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 114-39-5 - 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 the following subdivisions. No health insurer may deliver or issue
				for delivery in this state a policy which does not meet the required minimum
				standards of subdivisions a and b of this subsection, if applicable. Except for
				coverage under policies issued to employers of fifty-one (51) or more employees,
				under which the coverage is negotiated by the policyholder, no health insurer may
				deliver or issue for delivery in this state a policy which does not meet the
				required minimum standards of subdivisions c through k of this subsection unless the
				commissioner finds that policies 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.
				The benefits described in a certificate issued under a policy subject to this rule
				shall be consistent with the benefits contained in the policy and shall be no less
				than those required under this section.
a. A
				health benefit plan issued in connection with a group health plan and providing
				inpatient benefits in connection with childbirth must meet all requirements of W.
				Va. Code §
										33-16-3 j
				with respect to both the mother and her newborn.
b. A health benefit plan issued in connection with
				a group health plan and providing mental health benefits must meet all requirements
				of W. Va. Code §
										33-16-3 a:
				Provided, That W. Va. Code §
										33-16-3
				a(d) does not apply to any health benefit plan for any group health plan year of a
				small employer.
c. 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.
d. If a health insurer terminates
				coverage under a policy providing pregnancy coverage, such policy 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,
				provided that this subsection shall not apply when termination of coverage is due to
				fraud, nonpayment of premium or any breach of the terms of the policy for which
				termination is authorized under chapter 33 of the W. Va. Code.
e. Policies providing convalescent or extended
				care benefits following hospitalization may not condition the benefits upon
				admission to the convalescent or extended care facility within a period of less than
				fourteen (14) days after discharge from the hospital.
f. 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:
(1) 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
(2)
				chiefly dependent on the policyholder for support and maintenance. The policy may
				require that within thirty-one (31) days of the termination date, the health insurer
				must 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.
g. 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 provided such benefits may be limited to those expenses directly relating to
				the organ donation.
h. 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.
i. 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 health 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.
j. Specific dismemberment benefits may not be in
				lieu of other benefits unless the specific benefit exceeds the other
				benefits.
k. Termination of coverage
				under a 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 disability of the
				individual covered under the policy or limited to the duration of the policy benefit
				period if any: Provided, That this subdivision shall not apply when termination of
				coverage is due to fraud, nonpayment of premium or any breach of the terms of the
				policy for which refusal to renew the policy is authorized under W. Va. Code,
				chapter thirty-three.