After the termination of extended basic hospital, surgical or medical expense coverage, extended major medical expense coverage shall cover expenses eligible under the major medical expense coverage which are normally covered under the basic coverage, subject to subd. 1.
A policy providing hospital, surgical or medical expense coverage which covers only expenses in excess of those covered by basic hospital-surgical-medical expense coverage and major medical coverage or comprehensive medical coverage, issued to the same group policyholder, need not provide extended coverage if the underlying coverage provides extended coverage.
Ins 6.51 Note
The effect of sub. (6) (d), with respect to pregnancy expense coverage, is to require that extended coverage provide benefits only for pregnancy complication expenses, to be consistent with s. Ins 6.55 (4) (b) 5.
However, employers and insurers may wish to consider the provisions of federal public law 95-555 enacted October 31, 1978, which requires that employers subject to it provide benefits for pregnancy, including extended benefits, under employee benefit programs to the same extent that benefits are provided for injury and sickness. Also, the equal rights division of the Wisconsin department of workforce development has taken the position, based on Wisconsin case law, that the Wisconsin fair employment act, ss. 111.31
, Stats., applies to temporary disability resulting from pregnancy and requires that employee benefit programs provide loss of time benefits for temporary disability resulting from pregnancy, including extended benefits, to the same extent that such benefits are provided for injury and sickness.
A provision for extending coverage shall be contained in each group policy as well as in corresponding certificates.
The benefits payable during any period of extended coverage shall be subject to the group policy's regular coverage limits. The extended coverage shall terminate at the end of a normal benefit period or when the maximum benefit amount has been paid.
Liability of prior insurer.
The prior insurer shall be liable only to the extent of its extensions of coverage. Its liability shall be the same whether the group policyholder secures replacement coverage from another insurer, self-insures or declines to provide the group with insurance.
Liability of succeeding insurer.
The succeeding insurer shall be liable as provided in this paragraph where its group policy replaces another providing similar coverage:
(a) Regular coverage.
Regular coverage shall be provided under the succeeding insurer's group policy to:
Each employee who is eligible for coverage in accordance with the succeeding insurer's group policy provisions regarding classes eligible and actively at work requirements.
Each dependent who is eligible for coverage in accordance with the succeeding insurer's group policy provisions regarding classes eligible and non-hospital confinement requirements.
A dependent of a disabled employee if the dependent is eligible for coverage in accordance with the succeeding insurer's group policy provisions regarding classes eligible and non-hospital confinement requirements and if the disabled employee is covered under the succeeding insurer's group policy, and
(b) Temporary coverage.
Each employee or dependent not covered under the succeeding insurer's group policy in accordance with par. (a)
shall be provided with temporary coverage by the succeeding insurer, for losses occurring or beginning under the replacement policy, subject to:
Temporary coverage need be provided only if the individual was validly covered under the prior group policy on the date of its termination and meets the requirements necessary to be a member of an eligible class under the succeeding insurer's group policy, other than requirements for working full time, part time or a stated number of hours.
The coverage to be provided by the succeeding insurer shall be the coverage of the prior group policy reduced by any benefits payable under such policy. The benefits of the succeeding insurer's group policy shall be determined after the benefits of the prior group policy have been determined.
Temporary coverage shall be provided by the succeeding insurer until the first of:
The date the individual becomes eligible under the coverage and under the circumstances described in par. (a)
For each type of coverage, the date the individual's coverage would terminate in accordance with the succeeding insurer's group policy provisions regarding individual termination of coverage, such as at termination of employment or when ceasing to be an eligible dependent.
For an individual who is totally disabled on the effective date of the succeeding group policy, under a type of coverage for which sub. (6)
requires an extension of coverage, the end of any period of extended coverage required of the prior insurer or, if the prior insurer's group policy was not subject to sub. (6)
, would have been required of the prior insurer had its group policy been so subject.
(c) Pre-existing conditions.
If the succeeding insurer's group policy contains a pre-existing condition limitation, the coverage for these conditions of persons becoming covered by the succeeding group policy under par. (a)
, during the period the limitation applies under that group policy, shall be the lesser of:
The coverage of the succeeding group policy determined without application of the limitation and
The coverage of the prior group policy determined after application of any such limitation contained in the policy.
(d) Deductibles and waiting periods.
The succeeding insurer, in applying any deductibles or waiting periods contained in its group policy, including pre-existing condition waiting periods, shall give credit for the satisfaction or partial satisfaction of the same or similar provisions under the prior group policy, to the extent that the prior and succeeding group policies provide similar coverage. Deductible provision credit shall be given for the same or overlapping benefit periods for expenses incurred and applied against the deductible provisions of the prior group policy during the 90 days preceding the effective date of the succeeding group policy, but only to the extent that these expenses are recognized under the succeeding group policy and are subject to a similar deductible provision.
