The policy may not define a preexisting condition more restrictively than a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received before the effective date of coverage.
The policy shall reduce the length of time during which a preexisting condition exclusion may be imposed by the aggregate of the insured's consecutive periods of coverage under the insurer's individual disability insurance policies that are short-term policies subject to s. 632.7495 (4)
. For purposes of this subd. 3. b.
, coverage periods are consecutive if there are no more than 63 days between the coverage periods.
Notwithstanding par. (a)
, no claim for loss incurred or disability commencing after 6 months from the date of issue of a medicare supplement policy, medicare replacement policy or long-term care insurance policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage. Notwithstanding par. (ac) 2.
, a medicare supplement policy, medicare replacement policy, or long-term care insurance policy may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage. Notwithstanding par. (a)
, if on the basis of information contained in an application for insurance a medicare supplement policy, medicare replacement policy, or long-term care insurance policy excludes from coverage a condition by name or specific description, the exclusion must terminate no later than 6 months after the date of issue of the medicare supplement policy, medicare replacement policy, or long-term care insurance policy. The commissioner may by rule exempt from this paragraph certain classes of medicare supplement policies, medicare replacement policies, and long-term care insurance policies, if the commissioner finds the exemption is not adverse to the interests of policyholders and certificate holders.
See also s. Ins 3.39
, Wis. adm. code.
A generic exclusion of all diseases or conditions diagnosed or treated before issuance of the policy does not constitute exclusion by “name or specific description" under sub. (2). Peterson v. Equitable Life Assurance Society, 57 F. Supp. 2d 692
Permitted provisions for disability insurance policies.
If any provisions are contained in a disability insurance policy dealing with the following subjects, they shall conform to the requirements specified:
Change of occupation.
Any provision respecting change of occupation may provide only for a lower maximum payment and for reduction of loss payments proportionate to the change in appropriate premium rates if the change is to a higher rated occupation, and must provide for retroactive reduction of premium rates from the date of change of occupation or the last policy anniversary date, whichever is the more recent, if the change is to a lower rated occupation.
Misstatement of age.
Any provision respecting misstatement of age may only provide for reduction of the loss payable to the amount that the premium paid would have purchased at the correct age.
Limitations on payments.
Any limitation on payments because of other insurance or because of the income of the insured must be in accordance with provisions approved by the commissioner by rule or explicitly approved in approving the policy form, but the commissioner may not promulgate a rule that conflicts with s. 632.755
nor approve a policy form that does not comply with s. 632.755
Facility of payment.
Reasonable facility of payment clauses may be inserted. Payment in accordance with such clauses shall discharge the insurer's obligation to pay claims.
Effect of power of attorney for health care. 632.775(1)(1)
Insurer may not require.
An insurer may not require an individual to execute a power of attorney for health care under ch. 155
as a condition of coverage under a disability insurance policy.
Effect on disability policies.
Executing a power of attorney for health care under ch. 155
may not be used to impair in any manner the procurement of a disability insurance policy or to modify the terms of an existing disability insurance policy. A disability insurance policy may not be impaired or invalidated in any manner by the exercise of a health care decision by a health care agent on behalf of a person who is insured under the policy and who has authorized the health care agent under ch. 155
History: 1989 a. 200
Required grace period for disability insurance policies.
Every disability insurance policy shall contain clauses providing for a grace period of at least 7 days for weekly premium policies, 10 days for monthly premium policies and 31 days for all other policies, for each premium after the first, during which the policy shall continue in force. In group and blanket policies the policy must provide for a grace period of at least 31 days unless the policyholder gives written notice of discontinuance prior to the date of discontinuance and in accordance with the policy terms. In group or blanket policies, the policy may provide for payment of a proportional premium for the period the policy is in effect during the grace period under this section.
Notice of termination of group hospital, surgical or medical expense insurance coverage due to cessation of business or default in payment of premiums. 632.79(1)(1)
This section shall apply to every group hospital, surgical or medical expense insurance policy or service plan purchased by or on behalf of an employer to provide coverage for employees and issued under s. 185.981
or by any insurer authorized under chs. 600
which has been delivered, renewed or is otherwise in force on or after June 12, 1976.
