An insurer that denies coverage under an individual or group life or disability insurance policy or a certificate of group life or disability insurance shall advise the applicant or proposed insured in writing of the reasons for the denial.
History: 1999 a. 95
APPROVAL OF FORMS
Filing and approval of forms. 631.20(1)(a)(a)
No form subject to s. 631.01 (1)
, except as exempted under par. (c)
, sub. (1g)
, or s. 631.01 (2)
, or (5)
or by rule under par. (b)
, may be used unless it has been filed with and approved by the commissioner and unless the insurer certifies that the form complies with chs. 600
and rules promulgated under chs. 600
. It is deemed approved if it is not disapproved within 30 days after filing, or within a 30-day extension of that period ordered by the commissioner prior to the expiration of the first 30 days.
Subject to s. 655.24 (1)
, the commissioner may by rule exempt certain classes of policy forms from prior filing and approval.
Subject to sub. (1m)
, a form first used and not already filed under par. (a)
on or after August 1, 2008, is exempt from par. (a)
except for any of the following:
A form for a Medicare replacement policy or a Medicare supplement policy.
A form for a long-term care insurance policy, including a form for a nursing home or home health care policy.
A form issued by an insurer ordered by the commissioner under s. 601.41 (4)
to file forms under par. (a)
. The commissioner may require an insurer to file forms under par. (a)
to secure compliance with the law, including if the commissioner determines that the insurer violated sub. (1m)
A form that includes an appraisal or arbitration provision not specifically authorized by rule. The entire form, including the appraisal or arbitration provision, is subject to par. (a)
A form required to be filed under par. (a)
by a rule promulgated by the commissioner.
(1g) Exempt if approved by commission.
A form for a product, as defined in s. 601.58 (2) (k)
, that is approved by or self-certified to, and not disapproved by, the Interstate Insurance Product Regulation Commission is exempt from subs. (1) (a)
and (1m) (a)
, unless otherwise provided by a rule promulgated by the commissioner under s. 601.58
Except as exempted under sub. (1g)
or s. 631.01 (2)
, or (5)
or by a rule promulgated by the commissioner, an insurer may not, on or after August 1, 2008, use a form that is exempt from sub. (1) (a)
under sub. (1) (c)
unless the insurer does all of the following:
Files the form with the commissioner 30 days before its use.
Files the form in the manner and format, and with the attachments, prescribed by the commissioner.
Certifies as required under par. (b)
that the form complies with chs. 600
and rules promulgated under chs. 600
. The commissioner may require an insurer to include specific compliance certifications.
An insurer shall provide the certification under par. (a) 3.
in the form prescribed by the commissioner. The certification shall be executed by a person who is an officer of the insurer and who is responsible for the form that is the subject of the filing. No insurer may file, and no insurer's officer may execute, a false certification.
(2) Grounds for disapproval.
The commissioner may disapprove a form under sub. (1) (a)
upon a finding:
That it is inequitable, unfairly discriminatory, misleading, deceptive, obscure or encourages misrepresentation, including cases where the form:
Is misleading because its benefits are too restricted to achieve the purposes for which the policy is sold;
Contains provisions whose natural consequence is to obscure or lessen competition;
Is misleading, deceptive or obscure because of such physical aspects as format, typography, style, color, material or organization;
That it provides benefits or contains other provisions that endanger the solidity of the insurer;
That in the case of the policy, though not of riders and endorsements, it fails to provide the exact name of the insurer and the full address of its home office; or
That it violates a statute or a rule promulgated by the commissioner, or is otherwise contrary to law.
In the case of a policy form under ch. 149
, that any of the following applies:
The benefit design is not comparable to a typical comprehensive individual health insurance policy offered in the private sector market in this state.
The benefit levels are not generally reflective of and commensurate with comprehensive health insurance coverage offered in the private individual market in the state.
The copayments, deductibles, and coinsurance are not actuarially equivalent to comprehensive individual plans and would create undue financial hardship.
It is inconsistent with the purpose of providing health care coverage to those unable to obtain coverage in the private market.
(3) Subsequent disapproval.
Whenever the commissioner finds, after a hearing, that a form approved or deemed to be approved under sub. (1) (a)
, a form filed under sub. (1m)
, or a form subject to subsequent disapproval under s. 601.58 (14)
should be disapproved under sub. (2)
, the commissioner may order that on or before a date not less than 30 nor more than 90 days after the order the use of the form shall be discontinued or appropriate changes shall be made.
(4) Contents of order of disapproval.
The commissioner's disapproval must be in writing and constitutes an order. It must state the reasons for disapproval sufficiently explicitly that the insurer is provided reasonable guidance in reformulating its proposals.
(5) Explicit approval of certain clauses.
General approval of a form under this section, or failure to disapprove, does not constitute approval of clauses specified in s. 631.21
(6) Form that violates statute or rule. 631.20(6)(a)1.
Using a form that does not comply with a statute or rule, including a rule or uniform standard adopted by the Interstate Insurance Product Regulation Commission, if the statute or rule was in effect on the date the form was approved or deemed to be approved under sub. (1) (a)
or s. 601.58
The use of a form solely based on a finding of the commissioner that the content of the form is misleading under s. 628.34 (1)
An insurer's use of a form that does not comply with a statute or rule, including a rule or uniform standard adopted by the Interstate Insurance Product Regulation Commission, that takes effect after the date the form was approved or deemed to be approved under sub. (1) (a)
or s. 601.58
is a violation of the statute or rule, and the penalties under s. 601.64
may be imposed against the insurer using the form.
