H. B. 2495


(By Delegates Boggs and Amores)

[Introduced February 23, 2001 ; referred to the

Committee on Banking and Insurance then the Judiciary.]





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.

ยง33-16-3. 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.