628.35(4)
(4) The case is within a class for which the commissioner by rule establishes an exception after a finding that the contract or other arrangement does not seriously impede the effective operation of a legitimate insurance business by other insurers.
628.35 History
History: 1975 c. 223,
371,
422.
628.36
628.36
Limitations on corporations supplying health care services. 628.36(1)(1)
Payment methods. Any corporation operating a voluntary health care plan may pay health care professionals on a salary, per patient or fee-for-service basis to provide health care to policyholders or beneficiaries of the corporation.
628.36(2)
(2) Discrimination against professionals. 628.36(2)(a)1.
1. "Health care plan" means an insurance contract providing coverage of health care expenses.
628.36(2)(a)2.
2. "Provider" means a health care professional, a health care facility or a health care service or organization.
628.36(2)(b)1.1. Except for health maintenance organizations, preferred provider plans and limited service health organizations, no health care plan may prevent any person covered under the plan from choosing freely among providers who have agreed to participate in the plan and abide by its terms, except by requiring the person covered to select primary providers to be used when reasonably possible.
628.36(2)(b)2.
2. No provider may be required to participate exclusively in a health care plan as a condition of participation in it.
628.36(2)(b)3.
3. Except as provided in
subd. 4., no provider may be denied the opportunity to participate in a health care plan, other than a health maintenance organization, a limited service health organization or a preferred provider plan, under the terms of the plan.
628.36(2)(b)4.
4. Any health care plan may exclude a provider from participation in the health care plan for cause related to the practice of his or her profession.
628.36(2)(b)5.
5. All health care plans, including health maintenance organizations, limited service health organizations and preferred provider plans are subject to
s. 632.87 (3).
628.36(2m)(a)2m.
2m. "Pharmaceutical services" do not include the administration of a drug product or device or vaccine under
s. 450.035.
628.36(2m)(e)1.1. A health maintenance organization, limited service health organization or preferred provider plan that provides coverage of pharmaceutical services when performed by one or more pharmacists who are selected by the organization or plan but who are not full-time salaried employes or partners of the organization or plan shall provide an annual period of at least 30 days during which any pharmacist registered under
ch. 450 may elect to participate in the health maintenance organization, limited service health organization or preferred provider plan under its terms as a selected provider for at least one year.
628.36(2m)(e)2.
2. Except as provided in
subd. 3.,
subd. 1. applies to health maintenance organizations on and after May 10, 1984. Except as provided in
subd. 4.,
subd. 1. applies to limited service health organizations and preferred provider plans on or after April 28, 1990.
628.36(2m)(e)3.
3. If compliance with the requirements of
subd. 1. during the period specified in
subd. 2. would impair any provision of a contract between a health maintenance organization and any other person, and if the contract provision was in existence prior to May 10, 1984, then immediately after the expiration of all such contract provisions the health maintenance organization shall comply with the requirements of
subd. 1.
628.36(2m)(e)4.
4. If compliance with the requirements of
subd. 1. during the period specified in
subd. 2. would impair any provision of a contract between a limited service health organization or preferred provider plan and any other person, and if the contract was in existence prior to April 28, 1990, then immediately after the expiration of all such contract provisions the limited service health organization or preferred provider plan shall comply with the requirements of
subd. 1.
628.36(3)
(3) Exemption by rule. By rule the commissioner may exempt from the application of any part of
subs. (1) to
(2m) plans which provide innovative approaches to the delivery of health care or which are designed to contain health care costs, and which cannot operate successfully consistent with all of the provisions in
subs. (1) to
(2m). The commissioner may promulgate such a rule only if on a finding that the interests of the public require such plans as an experiment, to supply health care services that are not otherwise available in adequate quantity or quality, or to contain health care costs. The promulgated rule shall be as narrow as is compatible with the success of the plans.
628.36(4)
(4) Facilitating cost-effective provision of health care services. 628.36(4)(a)(a) The commissioner shall provide information and assistance to the department of employe trust funds, employers and their employes, providers of health care services and members of the public, as provided in
par. (b), for the following purposes:
628.36(4)(a)1.
1. To facilitate the development and implementation of health care plans that provide innovative approaches to the delivery of health care services or that are designed to contain health care costs.
628.36(4)(a)2.
2. To increase the awareness and understanding among employers and their employes, providers of health care services and members of the public regarding the availability and nature of innovative or cost-effective health care plans.
628.36(4)(b)
(b) The commissioner's responsibilities in accomplishing the purposes set forth in
par. (a) shall include all of the following:
628.36(4)(b)1.
1. Assisting the department of employe trust funds in the development of health care plans under
s. 40.51 (7).
628.36(4)(b)2.
2. Providing employers and their employes with information regarding the availability and nature of health care coverage that may be obtained under
s. 40.51 (7).
628.36(4)(b)3.
3. Providing information to employers regarding how to proceed under
s. 40.51 (7) to obtain health care coverage for their employes.
