Ins 3.13(2)(g)(g) Surgical benefit provisions or schedules shall provide that the benefit for any covered surgical procedure not specifically listed in the schedule and not excluded by the provisions of the policy shall be determined by the company on a basis consistent with the benefit provided for a comparable listed procedure. Ins 3.13(2)(h)(h) A limited policy is one that contains unusual exclusions, limitations, reductions, or conditions of such a restrictive nature that the payments of benefits under such policy are limited in frequency or in amounts. All limited policies shall be so identified by having the words “THIS IS A LIMITED POLICY—READ IT CAREFULLY” imprinted or stamped diagonally across the face of the policy and the filing back, if any, in contrasting color from the text of the policy and in outline type not smaller than 18-point. When appropriate, these words may be varied by the insurer in a manner to indicate the type of policy; as for example, “THIS POLICY IS LIMITED TO AUTOMOBILE ACCIDENTS—READ IT CAREFULLY.” Without limiting the general definition above, policies of the following types shall be defined as “limited:” 1. School Accident, 2. Aviation Accident, 3. Polio, 4. Specified Disease, 5. Automobile Accident. Ins 3.13(2)(i)(i) If the policy excepts coverage while the insured is in military or naval service, the policy must provide for a refund of pro rata unearned premium upon request of the insured for any period the insured is not covered. However, if coverage is excluded only for loss resulting from military or naval service or war, the refund provision will not be required. This section shall not apply to non-cancellable policies or non-cancellable and guaranteed renewable policies or guaranteed renewable policies. Ins 3.13(2)(j)2.2. Have a caption or title which refers at least to the right to examine or to return the policy such as: “Right to Return Policy Within 10 Days of Receipt,” “Notice: Right to Return Policy,” “Right of Policy Examination,” “Right to Examine Policy,” “Right to Examine Policy for 10 Days,” “10 Day Right to Examine Policy,” “10 Day Right to Return Policy,” or “Notice of 10 Day Right to Return Policy,” or other wording, subject to approval by the commissioner, which is believed to be equally clear or more definite as to subject matter, and Ins 3.13(2)(j)3.3. Provide an unrestricted right to return the policy, within 10 days from the date it is received by the policyholder, to the issuer at its home or branch office, if any, or to the agent through whom it was purchased; except it shall provide an unrestricted right to return the policy within 30 days of the date it is received by the policyholder in the case of a Medicare supplement policy subject to s. Ins 3.39 (4), (4m), (4t), (5), (5m), (5t), and (6), issued pursuant to a direct response solicitation. Provision shall not be made to require the policyholder to set out in writing the reasons for returning the policy, to require the policyholder to first consult with an agent of the issuer regarding the policy, or to limit the reasons for return. Ins 3.13 NoteNote: Paragraph (j) was adopted to assist in the application of s. 204.31 (2) (a), Stats., to the review of accident and sickness policy and other contract forms. Those statutory requirements are presently included in s. 632.73, Stats. The original statute required that the provision of notice regarding the right to return the policy must be appropriately captioned or titled. Since the important rights given the insured are to examine the policy and to return the policy, the rule requires that the caption or title must refer to at least one of these rights—examine or return. Without such reference, the caption or title is not considered appropriate. Ins 3.13 NoteThe original statute permitted the insured to return the policy for refund to the home office or branch office of the insurer or to the agency with whom it was purchased. In order to assure the refund is made promptly, some insurers prefer to instruct the insured to return the policy to a particular office or agent for a refund. Notices or provisions with such requirements will be approved on the basis that the insurer must recognize an insured’s right to receive a full refund if the policy is returned to any other office or agent mentioned in the statute.
Ins 3.13 NoteAlso, the statute permits the insured to return a policy for refund within 10 days from the date of receipt. Some insurers’ notices or provisions regarding such right, however, refer to delivery to the insured instead of receipt by the insured or do not specifically provide for the running of the 10 days from the date the insured receives the policy. Notices or provisions containing such wording will be approved on the basis that the insurer will not refuse refund if the insured returns the policy within 10 days from the date of receipt of the policy.
Ins 3.13 NoteSections 632.73 (2m) and 600.03 (35) (e), as created by Chapter 82, Laws of 1981, provide for the right of return provisions in certain certificates of group Medicare supplement policies. Therefore, for purposes of this subparagraph, the word policy includes a Medicare supplement certificate subject to s. Ins 3.39 (4), (4m), (4t), (5), (5m), (5t), and (6). Ins 3.13(2)(k)(k) A policy which contains any provision under which the claimant may elect one benefit in lieu of another shall not limit to a specified period the time within which election may be made. Ins 3.13(3)(a)(a) A rider is an instrument signed by one or more officers of the insurer issuing the same to be attached to and form a part of a policy. All riders shall comply with the requirements of s. 204.31 (2) (a) 4., 1973 Stats. Ins 3.13(3)(b)(b) If the rider reduces or eliminates coverage of the policy, signed acceptance of the rider by the insured is necessary. However, signed acceptance of the rider is not necessary when the rider is attached at the time of the original issuance of the policy if notice of the attachment of the rider is affixed on the face and filing back, if any, in contrasting color, in not less than 12-point type. Such notice shall be worded in one of the following ways: “Notice! See Elimination Rider Attached”
“Notice! See Exclusion Rider Attached”
“Notice! See Exception Rider Attached”
“Notice! See Limitation Rider Attached”
A company may submit, subject to approval by the commissioner, other wording which it believes is equally clear or more definite as to subject matter.
Ins 3.13(3)(c)(c) An endorsement differs from a rider only in that it is applied to a policy by means of printing or stamping on the body of the policy. All endorsements shall comply with the requirements of s. 204.31 (2) (a) 4., 1973 Stats. Ins 3.13(3)(d)(d) If the endorsement reduces or eliminates coverage of the policy, signed acceptance of the endorsement by the insured is necessary. However, signed acceptance of the endorsement is not necessary when the endorsement is affixed at the time of the original issuance of the policy if notice of the endorsement is affixed on the face and filing back, if any, in contrasting color, in not less than 12-point type. Such notice shall be worded in one of the following ways: “Notice! See Elimination Endorsement Included Herein”
“Notice! See Exclusion Endorsement Included Herein”
“Notice! See Exception Endorsement Included Herein”
“Notice! See Limitation Endorsement Included Herein”
“Notice! See Reduction Endorsement Included Herein”
A company may submit, subject to approval by the commissioner, other wording which it believes is equally clear or more definite as to subject matter.