West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-39 - Group Accident And Sickness Insurance Minimum Policy Coverage Standards › Section 114-39-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope and
				Applicability. -- This rule applies to all group accident and sickness insurance
				policies, all group subscriber contracts of hospital, medical, dental and health
				service corporations, health care corporations and fraternal benefit societies and
				all enrollee agreements or contracts of health maintenance organizations, issued in
				connection with a group health plan and delivered or issued for delivery in this
				state on and after the effective date hereof, except that it does not apply to:
a. Individual policies or contracts issued
				pursuant to a conversion privilege under a policy or contract of group
				insurance;
b. Individual policies or
				contracts issued to eligible individuals.
c. Credit accident and sickness insurance subject
				to WV 114CSR6 "Regulation of Credit Life Insurance and Credit Accident and Sickness
				Insurance;"
d. Medicare supplement
				insurance policies subject to WV 114CSR24 "Medicare Supplement Insurance;
				"
e. Long-term care insurance policies
				subject to WV 114CSR32 "Long-Term Care Insurance; "
f. Coverage under the West Virginia Public
				Employees Insurance Act (W. Va. Code §§
										5-16-1
				et seq.): Provided, That this rule applies to a health benefit plan issued by a
				health insurer to provide medical care under the West Virginia Public Employees
				Insurance Act;
g. Coverage under
				Medicare or Medicaid: Provided, That this rule applies to a health benefit plan
				issued by a health insurer to provide medical care under Medicare or
				Medicaid;
h. Coverage under any
				automobile no-fault, workers' compensation, employer's liability, occupational
				disease or similar law;
i. Basic
				Hospital and Medical-Surgical Expense Coverage; and
j. Individual limited benefits. "Limited benefits
				policy" means any individual or group accident and sickness insurance policy,
				including all riders thereto (and certificates in the case of a group policy), that
				covers one or more residents of this state and that is not required to offer or
				provide all benefits mandated by any other applicable provision of this chapter.
				Such policies include, but are not limited to, accident only, sickness only
				disability, sickness only, accident only disability, hospital indemnity, specified
				disease and travel accident insurance policies:
Provided, that the following types of policies and certificates
				  are excluded from the definition of "limited benefits policy:"
1. Credit accident and sickness
				insurance;
2. Long-term care
				insurance;
3. Medicare supplement
				insurance;
4. Minimum benefits accident
				and sickness insurance issued pursuant to section fifteen, article fifteen of this
				chapter or article sixteen-c of this chapter;
5. Accident and sickness policies which provide
				benefits for loss of income due to disability;
6. Major medical policies;
7. Dental policies; and
8. Vision policies.
k. Disability income insurance