Except as provided in par. (a) 2.
, an insurer's use of a form filed under sub. (1m)
that violates chs. 600
or rules promulgated under chs. 600
is a violation of the statute or rule, regardless of whether the form has been subsequently disapproved under sub. (3)
. The insurer is subject to the penalties and remedial orders provided under chs. 600
, including ss. 601.41 (4)
(7) Surplus lines insurance.
Except as provided in sub. (1) (c) 9.
and s. 618.41 (6m)
, this section does not apply to a surplus lines insurance form issued under s. 618.41
before, on, or after April 20, 2012.
See also ss. Ins 6.05
, and 6.76
, Wis. adm. code.
Explicit approval required. 631.21(1)
Despite filing or general approval of a form under s. 631.20
, the following clauses may not be used even if contained in the form unless the commissioner gives explicit approval to them:
Clauses requiring more expeditious notice than 1st class mail, as provided in s. 631.81 (2)
A schedule of reinstatement fees under s. 632.74
, if made a part of the policy. Such a schedule need not be included in the contract but may be given approval as a separate document specifically made applicable to particular classes of policies.
(2) Effect of failure to obtain explicit approval.
If an insurer fails to obtain explicit approval from the commissioner for the clauses under sub. (1)
, the clauses shall be null and void.
See also ss. Ins 6.05
, Wis. adm. code.
Consumer insurance policy readability. 631.22(1)
In this section "consumer insurance policy" means a life, disability, property or casualty insurance policy, or a certificate or a substitute for a certificate for group life, disability, property or casualty insurance coverage, which is issued to a person for a personal, family or household purpose and a copy of which is customarily, in the insurance industry, delivered or is required by law, rule or agreement to be delivered to the person obtaining insurance coverage.
An insurer may provide a consumer insurance policy which is delivered to a person obtaining insurance coverage and is not exempt under sub. (5)
only if the consumer insurance policy is coherent, written in commonly understood language, legible, appropriately divided and captioned by its various sections and presented in a meaningful sequence. The commissioner shall promulgate rules establishing standards for the determination of compliance with this subsection.
This section does not apply to specific language or format required by state or federal law, rule or regulation.
This section applies only to consumer insurance policies delivered on or after the date which is 6 months after May 8, 1980 except the commissioner may provide by rule that this section will not apply to specific types of consumer insurance policies until a later date which is not later than the date which is 2 years after May 8, 1980 if the commissioner determines that delayed application is necessary to prevent an unreasonable burden upon insurers issuing those types of consumer insurance policies.
The commissioner may by rule exempt a type of consumer insurance policy from the application of this section if the commissioner finds that type of consumer insurance policy is generally understood by persons to whom it is delivered or that those persons are otherwise adequately protected.
A violation of this section does not void or render voidable any portion of an insurance policy and is not a defense to an action under the insurance policy.
History: 1979 c. 218
Authorized clauses for insurance forms. 631.23(1)(1)
Promulgation of clauses.
The commissioner may not promulgate mandatory uniform clauses that preclude an insurer from filing its own forms under s. 631.20
; the commissioner may only disapprove such forms on the basis of the criteria stated in that section. Subject thereto, the commissioner may promulgate authorized clauses by rule upon a finding that:
Price or coverage competition is ineffective because diversity in language or content makes comparison difficult;
Provision of language, content or form of specific clauses is necessary to provide certainty of meaning of those clauses;
Regulation of contract forms would be more effective or litigation would be substantially reduced if there were increased standardization of certain clauses; or
Reasonable minimum standards of insurance protection are needed for policies to serve a useful purpose.
(2) Degree of specificity.
Any rule creating an authorized clause may prescribe that to be treated as an authorized clause there must be verbatim or substantial adherence to prescribed language, that certain standards or criteria must be met, or that certain drafting principles must be followed. The rules may also permit liberalization of prescribed language. If the proposed rule prescribed verbatim adherence, the commissioner shall make a finding that substantial adherence to the prescribed language is not sufficient and that liberalization of prescribed language will frustrate the purposes of the prescription. If an insurer uses authorized clauses as part of filed forms the commissioner may only disapprove those clauses under s. 631.20
upon a finding that improper combination of clauses makes them violate the criteria of s. 631.20
See also s. Ins 6.76
, Wis. adm. code.
Credit life and disability insurance. Section 631.20
does not apply to credit life and disability insurance forms which are subject to approval under s. 424.209
History: 1979 c. 102
Rules of law as provisions of contracts.
By rule, the commissioner may require an insurer to insert in a policy any rule of law stated in chs. 600
that is applicable to the contents or interpretation of an insurance contract.
Notice of right to file complaint. 631.28(1)
Requirement to provide notice.
Every insurer shall provide notice to its policyholders and its insureds of the right to file a complaint with the office in the manner prescribed by rule under sub. (2)
(2) Contents by rule.
The commissioner shall promulgate rules specifying the contents of a notice that insurers must disseminate under sub. (1)
, and when and in what manner the notice must be provided. The rules shall describe how a policyholder, insured or other person may make a complaint with the office about an insurer, an intermediary or other insurance matter. The rules may also specify the form, including the type size, in which insurers must present the notice.
History: 1991 a. 154
See also s. Ins 6.85
, Wis. adm. code.