H. B. 4288
(By Delegates Compton, Boggs, C. White and Beane)
[Introduced January 29, 2002; referred to the
Committee on Banking and Insurance then the Judiciary.]
A BILL to amend and reenact section five, article fifteen, chapter
thirty-three of the code of West Virginia, one thousand nine
hundred thirty-one, as amended, relating to accident and
sickness provisions to prohibit the exclusion of treatment for
intoxication as a medical expense.
Be it enacted by the Legislature of West Virginia:
That section five, article fifteen, 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 15. ACCIDENT AND SICKNESS INSURANCE.
§33-15-5. Optional policy provisions.
Except as provided in section six of this article, no such
policy delivered or issued for delivery to any person in this state shall contain provisions respecting the matters set forth below
unless such provisions are in the words in which the same appear in
this section: Provided, That the insurer may, at its option, use
in lieu of any such provision a corresponding provision of
different wording approved by the commissioner which is not less
favorable in any respect to the insured or the beneficiary. Any
such provision contained in the policy shall be preceded
individually by the appropriate caption appearing in this section
or, at the option of the insurer, by such appropriate individual or
group captions or subcaptions as the commissioner may approve.
(a) A provision as follows:
"Change of Occupation: If the insured be injured or contract
sickness after having changed his occupation to one classified by
the insurer as more hazardous than that stated in this policy or
while doing for compensation anything pertaining to an occupation
so classified, the insurer will pay only such portion of the
indemnities provided in this policy as the premium paid would have
purchased at the rates and within the limits fixed by the insurer
for such more hazardous occupation. If the insured changes his
occupation to one classified by the insurer as less hazardous than
that stated in this policy, the insurer, upon receipt of proof of such change of occupation, will reduce the premium rate
accordingly, and will return the excess pro rata unearned premium
from the date of change of occupation or from the policy
anniversary date immediately preceding receipt of such proof,
whichever is the more recent. In applying this provision, the
classification of occupational risk and the premium rates shall be
such as have been last filed by the insurer prior to the occurrence
of the loss for which the insurer is liable or prior to date of
proof of change in occupation with the state official having
supervision of insurance in the state where the insured resided at
the time this policy was issued; but if such filing was not
required, then the classification of occupational risk and the
premium rates shall be those last made effective by the insurer in
such state prior to the occurrence of the loss or prior to the date
of proof of change in occupation."
(b) A provision as follows:
"Misstatement of Age: If the age of the insured has been
misstated, all amounts payable under this policy shall be such as
the premium paid would have purchased at the correct age."
(c) A provision as follows:
"Other Insurance in This Insurer: If an accident or sickness or accident and sickness policy or policies previously issued by
the insurer to the insured be in force concurrently herewith,
making the aggregate indemnity for ____________ (insert type of
coverage or coverages) in excess of $____________ (insert maximum
limit of indemnity or indemnities) the excess insurance shall be
void and all premiums paid for such excess shall be returned to the
insured or to his estate."
Or, in lieu thereof:
"Insurance effective at any one time on the insured under a
like policy or policies in this insurer is limited to the one such
policy elected by the insured, his beneficiary or his estate, as
the case may be, and the insurer will return all premiums paid for
all other such policies."
Provided that no policy hereafter issued for delivery in this
state which provides, with or without other benefits, for the
payment of benefits or reimbursement for expenses with respect to
hospitalization, nursing care, medical or surgical examination or
treatment, or ambulance transportation shall contain any provision
for a reduction of such benefits or reimbursement, or any provision
for avoidance of the policy, on account of other insurance of such
nature carried by the same insured with the same or another insurer.
(d) A provision as follows:
"Insurance with Other Insurers: If there be other valid
coverage, not with this insurer, providing benefits for the same
loss on other than an expense incurred basis and of which this
insurer has not been given written notice prior to the occurrence
or commencement of loss, the only liability for such benefits under
this policy shall be for such proportion of the indemnities
otherwise provided hereunder for such loss as the like indemnities
of which the insurer had notice (including the indemnities under
this policy) bear to the total amount of all like indemnities for
such loss, and for the return of such portion of the premium paid
as shall exceed the pro rata portion for the indemnities thus
determined."
