under the
							 Policy3
10
Benefit Eligibility Criteria Not
							 Met4
11
Other
1 The nationwide data may be viewed as a more representative
				and credible indicator where the data for claims reported and denied for your
				state are small in number.
2 Example-home health care claim filed under a nursing home
				only policy.
3 Example-a facility that does not meet the minimum level of
				care requirements or the licensing requirements as outlined in the
				policy.
4 Examples-a benefit trigger not met, certification by a
				licensed health care practitioner not provided, no plan of care.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Appendix 10

Current through June 24, 2024
LONG-TERM CARE INSURANCE
REPLACEMENT AND LAPSE REPORTING FORM
For the State of
				____________________________________________
For the Reporting Year of ________________
Company Name:
				______________________________________________
Due: June 30 annually
Company Address:
				______________________________________________
Company NAIC Number: ______________
Contact Person:
				______________________________________________
Phone Number: (____) _____________
INSTRUCTIONS:
The purpose of this form is to report on a statewide basis
				information regarding long-term care insurance policy replacements and lapses.
				Specifically, every insurer shall maintain records for each agent on that
				agent's amount of long-term care insurance replacement sales as a percent of
				the agent's total annual sales and the amount of lapses of long-term care
				insurance policies sold by the agent as a percent of the agent's total annual
				sales. The tables below should be used to report the ten percent (10%) of the
				insurer's agents with the greatest percentages of replacements and
				lapses.
Listing of the 10% of Agents with the Greatest Percentage of
				Replacements
Agent's Name
Number of Policies Sold By This Agent
Number of Policies Replaced By This Agent
Number of Replacements As % of Number Sold By This
							 Agent
Listing of the 10% of Agents with the Greatest Percentage of
				Lapses
Agent's Name
Number of Policies Sold By This Agent
Number of Policies Lapsed By This Agent
Number of Lapses As % of Number Sold By This
							 Agent
Company Totals
Percentage of Replacement Policies Sold to Total Annual Sales
				____%
Percentage of Replacement Policies Sold to Policies In Force
				(as of the end of the preceding calendar year) ____%
Percentage of Lapsed Policies to Total Annual Sales
				_____%
Percentage of Lapsed Policies to Policies In Force (as of the
				end of the preceding calendar year) ____%
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Section Ins 3.465 - Wisconsin long-term care partnership program

Current through June 24, 2024
(1) GENERAL
			 APPLICABILITY. The provisions within s.
			 Ins
			 3.46 regarding insurance transactions for long-term
			 care and life insurance policies with long-term care provisions apply to
			 insurance transactions described within this section.
(2) DEFINITIONS. The definitions contained in
			 ss.
			 Ins
			 3.455 and 3.46 also apply in this section. In
			 addition, the following definitions apply in this section:
(a) "Automatic exchange" means the issuance
			 of a notice from an insurer informing an existing insured that the policy the
			 insured purchased prior to January 1, 2009, from the insurer has been approved
			 by the commissioner as a policy that meets the requirements of the state's
			 partnership program and, as such, the policy will be treated from the date of
			 the notice as a qualifying partnership policy.
(b) "Consumer price index" means the consumer
			 price index for all urban consumers, U.S. city average, all items, as
			 determined by the Bureau of Labor Statistics of the United States Department of
			 Labor.
(c) "Qualified long-term
			 care insurance contract" or federally tax-qualified long-term care insurance
			 contract" means an individual or group insurance long-term care, nursing home
			 or home health care contract that meets the requirements of section 7702B(b) of
			 the Internal Revenue Code of 1986, as amended, or the portion of a life
			 insurance contract that provides long-term care insurance coverage by rider or
			 as part of the contract and that satisfies the requirements of sections
			 7702B(b) and (c) of the Internal Revenue Code of 1986, as amended.
(d) "Qualifying partnership policy exchange"
			 means the exchange of an existing long-term care insurance plan with an
			 identical policy that on or after January 1, 2009 is certified by the insurer
			 to meet the federal requirements established for the state's partnership
			 program or the exchange of an existing long-term care insurance policy with an
			 identical policy except for the addition of a benefit or rider that, on or
			 after January 1, 2009, is certified by the insurer to meet the federal
			 requirements established for the state's partnership program.
(e) "Secretary" means the U. S. Secretary of
			 the Department of Health and Human Services.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Section Ins 3.47 - Cancer insurance solicitation

Current through June 24, 2024
(1) FINDINGS.
			 Information on file in the office of the commissioner of insurance shows that
			 significant misunderstanding exists with respect to cancer insurance. Consumers
			 are not aware of the limitations of cancer insurance and do not know how cancer
			 insurance policies fit in with other health insurance coverage. Many of the
			 sales presentations used in the selling of cancer insurance are confusing,
			 misleading and incomplete and consumers are not getting the information they
			 need to make informed choices. The commissioner of insurance finds that such
			 presentations and sales materials are misleading, deceptive and restrain
			 competition unreasonably as considered by s.
			 628.34(12),
			 Stats., and that their continued use without additional information would
			 constitute an unfair trade practice under s.
			 628.34(11),
			 Stats., and would result in misrepresentation as defined and prohibited in s.
			 628.34(1),
			 Stats.
(2)PURPOSE. This section
			 interprets s.
			 628.34(12),
			 Stats., relating to unfair trade practices. It requires insurers and
			 intermediaries who sell cancer insurance to give all prospective buyers of
			 cancer insurance a shopper's guide prepared by the national association of
			 insurance commissioners.
(3)SCOPE.
			 This section applies to all individual, group and franchise insurance policies
			 or riders which provide benefits for or are advertised as providing benefits
			 primarily for the treatment of cancer. This section does not apply to
			 solicitations in which the booklet, "Health Insurance Advice for Senior
			 Citizens," is given to applicants as required by s.
			 Ins
			 3.39.
(4)DEFINITION. "A Shopper's Guide to Cancer
			 Insurance" means the document which contains the language set forth in Appendix
			 I to this section.
(5)DISCLOSURE
			 REQUIREMENTS.
(a) Each insurer offering a
			 policy or rider described in sub. (3) shall print, and the insurer and its
			 intermediaries shall provide to all prospective purchasers of any policy or
			 rider subject to this section, a copy of "A Shopper's Guide to Cancer
			 Insurance" at the time the prospect is contacted by the insurer or intermediary
			 with an invitation to apply, as defined in s.
			 Ins
			 3.27(5) (g).
(b) "A Shopper's Guide to Cancer Insurance"
			 shall be printed in an easy-to-read type of not less than 12-pt.
			 size.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Section Ins 3.49 - Wisconsin automobile insurance plan

Current through June 24, 2024
(1) PURPOSE. This
			 section interprets s.
			 619.01(6),
			 Stats., to continue a plan to make automobile insurance available to those who
			 are unable to obtain it in the voluntary market by providing for the equitable
			 distribution of applicants among insurers and outlines access and grievance
			 procedures for such a plan.
(2)DEFINITIONS. In this section:
(a) "Committee" means the governing committee
			 of the Wisconsin Automobile Insurance Plan which is the group of companies
			 administering the Plan.
(b) "Plan"
			 means the Wisconsin Automobile Insurance Plan, an unincorporated facility
			 established by s. , 1967 Stats., and continued under s.
			 619.01(6),
			 Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Section Ins 3.51 - Reports by individual practice associations

Current through June 24, 2024
(1) DEFINITIONS.
			 For the purpose of this section only:
(a)
			 "Accountant" means an independent certified public accountant who is duly
			 registered to practice and in good standing under the laws of this state or a
			 state with similar licensing requirements.
(b) "Individual practice association" means
			 an individual practice association as defined under s.
			 600.03(23g),
			 Stats., which contracts with a health maintenance organization insurer or a
			 limited service health organization to provide health care services which are
			 principally physician services.
(c)
			 "Work papers" are the records kept by the accountant of the procedures
			 followed, the tests performed, the information obtained, and conclusions
			 reached pertinent to the examination of the financial statements of the
			 independent practice association. Work papers include, but are not limited to,
			 work programs, analysis, memorandum, letters of confirmation and
			 representation, management letters, abstracts of company documents and
			 schedules or commentaries prepared or obtained by the accountant in the course
			 of the examination of the financial statements of the independent practice
			 association and which support the accountant's opinion.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Section Ins 3.53 - HIV testing

