Senate
House
Joint
Bill Status
WV Code
Audits/ Reports
Educational
Contact
home
home

West Virginia Code

Search

Chapter 33     Entire Code
‹ Chapter 32B  |  Chapter 34 › Printer Friendly Versions
Chapter 33  |  Article 33 - 16A

1 - DEFINITIONS

2 - INSURANCE COMMISSIONER

3 - LICENSING, FEES AND TAXATION OF

3A - STATE OF ENTRY FOR FOREIGN INS

4 - GENERAL PROVISIONS

4A - ALL-PAYER CLAIMS DATABASE

5 - ORGANIZATION AND PROCEDURES OF

6 - THE INSURANCE POLICY

6A - CANCELLATION OR NONRENEWAL OF

6B - DECLINATION OF AUTOMOBILE LIAB

6C - GUARANTEED LOSS RATIOS AS APPL

6D - MOTOR VEHICLE REPAIR AND REPLA

6F - DISCLOSURE OF NONPUBLIC PERSON

7 - ASSETS AND LIABILITIES

8 - INVESTMENTS

8A - USE OF CLEARING CORPORATIONS A

9 - ADMINISTRATION OF DEPOSITS

10 - REHABILITATION AND LIQUIDATIO

11 - UNFAIR TRADE PRACTICES

11A - INSURANCE SALES CONSUMER PRO

12 - INSURANCE PRODUCERS AND SOLIC

12A - CONTRACTUAL RELATIONSHIPS BE

12B - ADJUSTERS

12C - SURPLUS LINE

13 - LIFE INSURANCE

13A - VARIABLE CONTRACTS

13B - CHARITABLE GIFT ANNUITIES

13C - VIATICAL SETTLEMENTS ACT

14 - GROUP LIFE INSURANCE

15 - ACCIDENT AND SICKNESS INSURAN

15A - WEST VIRGINIA LONG-TERM CARE

15B - UNIFORM HEALTH CARE ADMINIST

15C - DIABETES INSURANCE

15D - INDIVIDUAL LIMITED HEALTH BE

15E - DISCOUNT MEDICAL PLAN ORGANI

16 - GROUP ACCIDENT AND SICKNESS I

16B - ACCIDENT AND SICKNESS RATES

16C - EMPLOYER GROUP ACCIDENT AND

16D - MARKETING AND RATE PRACTICES

16E - CONTRACEPTIVE COVERAGE

16F - GROUP LIMITED HEALTH BENEFIT

16G - WEST VIRGINIA HEALTH BENEFIT

16H - REVIEW OF ADVERSE DETERMINAT

17 - FIRE AND MARINE INSURANCE

17A - PROPERTY INSURANCE DECLINATI

18 - CASUALTY INSURANCE

19 - SURETY INSURANCE

20 - RATES AND RATING ORGANIZATION

20A - WEST VIRGINIA ESSENTIAL INSU

20B - RATES AND MALPRACTICE INSURA

20C - CANCELLATION OR NONRENEWAL O

20D - TAIL INSURANCE

20E - WEST VIRGINIA MEDICAL PROFES

20F - PHYSICIANS' MUTUAL INSURANCE

21 - RECIPROCAL INSURERS

22 - FARMERS' MUTUAL FIRE INSURANC

23 - FRATERNAL BENEFIT SOCIETIES

24 - HOSPITAL SERVICE CORPORATIONS

25 - HEALTH CARE CORPORATIONS

25A - HEALTH MAINTENANCE ORGANIZAT

25B - FEDERAL INSURANCE SUBSIDY FO

25C - HEALTH MAINTENANCE ORGANIZAT

25D - PREPAID LIMITED HEALTH SERVI

25E - PATIENTS' EYE CARE ACT

25F - COVERAGE FOR PATIENT COST OF

25G - PROVIDER SPONSORED NETWORKS

26 - WEST VIRGINIA GUARANTY ASSOCI

26A - WEST VIRGINIA LIFE AND HEALT

26B - WEST VIRGINIA HEALTH MAINTEN

27 - INSURANCE HOLDING COMPANY SYS

28 - INDIVIDUAL ACCIDENT AND SICKN

29 - LIFE AND ACCIDENT AND SICKNES

30 - MINE SUBSIDENCE INSURANCE

31 - CAPTIVE INSURANCE

31A - SPONSORED CAPTIVE INSURANCE

32 - RISK RETENTION ACT

33 - ANNUAL AUDITED FINANCIAL REPO

34 - ADMINISTRATIVE SUPERVISION

34A - STANDARDS AND COMMISSIONER'S

35 - CRIMINAL SANCTIONS FOR FAILUR

36 - BUSINESS TRANSACTED WITH PROD

37 - MANAGING GENERAL AGENTS

38 - REINSURANCE INTERMEDIARY ACT

39 - DISCLOSURE OF MATERIAL TRANSA

40 - RISK-BASED CAPITAL (RBC) FOR

41 - PRIVILEGES AND IMMUNITY

42 - WOMEN'S ACCESS TO HEALTH CARE

43 - INSURANCE TAX PROCEDURES ACT

44 - UNAUTHORIZED INSURERS ACT

45 - ETHICS AND FAIRNESS IN INSURE

46 - THIRD-PARTY ADMINISTRATOR ACT

46A - PROFESSIONAL EMPLOYER ORGANI

47 - INTERSTATE INSURANCE PRODUCT

48 - MODEL HEALTH PLAN FOR UNINSUR

WVC 33 - CHAPTER 33. INSURANCE.
WVC 33 - 16 A- ARTICLE 16A. GROUP HEALTH INSURANCE CONVERSION.

WVC 33 - 16 A- 1 §33-16A-1. Right of insured to convert from group coverage.
