Payment of claims (Cont’d) effective, such indemnity shall be payable to the estate of the insured. Any other accrued indemnities unpaid at the insured's death may, at the option of the insurer, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the insured. The following provisions, or either of them, may be included with the foregoing provision at the option of the insurer: "If any indemnity of this policy shall be payable to the estate of the insured, or to an insured or beneficiary who is a minor or otherwise not competent to give a valid release, the insurer may pay such indemnity, up to an amount not exceeding $. . . . . . (insert an amount which shall not exceed $1000), to any relative by blood or connection by marriage of the insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any payment made by the insurer in good faith pursuant to this provision shall fully discharge the insurer to the extent of such payment." "Subject to any written direction of the insured in the application or otherwise all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical, or surgical services may, at the insurer's option and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the service be rendered by a particular hospital or person." Physical examination and autopsy RCW 42.20.132 There must be a provision as follows: PHYSICAL EXAMINATIONS AND AUTOPSY: The insurer at its own expense shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law.
Coordination of Benefits (Cont’d) benefits, and insurance coverages written in connection with a closed panel plan to provide out-of-network benefits.) WAC Order of benefit determination. Each plan determines its order of benefits using the first of the following rules that applies: WAC 284-51-205 (4)(a)(i) Nondependent or dependent. Subject to the following, the plan that covers the person other than as a dependent (e.g., as an employee, member, subscriber, policyholder or retiree) is the primary plan and the plan that covers the person as a dependent is the secondary plan. WAC 284-51-205 (4)(a)(ii) If the person is a Medicare beneficiary, and, as a result of the provisions of Title XVIII of the Social Security Act and implementing regulations, Medicare is: WAC Secondary to the plan covering the person as a dependent; and WAC Primary to the plan covering the person as other than a dependent (e.g., a retired employee); WAC Then the order of benefits is reversed so that the plan covering the person as an employee, member, subscriber, policyholder or retiree is the secondary plan and the other plan covering the person as a dependent is the primary plan. WAC 284-51-205(4)(b) Dependent child covered under more than one plan. Unless there is a court decree stating otherwise, plans covering a dependent child must determine the order of benefits as follows: WAC 284-51-205 (4)(b)(i) For a dependent child whose parents are married or are living together, whether or not they have ever been married:
Cost Sharing for Substitute Drugs Cost Sharing for Substitute Drugs (Cont’d) WAC Issuer may not charge an ancillary charge, in addition to the plan's normal copayment or coinsurance requirements, for a drug that is covered because of one of the circumstances set forth in either WAC 284-43-5080 or 284-43-5100. An ancillary charge is any charge in addition to or excess of cost-sharing. WAC When an enrollee requests a formulary brand name drug in lieu of a therapeutically equivalent generic drug or a drug from a higher tier, and there is no clinical basis for the substitution, carrier may require enrollee to pay the difference in price between the drug that the formulary would have required, and the covered drug, in addition to the copayment. This charge must reflect the actual cost difference. WAC When carrier approves a substitution drug, whether or not the drug is in the formulary, enrollee's cost-sharing must be adjusted to reflect any discount agreements or other pricing adjustments for the substitution drug available to carrier. Any charge to the enrollee for a substitution drug must not increase carrier's underwriting gain for the plan beyond that calculated for the original formulary drug.
Maximum of six surfaces per for permanent anterior teeth; and Two occlusal restorations for the upper molars on teeth one, two, three, 14, 15 and 16. Subrogation Thiringer v. American Motors Ins., 91 WN 2d 215, 588 P.2d 191 (1978); Great West Life Annuity Ins v. Knudson If the policy includes a subrogation provision, it must: Make clear that the issuer is entitled only to excess after the enrollee is fully compensated Inform enrollee that legal expenses will be apportioned equitably The policy may not: Have any provision which would inappropriately require full reimbursement for all medical expenses The contract cannot unreasonably restrict or delay the payment of benefits. Delays are not justified because the expenses incurred, or the services received, resulted from an act or omission of a third party Unfair and Discriminatory Practices Unfair and Discriminatory Practices (Cont’d) False Advertising RCW 48.30.040 The forms may not contain any false, deceptive, or misleading representation or advertising relative to the business of a Disability insurer or to any person engaged therein. of Contract Terms RCW 48.30.090 The may not contain any misrepresentation of the terms of any contract, or the benefits or advantages promised thereby, or use the name or title of any contract or class of contract misrepresenting the nature thereof. No guarantee of future payments RCW 48.30.100 Contract must not guarantee or to the payment of future dividends or future refunds of unused charges or savings.