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) (1) (B), 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. 767.25 (4m)
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 workforce development 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to provide coverage for the child unless the insurer receives satisfactory written evidence that the court order is no longer in effect or that the child has coverage under another group policy or individual policy that provides comparable health care coverage.
(b) Paragraphs (a)
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 and family 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 and family 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.
See s. 49.45 (20)
concerning exemption from continuation of group coverage.
Employee retirement income security act 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.
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 section 13.172 (3)
of the statutes.
History: 1997 a. 27
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)
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)
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
Worker's compensation insurance. Sections 102.31
apply to worker's compensation insurance.
History: 1975 c. 375
; 1979 c. 102
Certifications of disability.
Every insurer doing a health or disability insurance business in this state shall afford equal weight to a certification of disability signed by a physician with respect to matters within the scope of the physician's professional license and to a certification of disability signed by a chiropractor with respect to matters within the scope of the chiropractor's professional license for the purpose of insurance policies they issue. This section does not require an insurer to treat any certification of disability as conclusive evidence of disability.
History: 1981 c. 55