A group policy or group subscriber contract which provides hospital, surgical or major medical expense insurance, or any combination of these coverages, on an expense incurred basis, but not a policy which provides benefits for specific diseases or for accidental injuries only, shall provide that an employee or member whose insurance under the group policy or contract has been terminated for any reason, including discontinuance of the group policy in its entirety or of an insured class, who has been continuously insured under the group policy, or under any group policy providing similar benefits which it replaces, for at least three months immediately prior to termination, shall be entitled to have issued to him by the insurer a converted policy of health insurance. An employee or member shall not be entitled to have a converted policy issued to him if termination of his insurance under the group policy occurred because he failed to pay any required contribution, or the discontinued group coverage was replaced by similar group coverage within thirty-one days.

WVC 33 - 16 A- 2 §33-16A-2. Issuance of converted policy.
Issuance of a converted policy shall be subject to the following conditions:

(a) Written application for the converted policy shall be made and the first premium paid to the insurer not later than thirty-one days after termination of the group policy or contract.

(b) The converted policy shall be issued without evidence of insurability.

(c) The initial premium for the converted policy for the first twelve months and subsequent renewal premiums shall be determined in accordance with premium rates applicable to individually underwritten standard risks, to the age and class of risk of each person to be covered under the converted policy and to the type and amount of insurance provided. The experience under converted policies shall not be an acceptable basis for establishing rates for converted policies.

If an insurer experiences or incurs losses for a period of two years on conversion policies which exceed earned premiums by more than twenty percent, the insurer may file with the commissioner amended renewal rates for the subsequent year, which will produce a loss ratio of not less than one hundred twenty percent.

Conditions pertaining to health shall not be an acceptable basis for classification for the purposes of this section. The frequency of premium payment shall be the frequency customarily required by the insurer for the policy form and plan selected: Provided, That the insurer shall not require premium payments less frequently than quarterly.

WVC 33 - 16 A- 3 §33-16A-3. Effective date of policy.
The effective date of the converted policy shall be the day following the termination of insurance under the group policy.

WVC 33 - 16 A- 4 §33-16A-4. Coverage of dependents.
The converted policy shall cover the employee or member and his dependents who were covered by the group policy on the date of termination of insurance. At the option of the insurer, a separate converted policy may be issued to cover any dependent.

WVC 33 - 16 A- 5 §33-16A-5. Persons for whom coverage not required.
The insurer shall not be required to issue a converted policy covering any person if such person is or could be covered by medicare (Title XVIII of the United State Social Security Act as supplemented by the Social Security Amendments of 1965 or as later amended or superseded). Furthermore, the insurer shall not be required to issue a converted policy covering any person if:

(a) (1) Such person is covered for similar benefits by another hospital, surgical, medical or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program; or

(2) Similar benefits are provided to such person, pursuant to or in accordance with the requirements of any state or federal law; and

(b) The benefits provided under the sources referred to in (1) above for such person or benefits provided under the sources referred to in (2) above for such person, together with the benefits provided by the converted policy, would result in overinsurance according to the insurer's standards. The insurer's standards must bear some reasonable relationship to actual health care costs in the area in which the insured lives at the time of conversion and must be filed with the commissioner prior to their use in denying coverage.