Current through June 24, 2024
(1) FINDINGS. The tests listed in sub. (4)
			 (e) have been specified by the state epidemiologist in part B (4) of a report
			 entitled "Validated positive, medically significant and sufficiently reliable
			 tests to detect the presence of human immunodeficiency virus (HIV), antigen or
			 nonantigenic products of HIV or an antibody to HIV," dated January 24, 1997.
			 The commissioner of insurance, therefore, finds that these tests are
			 sufficiently reliable for use in underwriting individual life, accident and
			 health insurance policies.
(2)PURPOSES. The purposes of this section
			 are:
(a) To implement s.
			 631.90(3)
			 (a), Stats.
(b) To establish procedures for insurers to
			 use in obtaining informed consent for HIV testing and informing individuals of
			 the results of a positive HIV test.
(c) To ensure the confidentiality of HIV test
			 results.
(d) To restrict the use of
			 certain information on HIV testing in underwriting group life, accident and
			 health insurance policies.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Section Ins 3.54 - Home health care benefits under disability insurance policies

Current through June 24, 2024
(1) PURPOSE.
			 This section implements and interprets ss.
			 628.34(1) and
			 (12),
			 631.20
			 and
			 632.895(1) and
			 (2), Stats., for the purpose of facilitating
			 the administration of claims for coverage of home health care under disability
			 insurance policies and the review of policy forms. The commissioner of
			 insurance shall disapprove a policy under s.
			 631.20,
			 Stats., if that policy does not meet the minimum requirements specified in this
			 section.
(2)SCOPE. This section
			 applies to disability insurance policies.
(3)DEFINITIONS. In this section:
(a) "Disability insurance policy" means a
			 disability insurance policy as defined under s.
			 632.895(1)
			 (a), Stats., which provides coverage of
			 expenses incurred for in-patient hospital care.
(b) "Home health aide services" means
			 nonmedical services performed by a home health aide which:
1. Are not required to be performed by a
			 registered nurse or licensed practical nurse; and
2. Primarily aid the patient in performing
			 normal activities of daily living.
(c) "Home care visits" means the period of a
			 visit to provide home care, without limit on the duration of the visit, except
			 each consecutive 4 hours in a 24-hour period of home health aide services is
			 one visit.
(d) "Medically
			 necessary" means that the service or supply is:
1. Required to diagnose or treat an injury or
			 sickness and shall be performed or prescribed by the physician;
2. Consistent with the diagnosis and
			 treatment of the sickness or injury;
3. In accordance with generally accepted
			 standards of medical practice; and
4. Not solely for the convenience of the
			 insured or the physician.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Section Ins 3.55 - Benefit appeals under long-term care policies, life insurance-long-term care coverage

Current through June 24, 2024
(1) PURPOSE. This section implements and
			 interprets s.
			 632.84,
			 Stats., for the purpose of establishing minimum requirements for the internal
			 procedure for benefit appeals that insurers shall provide in long-term care
			 policies, life insurance-long-term care coverage. This section also facilitates
			 the review by the commissioner of these policy forms.
(2) SCOPE. This section applies to individual
			 and group nursing home insurance policies issued or renewed on or after August
			 1, 1988, and to long-term care policies and life insurance-long-term care
			 coverage issued or renewed on and after June 1, 1991, except for polices or
			 coverage exempt under s. Ins 3.455(2) (b). This section does not apply to
			 health maintenance organizations, limited service health organization or
			 preferred provider plan, as those are defined in s.
			 609.01,
			 Stats.
(3) DEFINITIONS. In this
			 section:
(a) "Benefit appeal" means a request
			 for further consideration of actions involving the denial of a
			 benefit.
(b) "Denial of a benefit"
			 means any denial of a claim, the application of a limitation or exclusion
			 provision, and any refusal to continue coverage.
(c) "Internal procedure" means the insurer's
			 written procedure for handling benefit appeals.
(cg) "Life insurance-long-term care coverage"
			 has the meaning provided under s. Ins 3.46(3) (j).
(cm) "Long-term care policy" has the meaning
			 provided under s. Ins 3.46(3) (k).
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Section Ins 3.60 - Disclosure of information on health care claim settlements

Current through June 24, 2024
(1) PURPOSE. This
			 section implements and interprets s.
			 628.34(1) (a) and
			 (12), Stats., for the purpose of allowing
			 insureds and providers access to information on the methodology health insurers
			 use to determine the eligible amount of a health insurance claim and permitting
			 insureds to obtain estimates of amounts that their insurers will pay for
			 specific health care procedures and services.
(2)DEFINITIONS. In this section:
(a) "C.D.T." means the American dental
			 association's current dental terminology.
(b) "C.P.T." means the American medical
			 association's current procedural terminology.
(c) "Provider" means a licensed health care
			 professional.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Section Ins 3.651 - Standardized explanation of benefits and remittance advice format

Current through June 24, 2024
(1) PURPOSE.
			 This section implements s.
			 632.725(2)
			 (c), Stats., by prescribing the requirements
			 for the following, to be used by insurers providing health care coverage to one
			 or more residents of this state:
(a)
			 Remittance advice forms that insurers furnish to health care
			 providers.
(b) Explanation of
			 benefits forms that insurers furnish to insureds.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Section Ins 3.67 - Benefit appeals under certain policies

Current through June 24, 2024
(1) DEFINITIONS. In
			 this section:
(a) "Defined network plan" has
			 the meaning provided under s.
			 609.01(1b),
			 Stats.
(am) "Expedited request"
			 means a request where the standard resolution process may include any of the
			 following:
1. Serious jeopardy to the life or
			 health of the enrollee or the ability of the enrollee to regain maximum
			 function.
2. In the opinion of a
			 physician with knowledge of the enrollee's medical condition, would subject the
			 enrollee to severe pain that cannot be adequately managed without the care or
			 treatment that is the subject of the request.
3. Is determined to be an expedited request
			 by a physician with knowledge of the enrollee's medical condition.
(b) "Grievance" means any
			 dissatisfaction with the provision of services or claims practices of an
			 insurer offering a defined network plan, limited service health organization or
			 preferred provider plan or administration of a defined network plan, limited
			 service health organization or preferred provider plan by the insurer that is
			 expressed in writing to the insurer by, or on behalf of, an enrollee.
(c) "Health care plan" has the meaning
			 provided under s.
			 628.36(2)
			 (a) 1, Stats., including fixed indemnity and
			 specified disease insurance but does not include coverage ancillary to property
			 and casualty insurance and Medicare + Choice plans.
(d) "Limited service health organization" has
			 the meaning provided under s.
			 609.01(3),
			 Stats.
(f) "Self-insured plan" has
			 the meaning provided under s.
			 632.85(1)
			 (c), Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Section Ins 3.75 - Continuation of discontinued employer provided health group policy coverage for employees and their dependents

Current through June 24, 2024
(1) PURPOSE. The
			 purpose of this section is to allow assistance eligible individuals to elect
			 continued coverage provided under s.
			 632.897,
			 Stats., in circumstances where the group policy is discontinued on or after
			 June 30, 2009, and not replaced. The rule applies only to individuals who are
			 eligible for a premium subsidy under the federal American Recovery and
			 Reinvestment Act of 2009 P.L. 111-5, as amended. The
			 federal act makes the premium subsidy available to those individuals who are
			 eligible due to an involuntary employment termination prior to June 1,
			 2010.
(2) DEFINITIONS. In addition
			 to the definitions in section 9126 of 2009 Wisconsin Act 11, in this section,
			 unless the context requires otherwise:
(a)
			 "Assistance eligible individual" has the meaning provided in section 3001 (a)
			 (3) of the federal act.
(b)
			 "Federal act" means the American Recovery and Reinvestment Act of 2009,
			 P.L.
			 111-5, as amended by section 1010 of the federal
			 department of defense appropriations act, 2010 (
			 P.L.
			 111-118 ), the temporary extension act of 2010 (
			 P.L.
			 111-144 ) and the continuing extension act of 2010
			 ( P.L.
			 111-157 ).
(c) "Terminated insured" means a n insured
			 under s.
			 632.897(1)
			 (f) and (2) (b) 2, Stats., whose employment
			 has been involuntarily terminated on or after September 1, 2008, and prior to
			 June 1, 2010, who has been continuously covered under a group policy for at
			 least 3 months and who satisfies one of the following:
1. Would be entitled to elect continued
			 coverage under s.
			 632.897,
			 Stats., but for the fact that the group policy was discontinued on or after
			 June 30, 2009, and not replaced by another group policy offered by the employer
			 during the terminated insured's 30-day election period under s.
			 632.897(3)
			 (a), Stats.
2. Is receiving, on behalf of themselves and,
			 if applicable, a spouse or dependents, continued coverage under s.
			 632.897,
			 Stats., due to an involuntary termination of employment that occurred on or
			 after September 1, 2008, but prior to June 1, 2010, and, on or after June 30,
			 2009, the group policy is discontinued and not replaced by a group policy
			 offered by the employer.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 4 - Fire And Allied Lines Insurance › Section Ins 4.01 - Interpretation and implementation of s 632.05 (2), Stats

Current through June 24, 2024
(1) SCOPE. Section
			 632.05, Stats.,
			 and this section apply to policies issued or renewed on or after November 29,
			 1979, which insure real property owned and occupied by the insured as a
			 dwelling.
(2) INTERPRETATIONS.
(a)
Seasonal dwellings.
A
			 dwelling used seasonally shall be considered as owned and occupied by the
			 insured if it is not rented to a non-owner for any period of time.
(b)
Outbuildings.
Outbuildings insured under the same policy as an owner-occupied dwelling are
			 not subject to s.
			 632.05(2),
			 Stats.
(c)
Mobile
			 homes.
Mobile homes as defined in s.
			 66.0435(1)
			 (d), Stats., shall not be considered real
			 property and shall not be subject to the requirements of s.
			 632.05(2),
			 Stats.
(d)
Multifamily
			 units.
A policy insuring multiple unit residential property, with at
			 least one unit occupied by the owner shall be subject to s.
			 632.05(2),
			 Stats., if there are no more than 4 dwelling units on the property.
(e)
Combined commercial and
			 residential properties.
A policy insuring real property any part of
			 which is used for commercial (non-dwelling) purposes other than on an
			 incidental basis is not subject to s.
			 632.05(2),
			 Stats.
Note: In Seider v. Musser, 2000 WI 76, 236 Wis. 2d 211, 612
				N.W.2d 659, the supreme court ruled that sub. (2) (e) is invalid.
(g)
Property under
			 construction.
Section
			 632.05(2),
			 Stats., shall not apply to a policy which insures real property under
			 construction unless the property is completed and is occupied by the owner as a
			 dwelling.
(h)
Operation of
			 building laws.
Real property owned and occupied by the insured which
			 is partially destroyed but ordered destroyed under a fire ordinance or similar
			 law shall be considered wholly destroyed for purposes of s.
			 632.05(2),
			 Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 4 - Fire And Allied Lines Insurance › Section Ins 4.08 - Inland marine insurance exempt from filing requirements

Current through June 24, 2024
(1) PURPOSE. In
			 accordance with s.
			 625.04, Stats., the
			 purpose of this section is to exempt from the filing requirements of s.
			 625.13,
			 Stats., all classes of inland marine risks.
(2) SCOPE. This section shall apply to inland
			 marine insurance transacted under the authorization of s.
			 Ins 6.75(2)
			 (a).
(3) EXEMPT CLASSES. Insurers and rate service
			 organizations are exempt from s.
			 625.13,
			 Stats., in respect to the filing of rates and supplementary rate information
			 for all classes of inland marine insurance.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 4 - Fire And Allied Lines Insurance › Section Ins 4.10 - Wisconsin insurance plan

Current through June 24, 2024
(1) Purpose. This section is intended to
			 implement and interpret s.
			 619.01,
			 Stats., for the purpose of establishing procedures and requirements for a
			 mandatory risk sharing facility for basic property insurance coverage. This
			 section is also intended to encourage improvement of and reasonable loss
			 prevention measures for properties located in Wisconsin and to further orderly
			 community development.
(2) Scope.
			 This section shall apply to all insurers included in sub. (3) (d) except those
			 organized under ch. 612, Stats., assessment mutual insurance companies and
			 insurers who write reinsurance only.
(3) Definitions.
(a) "Basic property insurance" means the
			 insurance coverages described in subds. 1. and 3. against direct loss to real
			 and tangible property at a fixed location. The Plan may use customary policy
			 forms and endorsements to effect coverage contemplated by this paragraph. Other
			 coverage may be added to the Plan by endorsement or policy provision upon
			 approval by the commissioner.
1. Coverage
			 provided in the customary fire policy and in the customary extended coverage as
			 authorized by s.
			 Ins 6.75(2)
			 (a).
3. Coverage at least equivalent to that
			 provided in a modified coverage form homeowners policy.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 5 - Administrative Actions; Rules Of Procedure For Contested Cases › Subchapter I - Scope; Definitions › Section Ins 5.01 - Purpose; applicability

Current through June 24, 2024
(1) This chapter interprets subch. III of ch.
				227, Stats., and ss.
				102.31(4),
				153.78,
				601.44(6),
				and
				601.62, Stats., and
				applies to administrative actions under the jurisdiction of the commissioner,
				and the PCF board.
(2) This chapter
				does not apply to rule-making hearings under subch. II of ch. 227,
				Stats.
(3) This chapter does not
				require a contested case proceeding before the issuance of a declaratory order
				under s.
				601.41(4)
				(b), Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 5 - Administrative Actions; Rules Of Procedure For Contested Cases › Subchapter I - Scope; Definitions › Section Ins 5.03 - Definitions

Current through June 24, 2024
In this chapter:
(1)
				"Commissioner" means the commissioner of insurance or the deputy commissioner
				of insurance acting under s.
				601.11(1)
				(b), Stats.
(2) "Contested case" has the meaning given in
				s.
				227.01(3),
				Stats.
(3) "Declaratory ruling"
				means an administrative decision by the commissioner or a board which, after a
				contested case proceeding, determines the applicability of a statute or rule
				enforced by the commissioner to any person, property or state of
				facts.
(4) "Hearing" means the
				trial of the issues in a contested case.
(6) "License" means any license, permit,
				approval, certificate of authority, certificate of registration or similar form
				of permission required by law and issued under chs. 601 to 655,
				Stats.
(7) "Office" means the
				office of the commissioner.
(8)
				"PCF board" means the board of governors of the Wisconsin health care liability
				insurance plan and patients compensation fund established under s.
				619.04(3),
				Stats.
(9) "Person" means a natural
				person, corporation, limited liability company, partnership, cooperative,
				association, trust, other business entity or government entity.
(10) "Subpoena" means a command to give
				testimony or provide evidence.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 5 - Administrative Actions; Rules Of Procedure For Contested Cases › Subchapter II - Declaratory Ruling › Section Ins 5.05 - Petition for declaratory ruling

Current through June 24, 2024
An interested person may file with the commissioner or a
				  board a petition for a declaratory ruling under s.
				  227.41,
				  Stats. The petition shall comply with s.
				  227.41(2),
				  Stats., and shall state how the petitioner may be affected by the statute or
				  rule referenced in the petition.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 5 - Administrative Actions; Rules Of Procedure For Contested Cases › Subchapter II - Declaratory Ruling › Section Ins 5.06 - Response to petition

Current through June 24, 2024
Within a reasonable time after a petition is filed under s.
				  Ins
				  5.05, the commissioner or board shall grant or deny
				  the petition. If the petition is granted, the commissioner or board shall
				  initiate a contested case under s.
				  227.41(1),
				  Stats., by issuing a notice of hearing in the form specified in s.
				  Ins 5.12. If
				  the petition is denied, the commissioner or board shall issue a denial notice
				  in writing, specifying the reason for the denial. The commissioner or board may
				  permit the petitioner to amend the petition if it does not fully comply with s.
				  227.41(2),
				  Stats., or s.
				  Ins
				  5.05.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 5 - Administrative Actions; Rules Of Procedure For Contested Cases › Subchapter III - Investigations; Orders Issued by Office; Form Filing Disapprovals › Section Ins 5.07 - Complaint; investigation

Current through June 24, 2024
(1) Any person may file with the office a
				complaint about any person subject to regulation under ch. 153, Stats., or chs.
				600 to 655, Stats.
(2) Based on a
				complaint under sub. (1) or other information available, the office may
				investigate to determine whether there is probable cause to take action against
				a person subject to regulation under ch. 153, Stats., or chs. 600 to 655,
				Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 5 - Administrative Actions; Rules Of Procedure For Contested Cases › Subchapter III - Investigations; Orders Issued by Office; Form Filing Disapprovals › Section Ins 5.08 - Orders

Current through June 24, 2024
(1) ISSUANCE. If the office determines, based
				on its examination or investigation of a person regulated under ch. 153,
				Stats., or chs. 600 to 655, Stats., that there is probable cause to believe
				that a person has violated any provisions of those chapters, a rule promulgated
				under those chapters or an order under s.
				601.41(4)
				(a) and
				601.63,
				601.64 or
				601.65,
				Stats., the office may issue an order under s.
				153.78 or
				601.41(4)
				(a), Stats., or issue a notice of hearing
				under s.
				601.62, Stats., and s.
				Ins 5.12, or
				both.
(2) CONTENTS OF ORDER.
(a) An order under s.
				153.78, Stats., or ss.
				601.41(4)
				(a) and
				601.63,
				601.64 or
				601.65,
				Stats., shall be accompanied by notice of the right to a hearing under s.
				601.62(3)
				(a), Stats., shall be captioned as provided
				in s.
				Ins
				5.17(1) and shall include all of the
				following:
1. The identity and, if known, the
				address of each respondent to whom the order is directed.
2. A statement of the facts constituting the
				basis for the order.
3. A reference
				to each statute, rule or order which each respondent allegedly
				violated.
4. A description of what
				the order requires each respondent to do.
5. The signature and title of the designated
				employee of the office who issued the order.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 5 - Administrative Actions; Rules Of Procedure For Contested Cases › Subchapter IV - Adverse Decision of Office, Board, Plan, Fund or Council; Right to Hearing; Petition › Section Ins 5.09 - Right to hearing before commissioner

Current through June 24, 2024
Any of the following may initiate a contested case proceeding
				  before the commissioner by filing with the commissioner a petition meeting the
				  requirements of s.
				  Ins
				  5.11 within the time limit specified in the applicable
				  statute or administrative rule:
(1) A
				person named as respondent in an order issued under s.
				Ins
				5.08.
(2)
				An insurer whose form filing has been disapproved under s.
				631.20,
				Stats.
(3) A person whose
				application for a license is denied.
(4) A person specified under s.
				626.31(4)
				(a), Stats., entitled to a review of an
				action or decision of the Wisconsin compensation rating bureau.
(5) An insurer entitled to a hearing under s.
				102.31(4),
				Stats., based on a recommendation of the department of workforce
				development.
(6) An applicant or
				policyholder who receives notice under s.
				Ins
				4.10(16) from the Wisconsin insurance
				plan of cancellation, nonrenewal, reduction in coverage or
				declination.
(7) An applicant,
				policyholder or insurer entitled under s.
				Ins 3.49(3)
				(d) 1. to appeal a decision of the governing
				committee of the Wisconsin automobile insurance plan.
(8) A person who receives a forfeiture
				assessment from the office of health care information under s.
				153.78,
				Stats.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 5 - Administrative Actions; Rules Of Procedure For Contested Cases › Subchapter IV - Adverse Decision of Office, Board, Plan, Fund or Council; Right to Hearing; Petition › Section Ins 5.10 - Right to hearing before PCF board

Current through June 24, 2024
(1) Any of the
				following may initiate a contested case proceeding before the PCF board by
				filing with the board a petition meeting the requirements of s.
				Ins
				5.11:
(a) A person
				adversely affected by a classification decision of the Wisconsin health care
				liability insurance plan or patients compensation fund under s.
				Ins
				17.24(3).
(b) A health care provider whose coverage
				under the Wisconsin health care liability insurance plan is cancelled or
				nonrenewed under s.
				Ins
				17.25(16).
(c) A health care provider entitled to a
				hearing under s.
				Ins 17.285(9)
				(a) on a recommendation of the patients
				compensation fund peer review council.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 5 - Administrative Actions; Rules Of Procedure For Contested Cases › Subchapter IV - Adverse Decision of Office, Board, Plan, Fund or Council; Right to Hearing; Petition › Section Ins 5.11 - Petition; response; effect

