632.749(2)(a)
(a) The plan sponsor has failed to pay premiums or contributions in accordance with the terms of the group health benefit plan or in a timely manner.
632.749(2)(b)
(b) The plan sponsor has performed an act or engaged in a practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage.
632.749(2)(c)
(c) The plan sponsor has failed to comply with a material plan provision that is permitted under law relating to employer contribution or group participation rules.
632.749(2)(d)
(d) The insurer is ceasing to offer coverage in the market in which the group health benefit plan is included in accordance with
sub. (3) and any other applicable state law.
632.749(2)(e)
(e) In the case of a group health benefit plan that the insurer offers through a network plan, there is no longer an enrollee under the plan who resides, lives or works in the service area of the insurer or in an area in which the insurer is authorized to do business and, in the case of the small group market, the insurer would deny enrollment under the plan under
s. 635.19 (2) (a) 1.
632.749(2)(f)
(f) In the case of a group health benefit plan that is made available only through one or more bona fide associations, the employer ceases to be a member of the association on which the coverage is based. Coverage may be terminated if this paragraph applies only if the coverage is terminated uniformly without regard to any health status-related factor of any covered individual.
632.749(3)(a)(a) Notwithstanding
s. 631.36 (2) to
(4m), an insurer may discontinue offering in this state a particular type of group health benefit plan offered in either the large group market or the group market other than the large group market, but only if all of the following apply:
632.749(3)(a)1.
1. The insurer provides notice of the discontinuance to each employer and, if applicable, plan sponsor for whom the insurer provides coverage of this type in this state, and to the participants and beneficiaries covered under the coverage, at least 90 days before the date on which the coverage will be discontinued.
632.749(3)(a)2.
2. The insurer offers to each employer and, if applicable, plan sponsor for whom the insurer provides coverage of this type in this state the option to purchase from among all of the other group health benefit plans that the insurer offers in the market in which is included the type of group health benefit plan that is being discontinued, except that in the case of the large group market, the insurer must offer each employer and, if applicable, plan sponsor the option to purchase one other group health benefit plan that the insurer offers in the large group market.
632.749(3)(a)3.
3. In exercising the option to discontinue coverage of this particular type and in offering the option to purchase coverage under
subd. 2., the insurer acts uniformly without regard to any health status-related factor of any covered participants or beneficiaries or any participants or beneficiaries who may become eligible for coverage.
632.749(3)(b)
(b) Notwithstanding
s. 631.36 (2) to
(4m), an insurer may discontinue offering in this state all group health benefit plans in the large group market or in the group market other than the large group market, or in both such group markets, but only if all of the following apply:
632.749(3)(b)1.
1. The insurer provides notice of the discontinuance to the commissioner and to each employer and, if applicable, plan sponsor for whom the insurer provides coverage of this type in this state, and to the participants and beneficiaries covered under the coverage, at least 180 days before the date on which the coverage will be discontinued.
632.749(3)(b)2.
2. All group health benefit plans issued or delivered for issuance in this state in the affected market or markets are discontinued and coverage under such group health benefit plans is not renewed.
632.749(3)(b)3.
3. The insurer does not issue or deliver for issuance in this state any group health benefit plan in the affected market or markets before 5 years after the day on which the last group health benefit plan is discontinued under
subd. 2.
632.749(4)
(4) This section does not apply to a group health benefit plan offered by the state under
s. 40.51 (6) or by the group insurance board under
s. 40.51 (7).
632.749 History
History: 1995 a. 289;
1997 a. 27.
632.7495
632.7495
Guaranteed renewability of individual health insurance coverage. 632.7495(1)(a)(a) Except as provided in
subs. (2) to
(4) and notwithstanding
s. 631.36 (2) to
(4m), an insurer that provides individual health benefit plan coverage shall renew such coverage or continue such coverage in force at the option of the insured individual and, if applicable, the association through which the individual has coverage.
632.7495(1)(b)
(b) At the time of coverage renewal, the insurer may modify the individual health benefit plan coverage policy form as long as the modification is consistent with state law and effective on a uniform basis among all individuals with coverage under that policy form.
632.7495(2)
(2) Notwithstanding
s. 631.36 (2) to
(4m), an insurer may nonrenew or discontinue the individual health benefit plan coverage of an individual, but only if any of the following applies:
632.7495(2)(a)
(a) The individual or, if applicable, the association through which the individual has coverage has failed to pay premiums or contributions in accordance with the terms of the health insurance coverage or in a timely manner.
