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 114-39-6 - Required Disclosure Provisions

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1.
				Each policy subject to this rule shall include a renewal, continuation or nonrenewal
				provision. The language or specifications of such provision shall be consistent with
				the type of policy to be issued. The provision shall be appropriately captioned, and
				shall clearly state the duration, where limited, of renewability and the duration of
				the term of coverage for which the policy is issued and for which it may be
				renewed.
6.2. Except for riders or
				endorsements by which the health insurer effectuates a request made in writing by
				the policyholder or certificate holder, or exercises a specifically reserved right
				under the policy, all riders or endorsements added to a policy after date of issue
				or at reinstatement or renewal which reduce or eliminate benefits or coverage in the
				policy require signed acceptance by the policyholder or certificate holder, as
				appropriate. After the date of policy issue, any rider or endorsement which
				increases benefits or coverage with a concomitant increase in premium during the
				policy term shall be agreed to in writing signed by the policyholder or certificate
				holder, as appropriate, except if the increased coverage or benefits are required by
				law.
6.3. Where a separate additional
				premium is paid for benefits provided in connection with riders or endorsements, the
				premium charge shall be set forth in the policy.
6.4. A policy which provides for the payment of
				benefits based on standards described as "usual and customary," "reasonable and
				customary," or words of similar import shall include a definition of those terms
				within the policy.
6.5. Any provisions
				limiting or excluding coverage of preexisting conditions shall appear in a separate
				paragraph of the policy and shall be labeled as "Preexisting Condition
				Limitations."
6.6. All accident-only
				policies shall contain on the first page of the policy or attached thereto in either
				contrasting color or in boldface type at least equal to the size of type used for
				policy captions, a prominent statement as follows: "This is an accident-only policy,
				and it does not pay benefits for loss from sickness."
6.7. Any accident-only policy providing benefits
				which vary according to the type of accidental cause shall prominently set forth the
				circumstances under which benefits are payable which are less than the maximum
				amount payable under the policy.
6.8.
				All specified disease policies shall contain on the first page of the policy or
				attached thereto, in either contrasting color or in boldface type at least equal to
				the size of type used for policy captions, a prominent statement as follows:
				"Caution: This is a limited benefits policy. Read it carefully."
6.9. All policies shall have a notice prominently
				printed on the first page of the policy or attached thereto, stating in substance
				that the group policyholder shall have the right to return the policy within ten
				(10) days of its delivery and to have the premium refunded if, after examination of
				the policy, the group policyholder is not satisfied for any reason. The notice shall
				also state that in the event the policyholder exercises this right, the health
				insurer shall not be obligated to pay any benefits under the policy for claims
				submitted to the health insurer during such ten (10) day period.
6.10. If age is to be used as a determining factor
				for reducing the maximum aggregate benefits made available in the policy as
				originally issued, that fact shall be prominently set forth in the policy and
				certificate.
6.11. If a policy contains
				a conversion privilege, it shall comply, in substance, with the following: The
				caption of the provision shall be "Conversion Privilege," or words of similar
				import. The provision shall indicate the persons eligible for conversion; the
				circumstances applicable to the conversion privilege, including any limitations on
				the conversion; and the person by whom the conversion privilege may be exercised.
				The provision shall specify the benefits to be provided on conversion, or may state
				that the converted coverage will be as provided on a policy form then being used by
				the health insurer for that purpose.