WVC 33 - 16 A- 6 §33-16A-6. Inquiries by insurer.
A converted policy may include a provision whereby the insurer may request information in advance of any premium due date of such policy of any person covered thereunder as to whether (i) he is covered for similar benefits by another hospital, surgical, medical or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program, (ii) he is covered for similar benefits under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis, or (iii) similar benefits are provided for or available to such person, pursuant to or in accordance with the requirements of any state or federal law. The converted policy may provide that the insurer may refuse to renew the policy or the coverage of any person insured thereunder for the following reasons only:

(a) Either the benefits provided under the sources referred to in (i) and (ii) above for such person or benefits provided or available under the sources referred to in (iii) above for such person, together with the benefits provided by the converted policy, would result in overinsurance according to the insurer's standards on file with the commissioner or the converted policyholder fails to provide the requested information;

(b) Fraud or material misrepresentation in applying for any benefits under the converted policy;

(c) Eligibility of the insured person for coverage under medicare (Title XVIII of the United States Social Security Act as supplemented by the Social Security Amendments of 1965 or as later amended or superseded) or under any other state or federal law providing for benefits similar to those provided by the converted policy;

(d) Other reasons approved by the commissioner.

WVC 33 - 16 A- 7 §33-16A-7. Limits of coverage.
An insurer shall not be required to issue a converted policy which provides benefits in excess of those provided under the group policy from which conversion is made.

WVC 33 - 16 A- 8 §33-16A-8. Preexisting conditions; reduction of benefits.
The converted policy shall not exclude a preexisting condition not excluded by the group policy. However, the converted policy may provide that any hospital, surgical or medical benefits payable thereunder may be reduced by the amount of any such benefits payable under the group policy after the termination of the individual's insurance thereunder. The converted policy may also include provisions so that during the first policy year the benefits payable under the converted policy, together with the benefits payable under the group policy, shall not exceed those that would have been payable had the individual's insurance under the group policy remained in force and effect.

WVC 33 - 16 A- 9 §33-16A-9. Alternate plans of conversion coverage.
If the group insurance policy from which conversion is made insures the employee or member for basic hospital or surgical expense insurance, the employee or member shall be entitled to obtain a converted policy providing, at his option, coverage on an expense incurred basis under any one of the plans meeting the following requirements:

Plan A

(a) Hospital room and board daily expense benefits in a maximum dollar amount approximating the average semiprivate rate charged in metropolitan areas of this state, for a maximum duration of seventy days;

(b) Miscellaneous hospital expense benefits of a maximum amount of ten times the hospital room and board daily expense benefits; and

(c) Surgical operation expense benefits according to a surgical schedule consistent with those customarily offered by the insurer under group or individual health insurance policies and providing a maximum benefit of eight hundred dollars; or

Plan B

(a) Hospital room and board daily expense benefits in a maximum dollar amount equal to seventy-five percent of the maximum dollar amount determined for Plan A, for a maximum duration of seventy days;

(b) Miscellaneous hospital expense benefits of a maximum amount of ten times the hospital room and board daily expense benefits; and

(c) Surgical operation expense benefits according to a surgical schedule consistent with those customarily offered by the insurer under group or individual health insurance policies and providing a maximum benefit of six hundred dollars; or

Plan C

(a) Hospital room and board daily expense benefits in a maximum dollar amount equal to fifty percent of the maximum dollar amount determined for Plan A, for a maximum duration of seventy days;

(b) Miscellaneous hospital benefits of a maximum amount of ten times the hospital room and board daily expense benefits; and

(c) Surgical operation expense benefits according to a surgical schedule consistent with those customarily offered by the insurer under group or individual health insurance policies and providing a maximum benefit of four hundred dollars.

The maximum dollar amounts in Plan A shall be determined by the commissioner and may be redetermined by him from time to time as to converted policies issued subsequent to such redetermination. Such redetermination shall not be made more often than once in three years. The maximum dollar amounts in Plans A, B and C shall be rounded to the nearest multiple of ten dollars.

WVC 33 - 16 A- 10 §33-16A-10. Additional coverage.
If the group insurance policy from which conversion is made insures the employee or member for major medical expense insurance, the employee or member shall be entitled to obtain a converted policy providing catastrophic or major medical coverage under a plan meeting the following requirements:

(a) A maximum benefit at least equal to either, at the option of the insurer, (1) or (2) below:

(1) The smaller of the following amounts:

(A) The maximum benefit provided under the group policy.

(B) A maximum payment of two hundred fifty thousand dollars per covered person for all covered medical expenses incurred during the covered person's lifetime.

(2) The smaller of the following amounts:

(A) The maximum benefit provided under the group policy.

(B) A maximum payment of two hundred fifty thousand dollars for each unrelated injury or sickness.