632.7495(2)(b)
(b) The individual or, if applicable, the association through which the individual has coverage has performed an act or engaged in a practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the health insurance coverage.
632.7495(2)(c)
(c) The insurer is ceasing to offer individual health benefit plan coverage in accordance with
sub. (3) and any other applicable state law.
632.7495(2)(d)
(d) In the case of individual health benefit plan coverage that the insurer offers through a network plan, the individual no longer resides, lives or works in the service area or in an area in which the insurer is authorized to do business. Coverage may be terminated if this paragraph applies only if the coverage is terminated uniformly without regard to any health status-related factor of covered individuals.
632.7495(2)(e)
(e) In the case of individual health benefit plan coverage that the insurer offers only through one or more bona fide associations, the individual ceases to be a member of the association on which the coverage is based. Coverage may be terminated if this paragraph applies only if the coverage is terminated uniformly without regard to any health status-related factor of covered individuals.
632.7495(2)(f)
(f) The individual is eligible for medicare and the commissioner by rule permits coverage to be terminated.
632.7495(3)(a)(a) Notwithstanding
s. 631.36 (2) to
(4m), an insurer may discontinue offering in this state a particular type of individual health benefit plan coverage, but only if all of the following apply:
632.7495(3)(a)1.
1. The insurer provides notice of the discontinuance to each individual for whom the insurer provides coverage of this type in this state and, if applicable, to the association through which the individual has coverage at least 90 days before the date on which the coverage will be discontinued.
632.7495(3)(a)2.
2. The insurer offers to each individual for whom the insurer provides coverage of this type in this state and, if applicable, to the association through which the individual has coverage the option to purchase any other type of individual health insurance coverage that the insurer offers for individuals.
632.7495(3)(a)3.
3. In electing to discontinue coverage of this particular type and in offering the option to purchase coverage under
subd. 2., the insurer acts uniformly without regard to any health status-related factor of enrolled individuals or individuals who may become eligible for the type of coverage described under
subd. 2.
632.7495(3)(b)
(b) Notwithstanding
s. 631.36 (2) to
(4m), an insurer may discontinue offering individual health benefit plan coverage in this state, but only if all of the following apply:
632.7495(3)(b)1.
1. The insurer provides notice of the discontinuance to the commissioner and to each individual for whom the insurer provides individual health benefit plan coverage in this state and, if applicable, to the association through which the individual has coverage at least 180 days before the date on which the coverage will be discontinued.
632.7495(3)(b)2.
2. All individual health benefit plan coverage issued or delivered for issuance in this state is discontinued and coverage under such coverage is not renewed.
632.7495(3)(b)3.
3. The insurer does not issue or deliver for issuance in this state any individual health benefit plan coverage before 5 years after the day on which the last individual health benefit plan coverage is discontinued under
subd. 2.
632.7495(4)
(4) Notwithstanding
subs. (1) and
(2) and
s. 631.36 (4), an insurer is not required to renew individual health benefit plan coverage that is marketed and designed to provide short-term coverage as a bridge between coverages.
632.7495 History
History: 1997 a. 27,
237.
632.75
632.75
Prohibited provisions for disability insurance. 632.75(1)(1)
Death presumed from extended absence. Section 813.22 (1) applies to any disability insurance policy providing a death benefit.
632.75(2)
(2) Dividends conditioned on continuation of policy or payment of premiums. Except on the first or second anniversary, no dividend payable on a disability insurance policy may be made contingent on the continuation of the policy or on premium payments.
632.75(3)
(3) Prohibition of exclusion from coverage of certain dependent children. No disability insurance policy issued or renewed on or after April 30, 1980, may exclude or terminate from coverage any dependent child of an insured person or group member solely because the child does not reside with the insured person or group member. This subsection does not apply to a group policy, as defined in
s. 632.897 (1) (c), or an individual policy, as defined in
s. 632.897 (1) (cm), that is subject to
s. 632.897 (10).
632.75(4)
(4) Out-of-state service providers. Except as provided in
s. 628.36, no disability insurance policy may exclude or limit coverage of health care services provided outside this state, if the services are provided within 75 miles of the insured's residence in a facility licensed or approved by the state where the facility is located.
