No group policy or individual policy which provides coverage to dependent children of the group member or insured may deny eligibility for coverage to any child, or set a premium for any child which is different from that which is set for other dependent children, based solely on any of the following:
The fact that the child does not reside with the group member or insured or is dependent on another parent rather than the group member or insured.
The proportion of the child's support provided by the group member or insured.
The fact that the group member or insured does not claim the child as an exemption for federal income tax purposes under 26 USC 151
(c), or as an exemption for state income tax purposes under s. 71.07 (8) (b)
or under the laws of another state, if a court order under s. 767.513
or the laws of another state assigns responsibility for the child's health care expenses to the group member or insured.
The fact that the child resides outside the insurer's geographical service area.
If a court orders an individual to provide coverage for health care expenses for a child of the individual and the individual is eligible for family coverage under a group policy or individual policy, the insurer shall do all of the following:
Provide family coverage under the group policy or individual policy for the individual's child, if eligible for coverage, without regard to any enrollment period restrictions that may apply under the policy.
Provide family coverage under the group policy or individual policy for the individual's child, if eligible for coverage, upon application by the individual, the child's other parent, the department of children and families or the county child support agency under s. 59.53 (5)
After the child is covered under the group policy or individual policy, and as long as the individual is eligible for family coverage under the policy, continue to provide coverage for the child unless the insurer receives satisfactory written evidence that the court order is no longer in effect or that the child has coverage under another group policy or individual policy that provides comparable health care coverage.
do not prohibit an insurer from determining the eligibility of a group member's or insured's child for coverage under the group policy or individual policy, or the premium for that coverage, based on factors that are not prohibited by par. (a) 1.
and that the insurer applies generally to determine the eligibility of children for coverage, and the premium for coverage, under the group policy or individual policy.
If an insurer provides coverage under a group policy or an individual policy for a child of a group member or an insured who is not the custodial parent of the child, the insurer shall do all of the following:
Provide to the custodial parent of the child information related to the child's enrollment.
Permit the custodial parent of the child, a health care provider that provides services to the child or the department of health services to submit claims for covered services without the approval of the parent who is the group member or insured.
Pay claims directly to the health care provider, the custodial parent of the child or the department of health services, as appropriate.
This subsection applies to any group policy that would otherwise be exempt under s. 600.01 (1) (b) 3.
if at least 25 of the certificate holders or insureds are residents of this state.
Notwithstanding subs. (2)
, the commissioner may promulgate rules establishing standards requiring insurers to provide continuation of coverage for any individual covered at any time under a group policy who is a terminated insured or an eligible individual under any federal program that provides for a federal premium subsidy for individuals covered under continuation of coverage under a group policy, including rules governing election or extension of election periods, notice, rates, premiums, premium payment, application of preexisting condition exclusions, election of alternative coverage, and status as an eligible individual, as defined in s. 149.10 (2t)
, 2011 stats.
The commissioner may promulgate the rules under par. (a)
as emergency rules under s. 227.24
. Notwithstanding s. 227.24 (1) (c)
, emergency rules promulgated under this paragraph may remain in effect for one year and may be extended under s. 227.24 (2)
. Notwithstanding s. 227.24 (1) (a)
, the commissioner is not required to provide evidence that promulgating a rule under this paragraph as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to provide a finding of emergency for a rule promulgated under this paragraph.
See s. 49.45 (20)
concerning exemption from continuation of group coverage.
See also ss. Ins 3.41
, and 6.51
, Wis. adm. code.
The federal employee retirement income security act (ERISA) preempts any state law that relates to employee benefit plans. General Split Corp. v. Mitchell, 523 F. Supp. 427
Wisconsin health insurance continuation/conversion law. Michal, WBB February 1982.
Prohibiting abortion coverage. 632.8985(2)
A qualified health plan, as defined in 42 USC 18021
(a), that is offered through any American health benefit exchange, as described in 42 USC 18031
, that is operating in the state may not cover any abortion the performance of which is ineligible for funding under s. 20.927
History: 2011 a. 218
Medical savings accounts study.
If the federal government enacts legislation providing for a federal income tax exemption for amounts deposited in a medical savings account and for any interest, dividends or other gain that accrues in the account if redeposited in the account, the commissioner shall conduct a study, to be completed within 4 years after the enactment of the federal legislation, of individuals and groups that had coverage under a high cost-share health plan, as defined in s. 632.898 (1) (c)
, 1995 stats., and that terminated that coverage in order to enroll in a health benefit plan that was not a high cost-share health plan, as defined in s. 632.898 (1) (c)
, 1995 stats. The commissioner shall submit a report of all findings, conclusions and recommendations to the appropriate standing committees in the manner provided under s. 13.172 (3)
History: 1997 a. 27
; 2007 a. 96
Subch. VII of ch. 632 Cross-reference
See also ch. Ins 1
, Wis. adm. code.
In this subchapter:
“Insured employee" means an employee of a fraternal or of a subsidiary or other affiliate of a fraternal who is provided insurance benefits by the fraternal under s. 614.10 (2) (c) 2.
but is not a member of the fraternal.
“Owner" means the owner of a policy or certificate issued by a fraternal in accordance with s. 614.10
The fraternal contract. 632.93(1)(1)
Issuance of certificate.
A fraternal shall issue to each owner a policy or certificate specifying the benefits provided and containing at least in substance all sections of the laws of the fraternal which might result in the termination of coverage or the reduction of benefits. The policy or certificate, any riders or endorsements attached thereto, the laws of the fraternal, and the application and declarations made in connection therewith and signed by the applicant, constitute the agreement between the fraternal and the owner, and the policy or certificate shall so state.
