Ins 3.27(5)(m)(m) An individual policy issued on a group basis means an individual policy or contract issued where:
Ins 3.27(5)(m)1.1. Coverage is provided to employees or members or classes thereof defined in terms of conditions pertaining to employment or membership in an association or other group which is eligible for franchise or group insurance as provided in s. 600.03 (22) and (23), Stats.,
Ins 3.27(5)(m)2.2. The coverage is not available to the general public and can be obtained and maintained only because of the covered person’s membership in or connection with the group,
Ins 3.27(5)(m)3.3. Premiums or subscription charges are paid to the insurer by the employer, association or some designated person acting on behalf of the employer, association or covered persons, and
Ins 3.27(5)(m)4.4. The insurance plan is sponsored by the employer or association.
Ins 3.27(6)(6)Advertisements and representations in general.
Ins 3.27(6)(a)(a) Advertisements and representations shall be truthful and not misleading in fact or in implication and shall accurately describe the policy to which they apply. Words or phrases the meaning of which is clear only by implication or by familiarity with insurance terminology shall not be used.
Ins 3.27(6)(b)(b) Oral representations shall conform to the requirements of this rule.
Ins 3.27(7)(7)Suitability of policies. No agent or insurer shall recommend to a prospective buyer the purchase of any individual policy without reasonable grounds to believe that the recommendation is not unsuitable to the applicant. The agent or insurer shall make such inquiry as may be necessary under the circumstances to determine that the purchase of such insurance is not unsuitable for the prospective buyer. This requirement shall not apply to an individual policy issued on a group basis.
Ins 3.27(8)(8)Outline of coverage.
Ins 3.27(8)(a)(a) Every advertisement of a specific individual policy or policies which constitutes an invitation to apply shall include an outline of coverage as defined in sub. (5) (L).
Ins 3.27(8)(b)(b) Every agent at the time of taking an application for an individual policy shall furnish the applicant an outline of coverage as defined in sub. (5) (L).
Ins 3.27(8)(c)(c) The requirement for an outline of coverage shall not apply to an advertisement or the taking of an application for an individual policy issued on a group basis or an individual conversion policy issued under a group or franchise insurance plan.
Ins 3.27(9)(9)Deceptive words, phrases or illustrations.
Ins 3.27(9)(a)(a) An advertisement shall not exaggerate a benefit or minimize cost by overstatement, understatement or incompleteness. Information shall not be omitted or words, phrases, statements, references or illustrations shall not be used if such omission or use has the capacity and tendency or effect of misleading or deceiving purchasers or prospective purchasers as to the nature or extent of any policy benefit payable, loss covered or premium payable. An advertisement referring to any policy benefit payable, loss covered or premium payable shall be sufficiently complete and clear as to avoid deception or the capacity and tendency to mislead or deceive.
Ins 3.27(9)(b)(b) The words and phrases “all,” “full,” “complete,” “comprehensive,” “unlimited,” “up to,” “as high as,” “this policy will pay your hospital and surgical bills,” “this policy will fill the gaps under Medicare and your present insurance” or “this policy will replace your income,” or similar words and phrases shall not be used so as to exaggerate any benefit beyond the terms of the policy, but may be used only in such manner as fairly to describe such benefit.
Ins 3.27(9)(c)(c) A policy covering only one disease or a list of specified diseases shall not be advertised so as to imply coverage beyond the terms of the policy. A particular disease shall not be referred to by more than one term so as to imply broader coverage than is the fact.
Ins 3.27(9)(d)(d) The benefits of a policy which pays varying amounts for the same loss occurring under different conditions, or which pays benefits only when a loss occurs under certain conditions, shall not be advertised without disclosing the limited conditions under which the benefits referred to are provided by the policy.
Ins 3.27(9)(e)(e) The maximum benefit available under a policy shall not be emphasized in a manner which exaggerates its relationship to any internal limits or other conditions of the policy.
Ins 3.27(9)(f)(f) The aggregate amounts or the monthly or weekly benefits payable under coverages such as hospital or similar facility confinement indemnity or private duty nursing shall not be emphasized unless the actual amounts payable per day are disclosed with substantially equal prominence and in close conjunction with such statement. Any limit in the policy on the number of days of coverage provided shall be disclosed.
Ins 3.27(9)(g)(g) Phrases such as “this policy pays $1800 for hospital room and board expenses” are incomplete without indicating the maximum daily benefit and the maximum time limit for hospital room and board expenses.
Ins 3.27(9)(h)(h) An advertisement shall not state or imply that each member under a family policy is covered as to the maximum benefits advertised when such is not the fact.
Ins 3.27(9)(i)(i) The importance of diseases rarely or never found in the class of persons to whom the policy is offered shall not be exaggerated in an advertisement.
Ins 3.27(9)(j)(j) Examples of what benefits may be paid under a policy shall be shown only for losses from common illnesses or injuries rather than exceptional or rare illnesses or injuries.
Ins 3.27(9)(k)(k) When a range of hospital room expense benefits is set forth in an advertisement, it shall be made clear that the insured will receive only the benefit indicated in the policy purchased. It shall not be implied that the insured may select his or her room expense benefit at the time of hospitalization.
Ins 3.27(9)(L)(L) An advertisement shall not imply that the amount of benefits payable under a loss of time policy may be increased at time of disability according to the needs of the insured.
Ins 3.27(9)(m)(m) The term “confining sickness” is an abbreviated expression and shall be explained if used in an advertisement.
Ins 3.27(9)(n)(n) An advertisement shall not state that the insurer “pays hospital, surgical, medical bills,” “pays dollars to offset the cost of medical care,” “safeguards your standard of living,” “pays full coverage,” “pays complete coverage,” “pays for financial needs,” “provides for replacement of your lost paycheck,” “guarantees your paycheck,” “guarantees your income,” “continues your income,” “provides a guaranteed paycheck,” “provides a guaranteed income” or “fills the gaps in Medicare” or use similar words or phrases unless the statement is literally true. Where appropriate, such or similar words or phrases may properly be used if preceded by the words “help,” “aid,” “assist,” or similar words.
Ins 3.27(9)(o)(o) An advertisement shall not state that the premiums will not be changed in the future unless such is the fact.