(b) Payment of benefits at the rate of eighty percent of covered medical expenses which are in excess of the deductible, until twenty percent of such expenses in a benefit period reaches one thousand dollars, after which benefits will be paid at the rate of one hundred percent during the remainder of such benefit period. Payment of benefits for outpatient treatment of mental illness, if provided in the converted policy, may be at a lesser rate but not less than fifty percent.

(c) A deductible for each benefit period which, at the option of the insurer, shall be (1) the sum of the benefits deductible and one hundred dollars, or (2) the corresponding deductible in the group policy. The term "benefits deductible," as used herein, means the value of any benefits provided on an expense incurred basis which are provided with respect to covered medical expenses by any other hospital, surgical, or medical insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan, or any other plan or program whether on an insured or uninsured basis, or in accordance with the requirements of any state or federal law and, if pursuant to section eleven of this article, the converted policy provides both basic hospital or surgical coverage and major medical coverage, the value of such basic benefits.

If the maximum benefit is determined by (a) (2) above, the insurer may require that the deductible be satisfied during a period of not less than three months if the deductible is one hundred dollars or less, and not less than six months if the deductible exceeds one hundred dollars.

(d) The benefit period shall be each calendar year when the maximum benefit is determined by (a) (1) above or twenty-four months when the maximum benefit is determined by (a) (2) above.

(e) The term "covered medical expenses," as used above, shall include at least, in the case of hospital room and board charges, the lesser of the dollar amount in Plan A and the average semiprivate room and board rate for the hospital in which the individual is confined and twice such amount for charges in an intensive care unit. Any surgical schedule shall be consistent with those customarily offered by the insurer under group or individual health insurance policies and must provide at least a one thousand two hundred dollar maximum benefit.

WVC 33 - 16 A- 10 A §33-16A-10a. Continuum of care services.

If the group insurance policy from which conversion is made insures the employee or member for continuum of care services pursuant to article five-d, chapter sixteen of this code, the employee or member shall be entitled to obtain a converted policy providing benefits for continuum of care services to the same extent such benefits are provided in the group insurance policy: Provided, That any insurance carrier required to provide supplemental insurance coverage for continuum of care services hereunder shall not be required to expend funds for underwriting such supplemental coverage until the continuum of care board, in cooperation with the West Virginia state insurance commissioner, shall have completed a written master plan related to insurance coverage as set forth in section five, article five-d, chapter sixteen of the code of West Virginia, one thousand nine hundred thirty-one, as amended, including, but not limited to, the specific standards and coverages to be provided in such supplemental coverage: Provided, however, That a public hearing shall be held pursuant to the provisions of chapter twenty-nine-a of this code applicable to such proceedings prior to the considerations of the aforesaid plan by said board. The rates for continuum of care coverage shall accurately reflect the cost of such coverage and shall not be subsidized by the rate structure for any other coverage.

WVC 33 - 16 A- 11 §33-16A-11. Combined policy coverage.
The conversion privilege required by this article shall, if the group insurance policy insures the employee or member for basic hospital or surgical expense insurance as well as major medical expense insurance, make available the plans of benefits set forth in sections nine and ten of this article. At the option of the insurer, such plans or benefits may be provided under one policy.

The insurer may also, in lieu of the plans of benefits set forth in sections nine and ten of this article, provide a policy of comprehensive medical expense benefits without first dollar coverage. Said policy shall conform to the requirements of section ten of this article: Provided, That an insurer electing to provide such a policy shall make available a low deductible option, not to exceed one hundred dollars, a high deductible option between five hundred and one thousand dollars, and a third deductible option midway between the high and low deductible options.

The insurer may, at its option, also offer alternative plans for group health conversion in addition to those required by this article.

WVC 33 - 16 A- 12 §33-16A-12. Coverage following retirement.
In the event coverage would be continued under the group policy on an employee following his retirement, but prior to the time he is or could be covered by medicare, he may elect, in lieu of such continuation of group insurance, to have the same conversion rights as would apply had his insurance terminated at retirement by reason of termination of employment or membership.

The converted policy may provide for reduction of coverage on any person upon his eligibility for coverage under medicare or under any other state or federal law providing for benefits similar to those provided by the converted policy.

