A "group policy providing medical expense coverage" does not include a policy providing coverage for dental, vision care, hearing care or prescription drug expense coverage only.
"Group policyholder" means an employer, labor union, association, trust fund or other entity responsible for making group policy premium payments to an insurer.
"Group type plan" means an insurance plan using individual policies which meets the following conditions:
Coverage is provided to classes of employees defined in terms of conditions pertaining to employment or membership.
The coverage is not available to the general public and can be obtained and maintained only because of the covered person's connection with the particular organization or group.
Premiums are paid by the group policyholder to the insurer on behalf of covered employees, and
An employer, union, association or trust fund sponsors or authorizes the plan.
"Individual policy" means an individual or family policy or subscriber contract issued by an insurer.
"Insurer" means an insurance company subject to chs. 631
, Stats., or a service insurance corporation subject to ch. 613, Stats.
"Premium" means a policy premium or a subscriber contract subscription fee.
"Pre-existing condition" means a disease or physical condition including pregnancy which manifested itself prior to the effective date of coverage through medical diagnosis or treatment or the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis or treatment.
"Validly covered" means that the individual involved was covered and met all policy requirements regarding eligibility for coverage, as opposed to an individual who was covered without having met all such requirements.
(4) Effective date of termination for non-payment of premium; Notice of termination; liability of insurer. Ins 6.51(4)(a)(a)
A group policy subject to s. 632.79
, Stats., as defined in sub. (3) (c) 2.
may not be terminated by the insurer unless it has provided the termination notices required by s. 632.79 (2)
, Stats., except as provided in s. 632.79 (5)
, Stats. The insurer shall be liable for valid claims for covered losses as provided in s. 632.79 (3)
Under a group policy other than one subject to s. 632.79
, Stats., the insurer shall be liable for valid claims for covered losses incurred prior to the end of the grace period provided in the policy. This provision does not prevent a group policyholder from giving written notice of termination of the group policy, prior to the termination date, in accordance with the group policy terms, to reduce or eliminate the grace period.
The insurer shall also be liable for valid claims for covered losses beginning prior to the effective date of written notice of termination to the group policyholder if, after the end of the grace period provided in the policy:
It continues to recognize claims subsequently incurred for which recognition is not required by an applicable extension of coverage provision, or
It fails to request that the group policyholder notify covered employees of the termination and, except for life and disability income coverages, describe their rights, if any, upon termination.
The effective date of termination shall not be prior to midnight at the end of the third scheduled work day after the date on which the notice is delivered.
This paragraph shall not apply if a group policy is terminated and immediately replaced by another group policy providing similar coverage.
A notice of termination given by an insurer to a group policyholder in accordance with sub. (4) (a)
A request to notify covered employees of the termination and, except for life and disability income coverages, the rights, if any, available to them under the group policy,
A statement that, unless otherwise provided in the group policy, the insurer will not be liable for claims for losses incurred after the termination date, and
If the group policy involves employee contributions, a statement that, if the group policyholder continues to collect contributions for the coverage beyond the date of termination, the group policyholder may be held solely liable for the benefits with respect to which the contributions have been collected.
At the same time, the insurer shall furnish to the group policyholder for distribution to covered employees a supply of a notice form indicating the termination, its effective date and the rights, if any, available to them upon termination, except that, for life and disability income coverages, the notice need only urge the covered employees to refer to their certificate or individual policy to determine what rights, if any, are available upon termination.
A group policy shall, if a covered employee or dependent is totally disabled at the date of termination of the policy, provide an extension of coverage for the individual, beginning at the date of termination of the group policy and continuing during the period of total disability as provided in this subsection.
Under a group life policy which contains a disability benefit extension of any type, such as premium waiver extension, extended death benefit in event of total disability, or payment of income for a specified period during total disability, the termination of the group policy shall not operate to terminate the extension.
Under a group policy providing benefits for loss of time from work or a specific indemnity during hospital confinement, termination of the group policy during a period of total disability or confinement shall have no effect on benefits payable for the condition or conditions causing continuing total disability or continuing confinement. The extension of coverage provision for loss of time benefits may provide for the integration of social security disability or retirement benefit increases which occur after the date of termination of the group policy only if integration of these benefit increases is also applicable prior to termination of the group policy.
Under a group policy providing hospital, surgical or medical expense coverages, the extension of coverage shall be at least 12 months under major medical or comprehensive medical coverage and at least 90 days under other hospital, surgical or medical expense coverage, subject to the following:
Coverage for the condition or conditions causing total disability is provided under similar coverage, other than temporary coverage under sub. (7m) (b) 2.
, under the succeeding insurer's group policy.
Extended coverage need not cover dental or uncomplicated pregnancy expenses or a condition other than the condition or conditions causing total disability.
The extension of coverage is not required where the succeeding insurer agrees, or the prior and succeeding insurers agree, to provide coverage, for individuals who are totally disabled at the date of termination of the group policy, which is not less favorable to them than would otherwise be required by this paragraph.
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.
(7) 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.
(7m) 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.
(8) 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.
(9) Effective date.
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.
(3) 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.
(5) 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 B, shown at the end of this rule.
(6) Subsequent reports.
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.
(7) Additional information.
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: