(17) Fraternal benefit societies.
Nothing in this section shall prohibit a fraternal benefit society under ch. 614
from enforcing the terms of its bylaws or rules regarding permitted beneficiaries and owners.
(18) Civil action.
Any person damaged by a violation of this section may bring a civil action against the person committing the violation in a court of competent jurisdiction.
Any person who violates this section is subject to the penalties provided under s. 601.64
, suspension or revocation of a license or certificate of authority, and an order under s. 601.41
(20) Powers of commissioner.
The commissioner may do any of the following:
Adopt rules implementing and administering this section.
Establish standards for evaluating the reasonableness of payments under life settlement contracts for persons who are terminally or chronically ill, including regulation of discount rates used to determine the amount paid in exchange for assignment, transfer, sale, devise, or bequest of a benefit under a policy insuring the life of a person who is terminally or chronically ill.
Establish appropriate licensing requirements and standards for continued licensure for providers and brokers.
Require a bond or other mechanism for financial accountability for providers and brokers.
Adopt rules governing the relationship and responsibilities of insurers, providers, and brokers during settlement of a policy.
Applicability of general transfers at death provisions. Chapter 854
applies to transfers at death under life insurance policies and annuities.
History: 1997 a. 188
Estoppel from medical examination, assignability and change of beneficiary. Sections 632.47
apply to disability insurance policies.
History: 1975 c. 373
Reports of action against health care provider.
Every insurer that has taken any action against a person who holds a license granted by the medical examining board or an affiliated credentialing board attached to the medical examining board shall notify the board or affiliated credentialing board of the action taken against the person if the action relates to unprofessional conduct or negligence in treatment by the person who holds the license.
History: 1985 a. 340
; 1993 a. 107
Medical benefits or assistance; assignment. 632.72(1g)(a)
"Department or contract provider" means the department of health services, the county providing the medical benefits or assistance or a health maintenance organization that has contracted with the department of health services to provide the medical benefits or assistance.
"Medical benefits or assistance" means health care services funded by a relief block grant, as defined in s. 49.001 (5p)
; medical assistance, as defined under s. 49.43 (8)
; or maternal and child health services under s. 253.05
The providing of medical benefits or assistance constitutes an assignment to the department or contract provider. The assignment shall be, to the extent of the medical benefits or assistance provided, for benefits to which the recipient would be entitled under any policy of health and disability insurance.
An insurer may not impose on the department or contract provider, as assignee of a person who is covered under the policy of health and disability insurance and who is eligible for medical benefits or assistance, requirements that are different from those imposed on any other agent or assignee of a person who is covered under the policy of health and disability insurance.
Standardization of health care billing and insurance claim forms. 632.725(2)
(2) Rules for standardization of forms.
The commissioner, in consultation with the department of health services, shall, by rule, do all of the following:
Establish a standardized billing format for health care services and require that a health care provider that provides health care services in this state use, by July 1, 1993, the standardized format for all printed billing forms.
Establish a standardized claim format for health care insurance benefits and require that an insurer that provides health care coverage to one or more residents of this state use, by July 1, 1993, the standardized format for all printed claim forms.
Establish a standardized explanation of benefits format for health care insurance benefits and require that an insurer that provides health care coverage to one or more residents of this state use, by July 1, 1993, the standardized format for all printed forms that contain an explanation of benefits. The rule shall also require that benefits be explained in easily understood language.
Establish a uniform statewide patient identification system in which each individual who receives health care services in this state is assigned an identification number. The standardized billing format established under par. (a)
and the standardized claim format established under par. (b)
shall provide for the designation of an individual's patient identification number.
(3) Proposals for legislation.
The commissioner shall develop proposals for legislation for the use of the patient identification system established under sub. (2) (d)
and for the implementation of the proposed uses, including any proposals for safeguarding patient confidentiality.
See also ss. Ins 3.65
, Wis. adm. code.
Current procedural terminology code changes. 632.726(1)(1)
In this section, "current procedural terminology code" means a number established by the American Medical Association that a health care provider puts on a health insurance claim form to describe the services that he or she performed.
If an insurer changes a current procedural terminology code that was submitted by a health care provider on a health insurance claim form, the insurer shall include on the explanation of benefits form the reason for the change to the current procedural terminology code and shall cite on the explanation of benefits form the source for the change.
History: 2007 a. 20
Right to return policy. 632.73(1)
Right of return.
A policyholder may return an individual or franchise disability policy within 10 days after receipt. If the policyholder does so, the contract is void, and all payments made under it shall be refunded. This subsection does not apply to medicare supplement policies, medicare replacement policies or long-term care insurance policies subject to sub. (2m)
(2) Notification. Subsection (1)
shall in substance be conspicuously printed on the first page of each such policy or conspicuously attached thereto.
(2m) Medicare supplement policies, medicare replacement policies and long-term care insurance policies.
Medicare supplement policies, medicare replacement policies and long-term care insurance policies shall have a notice that complies with this subsection prominently printed on the first page of the policy or certificate, or attached thereto. The notice shall state that the policyholder or certificate holder shall have the right to return the policy or certificate within 30 days of its delivery to the policyholder or certificate holder and to have the premium refunded to the person who paid the premium if, after examination of the policy or certificate, the policyholder or certificate holder is not satisfied for any reason. The commissioner may by rule exempt from this subsection 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.
This section does not apply to single premium nonrenewable policies issued for terms not greater than 6 months or covering accidents only or accidental bodily injuries only.
The commissioner may by rule permit exemptions from subs. (1)
for additional classes or parts of classes of insurance where the right to return the policy would be impracticable or is not necessary to protect the policyholder's interests.
Reinstatement of individual or franchise disability insurance policies. 632.74(1)
Conditions of reinstatement.
If an insurer, after termination of an individual or franchise disability insurance policy for nonpayment of premium, within one year after the termination accepts without reservation a premium payment, the policy is reinstated as of the date of the acceptance. There is no acceptance without reservation if the insurer delivers or mails a written statement of reservations within 45 days after receipt of the payment.
(2) Consequences of reinstatement.
If a policy is reinstated under sub. (1)
or if the insurer within one year after the termination issues to the policyholder a reinstatement policy, any losses resulting from accidents occurring or sickness beginning between the termination and the effective date of the reinstatement or the new policy are not covered, and no premium is payable for that period, except to the extent that the premium is applied to a reserve for future losses. The insurer may also charge a reinstatement fee in accordance with a schedule that has been filed with and expressly approved by the commissioner as not excessive and not unreasonably discriminatory. In all other respects, the reinstated or renewed contract shall be treated as an uninterrupted contract subject to any provisions which are endorsed on or attached to the contract in connection with the reinstatement and which are fully and prominently disclosed to the policyholder.
Coverage requirements for group and individual health benefit plans; definitions.
In this section and ss. 632.746
"Affiliation period" means the period which, under the terms of health insurance coverage offered by a health maintenance organization, must expire before the health insurance coverage becomes effective.
"Beneficiary" has the meaning given in section 3 (8) of the federal Employee Retirement Income Security Act of 1974.
"Bona fide association" means an association that satisfies all of the following:
The association has been actively in existence for at least 5 years.
The association has been formed and maintained in good faith for purposes other than obtaining insurance.
The association does not condition membership in the association on any health status-related factor of an individual, including an employee of an employer or a dependent of an employee.
The association makes health insurance coverage offered through the association available to all members, regardless of any health status-related factor of those members or individuals eligible for coverage through a member.
The association does not make health insurance coverage offered through the association available other than in connection with a member of the association.
The association meets any additional requirements that are imposed by a rule of the commissioner designed to prevent the use of an association for risk segmentation.
Except as provided in par. (b)
, "creditable coverage" means coverage under any of the following:
Part A or part B of title XVIII of the federal Social Security Act.
Title XIX of the federal Social Security Act, except for coverage consisting solely of benefits under section 1928 of that act.
A medical care program of the federal Indian health service or of an American Indian tribal organization.
A health plan offered under chapter 89
of title 5 of the United States Code.
A public health plan, as defined in regulations issued by the federal department of health and human services.
"Creditable coverage" does not include coverage consisting solely of coverage of excepted benefits, as defined in section 2791 (c) of P.L. 104-191
Except as provided in par. (b)
, "eligible employee" means an employee who works on a permanent basis and has a normal work week of 30 or more hours. The term includes a sole proprietor, a business owner, including the owner of a farm business, a partner of a partnership and a member of a limited liability company if the sole proprietor, business owner, partner or member is included as an employee under a health benefit plan of an employer, but the term does not include an employee who works on a temporary or substitute basis.
For purposes of a group health benefit plan, or a self-insured health plan, that is offered by the state under s. 40.51 (6)
or by the group insurance board under s. 40.51 (7)
, "eligible employee" has the meaning given in s. 40.02 (25)
An individual, firm, corporation, partnership, limited liability company or association that is actively engaged in a business enterprise in this state, including a farm business.
For purposes of this definition, all of the following apply:
All persons treated as a single employer under subsection (b), (c), (m) or (o) of section 414
of the Internal Revenue Code of 1986 shall be treated as one employer.
"Enrollment date" means, with respect to an individual covered under a group health plan or health insurance, the date of enrollment of the individual under the plan or insurance or, if earlier, the first day of the waiting period for such enrollment.
"Federal continuation provision" means any of the following:
of the Internal Revenue Code of 1986, except for section 4980B (f) (1) of that code insofar as it relates to pediatric vaccines.