Notice to policyholder or party responsible for payment of premiums. 632.79(2)(a)
Prior to termination of any group policy, plan or coverage subject to this section due to a cessation of business or default in payment of premiums by the policyholder, trust, association or other party responsible for such payment, the insurer or organization issuing the policy, contract, booklet or other evidence of insurance shall notify in writing the policyholder, trust, association or other party responsible for payment of premiums of the date as of which the policy or plan will be terminated or discontinued. At such time, the insurer or organization shall additionally furnish to the policyholder, trust, association or other party a notice form in sufficient number to be distributed to covered employees or members indicating what rights, if any, are available to them upon termination.
For purpose of notice and distribution to covered employees and members under par. (a)
, the administrator responsible for determining the persons covered and the premiums payable to the insurer or organization under any group policy or plan of disability insurance is responsible for providing such notices.
Liability of insurer or service organization for payment of claims.
Under any group policy or plan subject to this section, the insurer or organization shall be liable for all valid claims for covered losses prior to the expiration of any grace period specified in the group policy or plan.
The notice requirements of this section shall not apply if a group policy or plan providing coverage to employees or members is terminated and immediately replaced by another policy or plan providing similar coverage to such employees or members.
History: 1975 c. 352
; Stats. 1975 s. 204.324; 1975 c. 422
; Stats. 1975 s. 632.79; 1979 c. 32
See also s. Ins 6.51
, Wis. adm. code.
Notice of loss of primary insurance coverage due to age. 632.793(1)(1)
Notice to insured and employer.
If an individual who is covered under a group disability insurance policy, as defined in s. 632.895 (1) (a)
, that is purchased by or on behalf of an employer to provide coverage for employees will lose primary coverage under the policy upon reaching age 65, the insurer issuing the policy shall provide written notice of the change in coverage status by regular mail to the individual and shall send a copy of the notice by regular mail to the employer. The insurer shall provide the notice not less than 30 nor more than 60 days before the individual becomes 65 years of age. The notice shall specify the date on which the insurance coverage will no longer be primary and shall inform the individual that he or she will be eligible for coverage under the federal medicare program at age 65.
does not apply if the employer has at least 20 employees for each working day in at least 20 calendar weeks in the current year or the preceding year.
History: 1993 a. 108
Open enrollment upon liquidation. 632.795(1)(1)
In this section, “liquidated insurer" means an insurer ordered liquidated under ch. 645
or under similar laws of another jurisdiction.
Coverage for group members.
Except as provided in sub. (5)
and unless otherwise provided by rule or order of the commissioner, an insurer described in sub. (3)
shall permit insureds or enrolled participants of a liquidated insurer's group health care policy or plan to obtain coverage under a comprehensive group health care policy or plan offered by the insurer in the manner and under the terms required by sub. (4)
applies to an insurer that participated in the most recent enrollment period in which the group members were able to choose among coverage offered by the liquidated insurer and coverage offered by one or more other insurers, if all of the following are satisfied:
Coverage under a comprehensive group health care policy or plan offered by the insurer was selected by one or more members of the group in the most recent enrollment period.
The most recent enrollment period occurred on or after July 1, 1989.
An insurer subject to sub. (2)
shall provide coverage under the same policy form and for the same premium as it originally offered in the most recent enrollment period, subject only to the medical underwriting used in that enrollment period. Unless otherwise prescribed by rule, the insurer may apply deductibles, preexisting condition limitations, waiting periods or other limits only to the extent that they would have been applicable had coverage been extended at the time of the most recent enrollment period and with credit for the satisfaction or partial satisfaction of similar provisions under the liquidated insurer's policy or plan. The insurer may exclude coverage of claims that are payable by a solvent insurer under insolvency coverage required by the commissioner or by the insurance regulator of another jurisdiction. Coverage shall be effective on the date that the liquidated insurer's coverage terminates.
An insurer subject to sub. (2)
shall offer coverage to the group members, and the policyholder shall provide group members with the opportunity to obtain coverage, in the manner and within the time limits required by the commissioner by rule or order.
Medical assistance enrollees.
This section does not apply to persons enrolled in a health care plan offered by a liquidated insurer if the persons are enrolled in that plan under a contract between the department of health services and the liquidated insurer under s. 49.45 (2) (b) 2.
Disclosure of group health claims experience. 632.797(1)(a)
Except as provided in subs. (2)
, an insurer shall provide the policyholder of a group or blanket disability insurance policy, or an employer that provides health care coverage to its employees through a multiple-employer trust, with the policyholder's or the employer's aggregate group health claims experience for the current policy period, and for up to 2 policy periods immediately preceding the current policy period if the insurer provided coverage during those periods, upon request from the policyholder or employer.