WVC 33 - 16 A- 13 §33-16A-13. Other conversion privileges.
Subject to the conditions set forth in the previous sections of this article, the conversion privilege shall also be available (a) to the surviving spouse, if any, at the death of the employee or member, with respect to the spouse and such children whose coverage under the group policy terminates by reason of such death, otherwise to each surviving child whose coverage under the group policy terminates by reason of such death, or, if the group policy provides for continuation of dependents coverage following the employee's or member's death, at the end of such continuation, (b) to the spouse of the employee or member upon termination of coverage of the spouse, while the employee or member remains insured under the group policy, by reason of ceasing to be a qualified family member under the group policy, with respect to the spouse and such children whose coverage under the group policy terminates at the same time, or (c) to a child solely with respect to himself upon termination of his coverage by reason of ceasing to be a qualified family member under the group policy, if a conversion privilege is not otherwise provided above with respect to such termination.

WVC 33 - 16 A- 14 §33-16A-14. Benefit levels; election to provide group coverage; notification of conversion privilege; policy delivered outside state.

(a) If the benefit levels required in section nine of this article exceed the benefit levels provided under the group policy, the conversion policy may offer benefits which are substantially similar to those provided under the group policy in lieu of those required in section nine.

(b) The insurer may elect to provide group insurance coverage in lieu of the issuance of a converted individual policy.

(c) The insurer, prior to terminating the policy for any reason, shall notify each employee or member, or such employee's or member's spouse, child or dependent entitled to the conversion privilege under this article, at least sixty days in advance of the termination, in writing, of the pending termination. The notice shall inform the employee or member of the conversion privilege provided in this article.

(d) A notification of the conversion privilege shall also be included in each certificate of coverage.

(e) A converted policy which is delivered outside this state must be on a form which could be delivered in such other jurisdiction as a converted policy had the group policy been issued in that jurisdiction.

WVC 33 - 16 A- 15 §33-16A-15. Child immunization services coverage.

All policies issued pursuant to this article shall cover the cost of child immunization services as described in section five, article three, chapter sixteen of this code, including the cost of the vaccine, if incurred by the health care provider, and all costs of vaccine administration. These services shall be exempt from any deductible, per-visit charge and/or copayment provisions which may be in force in these policies or contracts. This section does not require that other health care services provided at the time of immunization be exempt from any deductible and/or copayment provisions.

Note: WV Code updated with legislation passed through the 2013 1st Special Session
The WV Code Online is an unofficial copy of the annotated WV Code, provided as a convenience. It has NOT been edited for publication, and is not in any way official or authoritative.


Recent legislation affecting the Code

Citation Year/Session Short Title
§33 - 22 - 2 - (Amended Code)
SENATE BILL - 88
PASSED - Regular Session

SB88 ENR  (Uploaded - 03/25/2014)
Relating to claims for total loss and debris removal proceeds under farmers' mutual fire insurance companies
§33 - 49 - 1 - (New Code)
§33 - 49 - 2 - (New Code)
§33 - 49 - 3 - (New Code)
§33 - 49 - 4 - (New Code)
§33 - 49 - 5 - (New Code)
§33 - 49 - 6 - (New Code)
§33 - 49 - 7 - (New Code)
§33 - 49 - 8 - (New Code)
§33 - 49 - 9 - (New Code)
§33 - 49 - 10 - (New Code)
SENATE BILL - 621
PASSED - Regular Session

SB621 SUB1 ENR  (Uploaded - 03/25/2014)
Authorizing insurers offer flood insurance
§33 - 17 A- 4 - (Amended Code)
HOUSE BILL - 4204
PASSED - Regular Session

HB4204 SUB ENR  (Uploaded - 03/25/2014)
Relating to the nonrenewal or cancellation of property insurance coverage policies in force for at least four years
§33 - 37 - 2 - (Amended Code)
HOUSE BILL - 4359
PASSED - Regular Session

hb4359 ENR  (Uploaded - 03/25/2014)
Relating to licensure of managing general agents of insurers
§33 - 7 - 9 - (Amended Code)
§33 - 13 - 30 - (Amended Code)
HOUSE BILL - 4432
PASSED - Regular Session

HB4432 ENR SUB  (Uploaded - 03/25/2014)
Adopting Principle Based Reserving as the method by which life insurance company reserves are calculated
§33 - 3 - 14 D - (Amended Code)
HOUSE BILL - 2837
PASSED - Regular Session

HB2837 SUB ENR  (Uploaded - 05/07/2013)
Amending various provisions of the Code affecting the Treasurer's Office
Note: WV Code updated with legislation passed through the 2013 1st Special Session
The WV Code Online is an unofficial copy of the annotated WV Code, provided as a convenience. It has NOT been edited for publication, and is not in any way official or authoritative.
This Web site is maintained by the West Virginia Legislature's Office of Reference & Information.  |  Terms of Use  |   Web Administrator   |   © 2014 West Virginia Legislature ***