Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-50 - Washington disability insurance regulations › MINIMUM STANDARDS FOR INDIVIDUAL POLICIES › Section 284-50-330 - General rules as to minimum standards

Current through Register Vol. 24-14, July 15, 2024
(1) A "noncancellable," "guaranteed
				renewable" or "noncancellable and guaranteed renewable" policy shall 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.
(2) The
				terms "noncancellable," "guaranteed renewable" or "noncancellable and
				guaranteed renewable" shall not be used without further explanatory language in
				accordance with the disclosure requirements of WAC
				284-50-375(1).
				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 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: Provided, however, any accident and health or accident only policy
				which provides for periodic payments, weekly or monthly, for a specified period
				during the continuance of disability resulting from accident or sickness may
				provide that the insured has the right to continue the policy only to age 60
				if, at age 60, the insured has the right to continue the policy in force at
				least to age 65 while actively or regularly employed. Except as provided above,
				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 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: Provided, however, any accident and health or accident only
				policy which provides for periodic payments, weekly or monthly, for a specified
				period during the continuance of disability resulting from accident or sickness
				may provide that the insured has the right to continue the policy only to age
				60, if at age 60, the insured has the right to continue the policy in force at
				least to age 65 while actively and regularly employed.
(3) In a family policy covering both husband
				and wife the age of the younger spouse may be used as the basis for meeting the
				age and durational requirements of the definitions of "noncancellable" or
				"guaranteed renewable." However, this requirement shall not prevent termination
				of coverage of the older spouse upon attainment of the stated age limit (e.g.,
				age 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 said
				definition.
(4) When accidental
				death and dismemberment coverage is part of the insurance coverage offered
				under the contract, the insured shall have the option to include all insureds
				under such coverage and not just the principal insured.
(5) If a policy contains a status type
				military service exclusion or a provision which suspends coverage during
				military service, the policy shall provide, upon receipt of written request,
				for refund of premiums as applicable to such person on a pro rata
				basis.
(6) 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.
(7)
				Policies providing convalescent or extended care benefits following
				hospitalization shall not condition such benefits upon admission to the
				convalescent or extended care facility with a period of less than fourteen days
				after discharge from the hospital.
(8) In accord with
				RCW
				 48.20.420, coverage shall continue for any
				dependent child who is incapable of self-sustaining employment due to
				developmental or physical disability, on the date that such child's coverage
				would otherwise terminate under the policy due to the attainment of a specified
				age limit for children, and who is chiefly dependent on the insured for support
				and maintenance. The policy may require that within 31 days of such date the
				company receive due proof of such incapacity and dependency in order for the
				insured to elect to continue the policy in force with respect to such child, or
				that a separate converted policy be issued at the option of the insured or
				pol-icyholder.
(9) Any policy
				providing coverage for the recipient in a transplant operation shall also
				provide 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.
(10) A policy may contain a provision
				relating to recurrent disabilities; provided, however, that no such provision
				shall specify that a recurrent disability be separated by a period greater than
				six months.
(11) Accidental death
				and dismemberment benefits shall be payable if the loss occurs within no less
				than ninety days from the date of the accident, irrespective of total
				disability. Disability income benefits, if provided, shall not require the loss
				to commence less than thirty days after the date of accident, nor shall 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.
(12) Specific
				dismemberment benefits shall not be in lieu of other benefits unless the
				specific benefit equals or exceeds the other benefits.
(13) Any accident only policy providing
				benefits which vary according to the type of accidental cause shall prominently
				set forth in the outline of coverage the circumstances under which benefits are
				payable which are lesser than the maximum amount payable under the
				policy.
(14) All medicare
				supplement policies providing in-hos-pital benefits only shall include in their
				provided benefits the initial Part A medicare deductible as established from
				time to time by the Social Security Administration. Premiums may be reduced or
				raised to correspond with changes in the covered deductible.
(15) Termination of the policy 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 total disability of the insured,
				limited to the duration of the policy benefit period, if any, or payment of the
				maximum benefits.
(16) As an
				alternative to hospitalization or institutional-ization of an insured and with
				the intent to cover placement of the insured patient in the most appropriate
				and cost-effective setting, every individual disability insurance policy or
				contract issued, amended, or renewed on or after January 1, 1995, which
				provides coverage for hospitalization or other institutional expenses to a
				resident of this state shall include substitution of home health care, provided
				in lieu of hospitalization or other institutional care, furnished by home
				health, hospice, or home care agencies licensed under chapter 70.127 RCW, at
				equal or lesser cost.
(a) In addition, such
				expenses may include coverage for durable medical equipment which permits the
				insured to stay at home, care provided in Alzheimer's centers, adult family
				homes, assisted living facilities, congregate care facilities, adult day health
				care, home health, hospice, and home care, or similar alternative care
				arrangements which provide necessary care in less restrictive or less expensive
				environments.
(b) Substitution of
				less expensive or less intensive services shall be made only with the consent
				of the insured and upon the recommendation of the insured's attending physician
				or licensed health care provider that such services will adequately meet the
				insured patient's needs. The decision to substitute less expensive or less
				intensive services shall be determined based on the medical needs of the
				individual insured patient.
(c) An
				insurer may require that home health agencies or similar alternative care
				providers have written treatment plans which are approved by the insured
				patient's attending physician or other licensed health care provider.
(d) Coverage may be limited to no less than
				the maximum benefits which would be payable for hospital or other institutional
				expenses under the policy or contract, and may include all deductibles and
				coinsurances which would be payable by the insured under the hospital or other
				institutional expense coverage of the insured's policy or contract.
(e) This subsection shall not apply to
				long-term care, medicare supplement, or disability income protection insurance
				policies or contracts. This subsection shall not apply to guaranteed renewable
				disability insurance policies or contracts issued prior to January 1,
				1995.