632.75(5)
(5) Payments for hospital services. No insurer may reimburse a hospital for patient health care costs at a rate exceeding the rate established under ch.
54, 1985 stats., or s.
146.60, 1983 stats., for care provided prior to July 1, 1987.
632.755
632.755
Public assistance and early intervention services. 632.755(1g)(a)(a) A disability insurance policy may not exclude a person or a person's dependent from coverage because the person or the dependent is eligible for assistance under
ch. 49 or because the dependent is eligible for early intervention services under
s. 51.44.
632.755(1g)(b)
(b) A disability insurance policy may not terminate its coverage of a person or a person's dependent because the person or the dependent is eligible for assistance under
ch. 49 or because the dependent is eligible for early intervention services under
s. 51.44.
632.755(1g)(c)
(c) A disability insurance policy may not provide different benefits of coverage to a person or the person's dependent because the person or the dependent is eligible for assistance under
ch. 49 or because the dependent is eligible for early intervention services under
s. 51.44 than it provides to persons and their dependents who are not eligible for assistance under
ch. 49 or for early intervention services under
s. 51.44.
632.755(2)
(2) Benefits provided by a disability insurance policy shall be primary to those benefits provided under
ch. 49 or under
s. 51.44 or
253.05.
632.76
632.76
Incontestability for disability insurance. 632.76(1)(1)
Avoidance for misrepresentations. No statement made by an applicant in the application for individual disability insurance coverage and no statement made respecting the person's insurability by a person insured under a group policy, except fraudulent misrepresentation, is a basis for avoidance of the policy or denial of a claim for loss incurred or disability commencing after the coverage has been in effect for 2 years. The policy may provide for incontestability even with respect to fraudulent misstatements.
632.76(2)(a)(a) No claim for loss incurred or disability commencing after 2 years from the date of issue of the policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of loss. This paragraph does not apply to a group health benefit plan, as defined in
s. 632.745 (9), which is subject to
s. 632.746.
632.76(2)(b)
(b) 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. 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.
632.76 Cross-reference
Cross Reference: See also s.
Ins 3.39, Wis. adm. code.
632.76 Annotation
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 (1999).
632.77
632.77
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:
632.77(1)
(1) 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.
632.77(2)
(2) 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.
632.77(3)
(3) 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.
632.77(4)
(4) 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.
632.775
632.775
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.
632.775(2)
(2) 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.
632.775 History
History: 1989 a. 200.
632.78
632.78
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.
632.785
632.785
Notice of Health Insurance Risk-Sharing Plan. 632.785(1)(1) If an insurer issues one or more of the following or takes any other action based wholly or partially on medical underwriting considerations which is likely to render any person eligible under
s. 149.12 for coverage under
ch. 149, the insurer shall notify all persons affected of the existence of the mandatory health insurance risk-sharing plan under
ch. 149, as well as the eligibility requirements and method of applying for coverage under the plan:
632.785(1)(a)
(a) A notice of rejection or cancellation of coverage.
632.785(1)(b)
(b) A notice of reduction or limitation of coverage, including restrictive riders, if the effect of the reduction or limitation is to substantially reduce coverage compared to the coverage available to a person considered a standard risk for the type of coverage provided by the plan.
632.785(1)(c)
(c) A notice of increase in premium exceeding the premium then in effect for the insured person by 50% or more, unless the increase applies to substantially all of the insurer's health insurance policies then in effect.
632.785(1)(d)
(d) A notice of premium for a policy not yet in effect which exceeds the premium applicable to a person considered a standard risk by 50% or more for the types of coverage provided by the plan.
632.785(2)
(2) Any notice issued under
sub. (1) shall also state the reasons for the rejection, termination, cancellation or imposition of underwriting restrictions.
632.79
632.79
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)
Scope. 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 to
646 which has been delivered, renewed or is otherwise in force on or after June 12, 1976.
632.79(2)
(2) Notice to policyholder or party responsible for payment of premiums. 632.79(2)(a)(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.
632.79(2)(b)
(b) 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.
632.79(3)
(3) 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.
632.79(5)
(5) Notice exception. 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.
632.79 History
History: 1975 c. 352; Stats. 1975 s. 204.324;
1975 c. 422 s.
106; Stats. 1975 s. 632.79;
1979 c. 32,
221.