(e) Determination of prior insurer's coverage.
Where a determination of the prior insurer's coverage is required by the succeeding insurer, the prior insurer, at the succeeding insurer's request, shall furnish a statement of the coverage available and a copy of pertinent group policy provisions to permit the succeeding insurer to verify the coverage statement or make its own coverage determination. Coverage of the prior group policy shall be determined in accordance with the definitions, conditions and covered expense provisions of that group policy rather than those of the succeeding group policy. The coverage determination shall be made as if coverage had not been replaced by the succeeding insurer.
More favorable provisions permitted.
This section sets out minimum requirements. It does not prohibit a group policyholder and an insurer from agreeing to policy provisions which are more favorable to insured persons.
As provided in s. 227.22
, Stats., this section shall take effect on the first day of the month following its publication.
Ins 6.51 History
Cr. Register, October, 1972, No. 202
, eff. 11-1-72; emerg. am. (1) and (2), eff. 6-22-76; am. (1) and (2), Register, September, 1976, No. 249
, eff. 10-1-76; am. (1), (2) and (7) (c), Register, March, 1979, No. 279
, eff. 4-1-79; r. and recr., Register, March 1982, No. 315
, eff. 4-1-82; am. (2), Register, April, 1988, No. 388
, eff. 5-1-88; corrections in (7) made under s. 13.93 (2m) (b) 1. and 7., Stats., Register, June, 1997, No. 498
; corrections in (3) (a) and (9) made under s. 13.93 (2m) (b) 7., Stats., Register, February, 2000, No. 530
; corrections in (7m) (b) (intro.), 3. a. and (c) (intro.) made under s. 13.93 (2m) (b) 7., Stats., Register October 2006 No. 610
Biographical data relating to company officers and directors. Ins 6.52(1)(1)
This rule is intended to implement and interpret ss. 611.13 (2)
, 611.54 (1) (a)
, 618.11 (4)
and 618.21 (1) (b)
, Stats., for the purpose of setting standards for the reporting of biographical data relating to company officers, directors, promoters and incorporators, or other persons similarly situated.
This rule shall apply to all persons proposing to form an insurer under the laws of this state and to all nondomestic insurers applying for admission to this state and to all insurers authorized to do business in this state except as follows:
Nonprofit service plans, cooperative sickness care plans organized or operating under ss. 185.981
, Stats., voluntary benefit plans organized or operating under s. 185.991
, 1977 Stats., and motor club service companies organized or operating under ss. 616.71
, Stats., and donor annuity societies.
Report of organization of a domestic insurer or admission of a nondomestic insurer.
Biographical information in form and substance substantially in accordance with Form A, shown at the end of this rule, shall be furnished to the commissioner of insurance by all promoters, incorporators, directors, trustees and principal officers or proposed directors and principal officers, as the case may be, of an insurer being organized or of an insurer applying for admission. Financial and character reports of any such persons may be ordered by the commissioner and the cost or expense of such reports shall be paid by the incorporators as an organization expense or by the insurer applying for admission.
The term “officer" as used in this rule shall include the president, one or more vice presidents, secretary, treasurer, chief actuary, general counsel, comptroller and any person, however described, who enjoys in fact the executive authority of any such officers.
Reporting with respect to new officers and directors subsequent to organization or admission.
A report shall be provided by each domestic insurer to which this rule applies with respect to the appointment or election of any new director, trustee or officer elected or appointed within 15 days after such appointment or election. Such report shall be prepared by the company in form and substance substantially in accordance with Form A, shown at the end of this rule.
When such a report has been provided to the commissioner by a company in accordance with subs. (3)
of this rule, no further report concerning subsequent changes in his or her status as an officer or director of such company need be reported to the commissioner provided, however, the company shall promptly report to the commissioner any information concerning the conviction of an officer or director for a felony or the naming of a director, trustee or officer, other than as a party plaintiff or complainant, in any criminal action or in a civil action in which fraud was an issue.
The commissioner may request from any company such additional information with respect to any of its officers or directors as he or she may deem necessary and such request shall be promptly complied with by the company to which such request is directed.
STATEMENT OF EDUCATION, PRIOR OCCUPATION,
BUSINESS EXPERIENCE AND SUPPLEMENTARY
STATE OF :ss:
COUNTY OF :
The undersigned, being first duly sworn upon oath deposes and says:
1. The affiant's full name is (initials not acceptable):
2. The affiant's official title and principal duties with the insurance company is or will be:
3. The affiant's business address is:
4. The affiant's residence address is:
5. The affiant's age is:
Birthdate Social Security No.