The insurer may, at its option, include in this provision a
definition of "other valid coverage," approved as to form by the
commissioner, which definitions shall be limited in subject matter
to coverage provided by organizations subject to regulations by
insurance law or by insurance authorities of this or any other
state of the United States or any province of Canada, and to any
other coverage the inclusion of which may be approved by the commissioner. In the absence of such definition such term shall
not include group insurance, or benefits provided by union welfare
plans or by employer or employee benefit organizations. For the
purpose of applying the foregoing policy provisions with respect to
any insured any amount of benefit provided for such insured
pursuant to any compulsory benefit statute (including any workers'
compensation or employer's liability statute) whether provided by
a governmental agency or otherwise shall in all cases be deemed to
be "other valid coverage" of which the insurer has had notice. In
applying the foregoing policy provision no third party liability
coverage shall be included as "other valid coverage."
(e) A provision as follows:
"Relation of Earnings to Insurance: If the total monthly
amount of loss of time benefits promised for the same loss under
all valid loss of time coverage upon the insured, whether payable
on a weekly or monthly basis, shall exceed the monthly earnings of
the insured at the time disability commenced or his average monthly
earnings for the period of two years immediately preceding a
disability for which claim is made, whichever is the greater, the
insurer will be liable only for such proportionate amount of such
benefits under this policy as the amount of such monthly earnings or such average monthly earnings of the insured bears to the total
amount of monthly benefits for the same loss under all such
coverage upon the insured at the time such disability commences and
for the return of such part of the premiums paid during such two
years as shall exceed the pro rata amount of the premiums for the
benefits actually paid hereunder; but this shall not operate to
reduce the total monthly amount of benefits payable under all such
coverage upon the insured below the sum of two hundred dollars or
the sum of the monthly benefits specified in such coverages,
whichever is the lesser, nor shall it operate to reduce benefits
other than those payable for loss of time."
The insurer may, at its option, include in this provision a
definition of "valid loss of time coverage," approved as to form by
the commissioner, which definition shall be limited in subject
matter to coverage provided by governmental agencies or by
organizations subject to regulation by insurance law or by
insurance authorities of this or any other state of the United
States or any province of Canada, or to any other coverage the
inclusion of which may be approved by the commissioner or any
combination of such coverages. In the absence of such definition
such term shall not include any coverage provided for such insured pursuant to any compulsory benefit statute (including any workers'
compensation or employer's liability statute), or benefits provided
by union welfare plans or by employer or employee benefit
organizations.
(f) A provision as follows:
"Unpaid Premium: Upon the payment of a claim under this
policy, any premiums then due and unpaid or covered by any note or
written order may be deducted therefrom."
(g) A provision as follows:
"Return of Premium on Cancellation: If the insured cancels
this policy, the earned premium shall be computed by the use of the
short-rate table last filed with the state official having
supervision of insurance in the state where the insured resided
when the policy was issued. Cancellation shall be without
prejudice to any claim originating prior to the effective date of
cancellation."
(h) A provision as follows:
"Conformity with State Statutes: Any provision of this policy
which, on its effective date, is in conflict with the statutes of
the state in which the insured resides on such date is hereby
amended to conform to the minimum requirements of such statutes."
(i) A provision as follows:
"Illegal Occupation: The insurer shall not be liable for any
loss to which a contributing cause was the insured's commission of
or attempt to commit a felony or to which a contributing cause was
the insured's being engaged in an illegal occupation."
(j) A provision as follows:
"Intoxicants and Narcotics: The insurer shall not be liable
for any loss sustained or contracted in consequence of the
insured's being intoxicated or under the influence of any narcotic
unless administered on the advice of a physician: Provided, That
this provision may not be used with respect to a medical expense
policy. For purposes of this subsection, a "medical expense
policy" means an accident and sickness insurance policy that
provides hospital, medical and surgical expense coverage."
NOTE: The purpose of this bill is to
prohibit the exclusion
of treatment for intoxication as a medical expense under accident
and sickness insurance policies.
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
be added.