West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-12 - Individual Accident And Sickness Insurance Minimum Standards › Section 114-12-5 - Minimum Standards for Benefits

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. General.
				-- The following minimum standards for benefits are prescribed for the categories of
				coverage noted in this section. No policy or certificate subject to this rule may be
				delivered or issued for delivery in this State which does not meet the required
				minimum standards for the specified categories, unless the Commissioner finds that
				policies or certificates containing less than the prescribed minimum standards for
				benefits, which are filed for approval, will be in the public interest and otherwise
				meet the requirements set forth in W. Va. Code '33-6-9.
				Nothing in this section precludes the issuance of any policy combining two (2) or
				more categories of coverage set forth in W. Va. Code '33-28-5(a)(1) through
				(6), inclusive.
a. An insurer providing inpatient benefits in
				connection with childbirth must meet all requirements of W. Va. Code '33-15-4e
				with respect to both the mother and her newborn.
b. A "noncancellable,@ "guaranteed renewable" or
				"noncancellable and guaranteed renewable" policy may not provide for termination of
				coverage of the spouse solely because of the occurrence of an event specified for
				termination of coverage of the insured, other than nonpayment of premium. The policy
				shall provide that in the event of the insured's death, the spouse of the insured,
				if covered under the policy, shall become the insured.
c. The terms "noncancellable,@ "guaranteed
				renewable,@ or "noncancellable and guaranteed renewable" may not be used without
				further explanatory language in accordance with the disclosure requirements of
				subsection 6.1 of this rule. The terms "noncancellable" or "noncancellable and
				guaranteed renewable" may be used only in a policy which the insured has the right
				to continue in force by the timely payment of premiums set forth in the policy until
				the age of sixty-five (65) or to eligibility for Medicare, during which period the
				insurer has no right to make unilaterally any change in any provision of the policy
				while the policy is in force. Except as provided in this subdivision, the term
				"guaranteed renewable" may be used only in a policy which the insured has the right
				to continue in force by the timely payment of premiums until the age of sixty-five
				(65) or to eligibility for Medicare, during which period the insurer has no right to
				make unilaterally any change in any provision of the policy while the policy is in
				force, except that the insurer may make changes in premium rates by
				classes.
d. In a family policy covering
				both husband and wife, the age of the younger spouse shall be used as the basis for
				meeting the age and durational requirements of the definitions of "noncancellable"
				and "guaranteed renewable." However, this requirement may not prevent termination of
				coverage of the older spouse upon attainment of the stated age limit, e.g., age
				sixty-five (65), so long as the policy may be continued in force as to the younger
				spouse to the age or for the durational period as specified in the
				definition.
e. When accidental death and
				dismemberment coverage is part of the insurance coverage offered under the policy,
				the insured shall have the option to include all insureds under the policy and not
				just the principal insured.
f. If a
				policy contains a status-type military service exclusion which suspends coverage
				during military service, the policy shall provide, upon receipt of written request,
				for refund of premiums as applicable to an insured in military service on a pro rata
				basis.
g. In the event the insurer
				cancels or refuses to renew, policies providing pregnancy benefits shall provide for
				an extension of benefits as to pregnancy commencing while the policy is in force and
				for which benefits would have been payable had the policy remained in
				force.
h. Policies providing
				convalescent or extended care benefits following hospitalization may not condition
				such benefits upon admission to the convalescent or extended care facility within a
				period of less than fourteen (14) days after discharge from the hospital.
i. Any policy which provides coverage of a
				dependent child may not terminate coverage for the dependent child if, upon
				attainment of any limiting age set forth in the policy, the child is and continues
				to be both incapable of self-sustaining employment due to mental retardation or
				physical handicap on the date that the child's coverage would otherwise terminate
				under the policy due to the attainment of the specified limiting age; and chiefly
				dependent on the policyholder for support and maintenance. The policy may require
				that within thirty-one (31) days of such date, the insurer receive due proof of the
				incapacity in order for the insured to elect to continue the policy in force with
				respect to the dependent child. As an alternative to this requirement, a separate
				converted policy may be issued to the child at the option of the insured or
				policyholder.
j. Any policy providing
				coverage for the recipient in a transplant operation shall also provide for the
				reimbursement of any medical expenses of a live donor to the extent that benefits
				remain and are available under the recipient's policy, after benefits for the
				recipient's own expenses have been paid.
k. A policy may contain a provision relating to
				recurrent disabilities: Provided, That no such provision may specify that a
				recurrent disability be separated by a period greater than six (6) months from the
				last previous occurrence of the disability.
l. Accidental death and dismemberment benefits
				shall be payable if the loss occurs within ninety (90) days from the date of the
				accident, irrespective of total disability. Disability income benefits, if provided,
				may not require the loss to commence less than thirty (30) days after the date of
				accident, nor may any policy which the insurer cancels or refuses to renew require
				that it be in force at the time disability commences if the accident occurred while
				the policy was in force.
m. Specific
				dismemberment benefits may not be in lieu of other benefits unless the specific
				benefit equals or exceeds the other benefits.
n. Termination of the policy by the insurer shall
				be without prejudice to any continuous loss which commenced while the policy was in
				force, but the extension of benefits beyond the period the policy was in force may
				be predicated upon the continuous disability of the insured or limited to the
				duration of the policy benefit period, if any, or payment of the maximum
				benefits.