(2) Changes in laws of fraternals.
Except as provided in s. 614.24 (1m)
, any changes in the laws of a fraternal made subsequent to the issuance of a policy or certificate bind the owner and any beneficiary under the policy or certificate as if they had been in force at the time of the application, so long as they do not destroy or diminish benefits promised in the policy or certificate.
(3) Proof of terms.
Copies of any documents mentioned in subs. (1)
, certified by the secretary or corresponding officer of the fraternal, are evidence of the terms and conditions of the contract.
(5) Grace period.
Every fraternal certificate shall contain a provision entitling the owner to a grace period of not less than one month, or 30 days at the fraternal's option, for the payment of any premium due except the first, during which the death benefit shall continue in force. A fraternal may specify in the grace period provision that the overdue premium will be deducted from the death benefit in the event of death before it is paid.
(6) Compliance with other provisions.
If a fraternal's laws provide for expulsion or suspension of a member for any reason other than nonpayment of premium or under s. 632.46
, the fraternal's insurance certificate shall contain a provision that if a member is expelled or suspended for any reason other than nonpayment of premium or under s. 632.46
, the expelled member, or other owner who was provided insurance benefits under s. 614.10
on the application of the expelled member, has the right to maintain the policy in force by continuing payment of the required premium.
(7) Scope of application.
This section applies to all contracts made by a fraternal beginning 6 months after December 18, 1979. A fraternal may elect to have this section apply at an earlier date, so long as it applies simultaneously to all such contracts and the fraternal gives the commissioner at least 30 days' notice of intention to adopt this section.
Fraud in obtaining membership.
Subject to s. 632.46
, any certificate of membership secured by misrepresentation in or with reference to any application for membership or documentary or other proof for the purpose of obtaining membership in or noninsurance benefit from the fraternal is void, if the fraternal relied on it and it is either material or fraudulent.
History: 1975 c. 373
Legislative Council Note, 1975: This section continues the contractual portion of s. 208.38, edited with a change in meaning, to include nonfraudulent but material misrepresentation, and also to subject the provision to the rule of incontestability provided in s. 632.46. [Bill 643-S]
Beneficiaries in fraternal contracts. 632.96(1)(1)
Any owner may designate as beneficiary any person permitted by the laws of the fraternal. Those laws shall authorize the designation of the estate of a member or insured employee as beneficiary.
Legislative Council Note, 1975: Sub. (1) states a rule slightly more restrictive of the range of permitted beneficiaries than for commercial life insurance; this reflects the nature of the fraternal. Sub. (2) applies the general provision for life insurance, subject to sub. (1). [Bill 643-S]
Application of proceeds of credit insurance policy.
Payment to a creditor of any amounts insured under the terms of a credit insurance policy reduces the debt proportionately. This rule does not apply to an insurance policy on which the debtor pays no part of the premium, directly or indirectly.
History: 1975 c. 375
Portable electronics insurance. 632.975(1)(a)
“Customer" means a person who purchases or leases a portable electronic device.
“Enrolled customer" means a customer who elects coverage under a portable electronics insurance policy issued to a vendor of portable electronics.
“Location" means any physical location in the state or any Internet site, call center site, or similar location directed to residents of the state.
“Portable electronics" or “portable electronic devices" means electronic devices that are portable in nature, including accessories and services related to the use of the device, and that have an insured value of less than $5,000.
“Portable electronics insurance" means insurance providing coverage for the repair or replacement of portable electronics that may provide coverage for a portable electronic device against any of the following causes of loss:
“Portable electronics insurance" does not include any of the following:
A service contract or extended warranty providing coverage limited to the repair, replacement, or maintenance of property for the operational or structural failure of property due to a defect in materials, workmanship, accidental damage from handling, power surges, or normal wear and tear.
A policy of insurance covering a vendor's or a manufacturer's obligations under a warranty.
A homeowner's, renter's, private passenger automobile, commercial multi-peril, or similar insurance policy.
“Portable electronics insurance program" means the coverage options made available to customers of a vendor who elect to enroll for coverage of a portable electronic device under a policy of portable electronics insurance.
“Portable electronics transaction" means the sale or lease of a portable electronic device to a customer.
“Supervising entity" means a business entity that is a licensed insurer or licensed intermediary that is appointed by an insurer to supervise the administration of a portable electronics insurance program offered by a vendor to its customers.
“Vendor" means a person in the business of engaging in portable electronics transactions directly or indirectly.
A vendor or an employee or authorized representative of a vendor may sell or offer portable electronics insurance to customers without holding a certificate of authority under s. 601.04
or a license as an intermediary only if all of the following apply:
The vendor complies with the requirements of this section.
The insurer issuing the portable electronics insurance either directly supervises, or appoints a supervising entity to supervise, the administration of the sale of portable electronics insurance, including development of a training program, as described under sub. (4)
, for employees and authorized representatives of the vendors.
The supervising entity, if any, maintains a registry of vendor locations at which an employee or authorized representative is authorized to sell or offer portable electronics insurance in this state. Upon request by the commissioner after providing 10 days' notice to the supervising entity, the supervising entity shall make available the registry for inspection and examination by the commissioner.
Any employee or authorized representative who intends to sell or offer portable electronics insurance to customers shall complete a training program under sub. (4)
No employee or authorized representative of a vendor of portable electronics may advertise, represent, or otherwise hold himself or herself out as a licensed insurance intermediary, if the employee or authorized representative does not hold a license as an intermediary in this state.
Compliance by a vendor with this section shall authorize any employee or authorized representative of a vendor to sell or offer coverage under a policy of portable electronics insurance to a customer at each location at which the vendor engages in portable electronics transactions.