The insurer shall provide the information under par. (a)
no later than 30 days after receiving a request for that information from the policyholder or employer.
The insurer may not charge the policyholder or the employer for providing the information under par. (a)
one time in a 12-month period.
Except for charging a fee under par. (c)
, an insurer may not change the rating methodology between community rating and experience rating or otherwise penalize a policyholder or employer for requesting the information under par. (a)
An insurer is not required to provide the information under sub. (1)
unless the policyholder or employer requesting the information provides coverage under the policy for at least 50 individuals, exclusive of individuals who have coverage under the policy as a dependent of another individual.
Notwithstanding sub. (1)
, an insurer is not required to provide health claims experience under sub. (1)
for any period of time that is before 18 months before the date on which the information is requested.
does not require that an insurer provide the policyholder of a group or blanket disability insurance policy, or an employer that provides health care coverage to its employees through a multiple-employer trust, with the health claims experience of an individual employee or insured.
An insurer is not required under sub. (1)
to provide information that identifies an individual or that is confidential under s. 146.82
An insurer that provides aggregate health claims experience information in compliance with this section is immune from civil liability for its acts or omissions in providing such information.
History: 1993 a. 448
; 2011 a. 32
Out-of-pocket costs. 632.798(1)(c)
“Insured" includes an enrollee under a self-insured health plan and a representative or designee of an insured or enrollee.
“Self-insured health plan" means a self-insured health plan of the state or a county, city, village, town, or school district.
A self-insured health plan or an insurer that provides coverage under a disability insurance policy shall, at the request of an insured, provide to the insured a good faith estimate, as of the date of the request and assuming no medical complications or modifications in the insured's treatment plan, of the insured's total out-of-pocket cost according to the insured's benefit terms for a specified health care service in the geographic region in which the health care service will be provided.
An estimate provided by an insurer or self-insured health plan under this section is not a legally binding estimate of the out-of-pocket cost.
An insurer or self-insured health plan may not charge an insured for providing the information under this section.
Before providing the information requested under par. (a)
, the insurer or self-insured health plan may require the insured to provide in writing any of the following information:
The name of the health care provider providing the service.
The health care provider's estimate of the charge for the service.
The codes for the service under the Current Procedural Terminology of the American Medical Association or under the Current Dental Terminology of the American Dental Association.
The requirement to provide the information requested under par. (a)
does not apply if the health care provider providing the health care service is any of the following:
A health care provider that practices individually or in association with not more than 2 other individual health care providers.
A health care provider that is an association of 3 or fewer individual health care providers.
History: 2009 a. 146
Restrictions on medical payments insurance.
The provisions of this subchapter do not apply to medical payments insurance when it is a part of or supplemental to liability, steam boiler, elevator, automobile or other insurance covering loss of or damage to property, provided the loss, damage or expense arises out of a hazard directly related to such other insurance.
History: 1975 c. 375
Minimum standards for certain disability policies.
The commissioner may by rule establish minimum standards for benefits, claims payments, marketing practices, compensation arrangements and reporting practices for medicare supplement policies, medicare replacement policies and long-term care insurance policies. The commissioner may by rule exempt from the minimum standards certain types of coverage, if the commissioner finds the exemption is not adverse to the interests of policyholders and certificate holders.
See also ss. Ins 3.39
, and 3.46
, Wis. adm. code.
Renewability of long-term care insurance policies.
Notwithstanding s. 631.36 (2)
, the commissioner shall, by rule, require long-term care insurance policies that are issued on an individual basis to include a provision restricting the insurer's ability to terminate or alter the long-term care insurance policy except for nonpayment of premium. The rule may specify exceptions to the restriction, including exceptions that allow insurers to do any of the following:
Change the rates charged on a long-term care insurance policy if the rate change is made on a class basis.
Refuse to renew a long-term care insurance policy if conditions specified in the rule are satisfied. The conditions shall, at a minimum, require all of the following:
That the nonrenewal be on other than an individual basis.
That the insurer demonstrate to the commissioner that renewal will affect the insurer's solvency or loss experience as specified in the rule.
History: 1989 a. 31
Midterm termination of long-term care insurance policy by insured. 632.825(1)(a)(a)
No insurer that provides coverage under a long-term care insurance policy may prohibit the insured under the policy from canceling the policy before the expiration of the agreed term.
If an insured under a long-term care insurance policy cancels the policy before the expiration of the agreed term, the insurer shall issue a prorated premium refund to the insured.