Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 6 - General › Section Ins 6.51 - Group life and disability coverage termination and replacement

Current through June 24, 2024
(1) PURPOSE.
			 This section is intended to promote the fair and equitable treatment of group
			 policyholders, insurers, employees and dependents, and the general public by
			 setting out procedures to be followed when a group life or disability insurance
			 policy is terminated or replaced, and to interpret ss.
			 632.79
			 and
			 632.897,
			 Stats.
(2) SCOPE. This section
			 shall apply to all group life and group disability policies covering employees
			 or employees and dependents, issued by insurers providing insurance as defined
			 in s.
			 Ins 6.75(1) (a) or
			 (c) or (2) (c). It shall apply to blanket
			 policies only if they provide 24-hour coverage for both injury and sickness;
			 any blanket policy, covering any type of group, which provides for renewal
			 shall be subject to subs. (4) and (5); any blanket policy covering students of
			 a college or university, regardless of whether it provides for renewal, shall
			 be subject to subs. (6) and (7). Subsection (4) (a) shall apply only to group
			 policies as defined in sub. (3) (c) 2. Subsections (6) and (7) do not apply to
			 excess or stop-loss insurance purchased under s.
			 120.13(2)
			 (c), Stats., by a county or school district
			 that self-insures employee health benefits.
(3) DEFINITIONS.
(a) "Blanket policy" has the meaning in s.
			 600.03(4),
			 Stats.
(b) "Employee" means an
			 employee of an employer or a member of a union or association or a student of a
			 college or university.
(c) "Group
			 policy":
1. Means a policy or contract
			 covering employees issued by an insurer to an employer, labor union,
			 association or trust fund or, in the case of a blanket policy, a college or
			 university, or a group type plan, except that;
2. In sub. (4) (a), means only a policy or
			 contract issued by an insurer or a s.
			 185.981,
			 Stats., co-operative or a group type plan issued by a ch. 613, Stats.,
			 corporation, providing hospital, surgical or medical expense coverage to or on
			 behalf of an employer.
(d) A "group policy providing medical expense
			 coverage" does not include a policy providing coverage for dental, vision care,
			 hearing care or prescription drug expense coverage only.
(e) "Group policyholder" means an employer,
			 labor union, association, trust fund or other entity responsible for making
			 group policy premium payments to an insurer.
(f) "Group type plan" means an insurance plan
			 using individual policies which meets the following conditions:
1. Coverage is provided to classes of
			 employees defined in terms of conditions pertaining to employment or
			 membership.
2. The coverage is not
			 available to the general public and can be obtained and maintained only because
			 of the covered person's connection with the particular organization or
			 group.
3. Premiums are paid by the
			 group policyholder to the insurer on behalf of covered employees, and
4. An employer, union, association or trust
			 fund sponsors or authorizes the plan.
(g) "Individual policy" means an individual
			 or family policy or subscriber contract issued by an insurer.
(h) "Insurer" means an insurance company
			 subject to chs. 631 and 632, Stats., or a service insurance corporation subject
			 to ch. 613, Stats.
(i) "Premium"
			 means a policy premium or a subscriber contract subscription fee.
(j) "Pre-existing condition" means a disease
			 or physical condition including pregnancy which manifested itself prior to the
			 effective date of coverage through medical diagnosis or treatment or the
			 existence of symptoms which would cause an ordinarily prudent person to seek
			 diagnosis or treatment.
(k)
			 "Validly covered" means that the individual involved was covered and met all
			 policy requirements regarding eligibility for coverage, as opposed to an
			 individual who was covered without having met all such requirements.