Current through June 24, 2024
(1) CONTENTS.
(a) A petition for a hearing need not be in
				any particular form, but shall be in writing and shall include all of the
				following:
1. The name and address of the
				petitioner.
2. The date of the
				petition.
3. Any of the following:
a. The case number of the order that
				adversely affects the petitioner and an explanation of why the petitioner
				believes the order should be withdrawn or modified.
b. A statement of how the petitioner is
				adversely affected by a decision of the office, board, plan, fund or council, a
				reference to any legal deficiency in the decision and the date on which the
				petitioner received notice of the decision.
c. If the petition relates to a denial by the
				office of the petitioner's application for a license, a statement of why the
				petitioner believes the denial should be modified or rescinded.
d. If the petition relates to a form filing
				disapproval, a statement of why the petitioner believes the form should be
				approved.
4. If an
				attorney will appear on behalf of the petitioner, the attorney's name and
				address.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 5 - Administrative Actions; Rules Of Procedure For Contested Cases › Subchapter V - Notice of Hearing Pleadings; Form and Filing of Documents › Section Ins 5.12 - Notice of hearing

Current through June 24, 2024
(1) FORM. The office or administrative law
				judge shall serve on each named party in a contested case a notice of hearing
				which shall include all of the following:
(a)
				The title, in the form prescribed in s.
				Ins
				5.17(1) (d), and the case number of
				the contested case.
(b) The name
				and address of each party. In the case of a person licensed by the office, the
				latest address on file with the office shall be conclusively presumed to be the
				person's correct address.
(c) The
				date, time and place scheduled for a prehearing conference under s.
				227.44(4),
				Stats.
(d) The name of the
				administrative law judge.
(e) The
				class of the contested case under s.
				227.01(3),
				Stats.
(f) The statutory authority
				under which the contested case will be conducted.
(g) The purpose of the hearing.
(h) The matter to be decided.
(i) The date, time and place scheduled for
				the hearing.
(j) If the hearing is
				a class 2 proceeding, the allegations in the form specified in sub. (2), or in
				the alternative, the notice of hearing may incorporate by reference an order
				under s.
				Ins
				5.08.
(k)
				The date by which the respondent must submit an answer if an answer is
				required.
(L) The date the notice
				of hearing is issued.
(m) The
				signature of the attorney assigned to the contested case by the office, or the
				signature of the administrative law judge if no attorney is assigned by the
				office.
(n) A statement of the
				possible consequences of failing to answer or appear, as provided in s.
				Ins
				5.21.
Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 5 - Administrative Actions; Rules Of Procedure For Contested Cases › Subchapter V - Notice of Hearing Pleadings; Form and Filing of Documents › Section Ins 5.13 - Answer

Current through June 24, 2024
(1) ANSWER REQUIRED. Each named respondent
				required to file an answer shall answer the notice of hearing by the specified
				time, unless additional time is allowed by stipulation of the parties or the
				administrative law judge, for good cause, allows a respondent additional time
				to answer or to amend the answer. The answer shall be signed by the respondent
				or by an attorney representing the respondent. If the respondent is a
				corporation, limited liability company, partnership, cooperative or other
				association, the answer may be signed by any of its officers or
				employees.
(2) CONTENTS.
(a) An answer need not be in any particular
				form but shall include all of the following:
1. The case number designated in the notice
				of hearing.
2. The date of the
				answer.
3. A specific denial of
				each material allegation of fact or law which the respondent controverts. A
				denial shall meet the substance of the allegation denied. If the respondent
				intends in good faith to deny only a part or qualification of an allegation,
				the respondent shall admit as much of the allegation as is true and material
				and shall deny only the remainder.
4. If applicable, a statement that the
				respondent is without knowledge or information sufficient to form a belief as
				to the truth of a specified allegation. This statement has the effect of a
				denial.
5. A statement of any
				matter constituting a defense, affirmative defense or mitigation of the matter
				charged which the respondent wishes to have considered.