6. The affiant was never known by any other name(s) other than that shown above, except as follows (state such other name(s), when used, reason for change, and date of adoption of present name):
7. The affiant will subscribe to or owns, beneficially or of record the following amount of shares of stock of the insurance company and the consideration given for same:
8. The affiant states that his or her capital investment in the insurance company was not obtained from borrowed funds, except as follows:
9. The nature and tenure of each occupation or employment of the affiant for the last ten years prior to the date of this statement is as follows (present a continuous schedule, including time spent at educational institutions, and period of employment):
- See PDF for table
10. The affiant's educational history is as follows (include all schools attended of the college or graduate level):
- See PDF for table
11. The affiant has never been convicted of a felony, except as follows:
12. The affiant has never been named in a criminal or civil action in which fraud was an issue, except as follows:
13. The affiant is not an officer or director and has no other relationship with any other insurer which has the effect of lessening competition substantially or in which such insurers have material adverse interests except as follows:
(Signature of Affiant)
Subscribed and sworn before me,
a Notary Public, this day of , 2 ,
My commission expires:
Ins 6.52 History
Cr. Register, June, 1973, No. 210
, eff. 7-1-73; emerg. r. (2) (a), eff. 6-22-76; r. (2) (a), Register, September, 1976, No. 249
, eff. 10-1-76; am. (2) (c), Register, March, 1979, No. 279
, eff. 4-1-79; am. (5), Register, March, 1981, No. 303
, eff. 4-1-81; CR 17-015
: am. (5), r. Form B Register December 2017 No. 744
, eff. 1-1-18.
Prohibited classification of risks for rating purposes. Ins 6.54(2)
This rule applies to all contracts issued, renewed or amended in Wisconsin affording automobile insurance coverage and all contracts issued, renewed or amended in Wisconsin affording coverage for loss or damage to real property used for residential purposes for not more than 4 living units or affording coverage for loss or damage to personal property used for residential purposes.
No insurance company shall refuse, cancel or deny insurance coverage to a class of risks solely on the basis of any of the following factors (taken individually or in combination), nor shall it place a risk in a rating classification on the basis of any of the following factors without credible information supporting such a classification and demonstrating that it equitably reflects differences in past or expected losses and expenses and unless such information is filed in accordance with ss. 625.12
and 625.21 (2)
Nothing in par. (a)
shall be construed as including within the definition of prohibited practices any of the following:
Denying, cancelling or non-renewing the automobile or property insurance of a person convicted of an offense if the offense which resulted in the conviction is directly related to the risk to be insured;
Establishing a classification system merely for the purpose of developing statistical data;
Underwriting only the class of risks which are specified in the insurer's articles of incorporation;
Establishing a rate based on the record of all drivers of an insured automobile;
Establishing a rate based on the number of people residing in a household.
No insurer shall require an applicant or insured to undergo a physical examination to obtain or continue coverage unless the cost of such physical examination is borne by the insurer.
Violation of this rule may subject the insurer to the penalties set forth in s. 601.64
Ins 6.54 History
Cr. Register, March, 1976, No. 243
, eff. 4-1-76; emerg. am. (1) and (3) (c), eff. 6-22-76; am. (1) and (3) (c), Register, September, 1976, No. 249
, eff. 10-1-76; am. (3) (a) 2., Register, April, 1977, No. 256
, eff. 5-1-77; am. (3) (a) 2., and cr. (3) (d), Register, March, 1979, No. 279
, eff. 4-1-79; corrections in (1) and (3) (c) made under s. 13.93 (2m) (b) 7., Stats., Register, February, 2000, No. 530
; correction in (3) (c) made under s. 13.93 (2m) (b) 7., Stats., Register January 2002 No. 553
Discrimination based on sex, unfair trade practice. Ins 6.55(1)(1)
The purpose of this rule is to eliminate the act of denying benefits or refusing coverage on the basis of sex, to eliminate unfair discrimination in underwriting criteria based on sex, and to eliminate any differences in rates based on sex which cannot be justified by credible supporting information. This rule interprets and implements s. 601.01 (3)
, Stats., and ch. 628
Insurer has the meaning defined in s. 600.03 (27)
, Stats., and in addition includes nonprofit service plans or service insurance corporations.
Contract means any insurance policy, plan, certificate, subscriber agreement, statement of coverage, binder, rider or endorsement offered by an insurer subject to Wisconsin insurance law.
This rule shall apply to all contracts delivered in Wisconsin, or issued for delivery in Wisconsin on or after the effective date of this rule and to all existing group contracts subject to Wisconsin insurance law which are amended or renewed on or after the effective date of this rule.
This rule shall not affect the right of fraternal benefit societies to determine eligibility requirements for membership.