H. B. 2014
(By Delegates Boggs and Amores)
[Introduced January 13, 1999; referred to the
Committee on Banking and Insurance then Government Organization.]
A BILL to amend and reenact section three, article sixteen,
chapter thirty-three of the code of West Virginia, one
thousand nine hundred thirty-one, as amended, relating to
required insurance policy language.
Be it enacted by the Legislature of West Virginia:
That section three, article sixteen, chapter thirty-three of
the code of West Virginia, one thousand nine hundred thirty-one,
as amended, be amended and reenacted to read as follows:
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.
§33-16-3. Required policy provisions.
Each such policy hereafter delivered or issued for delivery
in this state shall contain in substance the following
provisions:
(a) A provision that the policy, the application of the policyholder, a copy of which shall be attached to such the
policy, and the individual applications, if any, submitted in
connection with such the policy by the employees or members,
shall constitute the entire contract between the parties, and
that all statements made by any applicant or applicants shall be
deemed are representations and not warranties, and that no such
statement shall void the insurance or reduce benefits thereunder
under the insurance unless contained in a written application.
(b) A provision that the insurer will furnish to the
policyholder, for delivery to each employee or member of the
insured group, an individual certificate setting forth in
substance the essential features of the insurance coverage of
such the employee or member and to whom benefits thereunder under
the insurance are payable. If dependents are included in the
coverage, only one certificate need needs to be issued for each
family unit.
(c) A provision that all new employees or members, as the
case may be, in the groups or classes eligible for insurance,
shall from time to time be added to such the groups or classes
eligible to obtain such insurance in accordance with the terms
of the policy.
(d) No provision relative to notice or proof of loss or the
time for paying benefits or the time within which suit may be
brought upon the policy shall be less favorable to the insured than would be permitted in the case of an individual policy by
the provisions set forth in article fifteen of this chapter.
(e) A provision that all members in groups or classes
eligible for insurance provided through an employee's group plan
shall be permitted to pay the premiums at the same group rate and
receive the same coverages for a period not to exceed eighteen
months when they are involuntarily laid off from work.
(f) A provision requiring full disclosure by the insurer as
to methods, statistics or other means by which the insurer sets
reasonable and customary hospital and medical costs schedules and
physician's fee schedules used by the insurer for the purpose of
determining acceptable hospital costs, medical costs and
physicians fees for the payment of the costs, fees or services
rendered within the scope of the policy.
(f) (g) Such Further provisions establishing group accident
and sickness minimum policy coverage standards as the
commissioner shall promulgate by rule pursuant to chapter
twenty-nine-a of this code.
NOTE: This bill provides that a provision must be in every
insurance policy which requires full disclosure by the insurer as
to the methods used to set reasonable and customary hospital and
medical costs and physician's fee schedules used by the insurer
for the purpose of determining acceptable fees for the payment of
benefits rendered within the scope of the policy.
Strike-throughs indicate language that would be stricken
from the present law, and underscoring indicates new language that would be added.