628.36(4)(b)4.
4. Providing information to employers and their employes and members of the public regarding the availability and nature of various kinds of health care plans, including their distinct and contrasting characteristics.
628.36(4)(b)5.
5. Providing information to employers and their employes, providers of health care services and members of the public regarding the relative effectiveness of various kinds of health care plans in containing health care costs.
628.37
628.37
Preservation of professional relationships in professional services. No insurance plan related to or providing health care, legal or other professional services may alter the direct relationship and responsibility of professional persons to their patients or clients for the professional services rendered. All professional relationships are subject to the same rules of contract and tort law and professional ethics as if no insurance plan were involved.
628.37 History
History: 1975 c. 223,
371,
422.
628.38
628.38
Disclosure requirements. The commissioner may by rule require insurers to deliver to prospective buyers of life or disability insurance, at a time specified in the rule, information consistent with
ss. 601.01 and
628.34 that will improve their ability to select appropriate coverage.
628.38 History
History: 1981 c. 82.
628.39
628.39
Extension of credit on premiums. The extension of credit to the insured upon a premium without interest for not exceeding 60 days from the effective date of the policy, or after that time with interest at not less than the legal rate nor more than 18% per year on the unpaid balance, is permissible. The payment of premiums on policies issued under a mass marketing program on an instalment basis through payroll deductions is not an extension of credit.
628.40
628.40
Effect of agent's appointment on insurer. Every insurer is bound by any act of its agent performed in this state that is within the scope of the agent's apparent authority, while the agency contract remains in force and after that time until the insurer has made reasonable efforts to recover from the agent its policy forms and other indicia of agency. Reasonable efforts shall include a formal demand in writing for return of the indicia, and notice to the commissioner if the agent does not comply with the demand promptly.
628.40 History
History: 1975 c. 371,
421.
628.46
628.46
Timely payment of claims. 628.46(1)
(1) Unless otherwise provided by law, an insurer shall promptly pay every insurance claim. A claim shall be overdue if not paid within 30 days after the insurer is furnished written notice of the fact of a covered loss and of the amount of the loss. If such written notice is not furnished to the insurer as to the entire claim, any partial amount supported by written notice is overdue if not paid within 30 days after such written notice is furnished to the insurer. Any part or all of the remainder of the claim that is subsequently supported by written notice is overdue if not paid within 30 days after written notice is furnished to the insurer. Any payment shall not be deemed overdue when the insurer has reasonable proof to establish that the insurer is not responsible for the payment, notwithstanding that written notice has been furnished to the insurer. For the purpose of calculating the extent to which any claim is overdue, payment shall be treated as being made on the date a draft or other valid instrument which is equivalent to payment was placed in the U.S. mail in a properly addressed, postpaid envelope, or, if not so posted, on the date of delivery. All overdue payments shall bear simple interest at the rate of 12% per year.
628.46(2)
(2) Notwithstanding
sub. (1), the payment of a claim shall not be overdue until 30 days after the insurer receives the proof of loss required under the policy or equivalent evidence of such loss. The payment of a claim shall not be overdue during any period in which the insurer is unable to pay such claim because there is no recipient who is legally able to give a valid release for such payment, or in which the insurer is unable to determine who is entitled to receive such payment, if the insurer has promptly notified the claimant of such inability and has offered in good faith to promptly pay said claim upon determination of who is entitled to receive such payment.
628.46 History
History: 1975 c. 375;
1979 c. 109 s.
16;
1979 c. 110 s.
60 (13);
1981 c. 38 s.
24; Stats. 1981 s. 628.46.
628.46 Annotation
Submission of legally binding offer from claimant is not necessary condition antecedent to maintenance of bad-faith excess liability action against insurer. Alt v. American Family Mut. Ins. Co. 71 W (2d) 340, 237 NW (2d) 706 (1976).
628.46 Annotation
Insured may bring tort action against insurer for failure to exercise good faith in settling insured's claim. This section is unrelated to such tort action. Anderson v. Continental Ins. Co. 85 W (2d) 675, 271 NW (2d) 368 (1978).
628.46 Annotation
Tort of bad faith handling of claim discussed. Davis v. Allstate Ins. Co. 101 W (2d) 1, 303 NW (2d) 596 (1981).
628.46 Annotation
Third party claimant cannot assert bad faith claim against insurer. Kranzush v. Badger State Mut. Cas. Co. 103 W (2d) 56, 307 NW (2d) 256 (1981).
628.46 Annotation
This section applies to service insurance corporations. Physicians Serv. Ins. Corp. v. Mitchell, 114 W (2d) 338, 338 NW (2d) 326 (Ct. App. 1983).
628.46 Annotation
Jury's imposition of punitive damages and finding of bad faith is adequate to show that insurer did not have reasonable proof that it was not responsible for claim and supports prejudgment interest pursuant to (1). Upthegrove v. Lumbermans Mut. Ins. Co. 146 W (2d) 470, 431 NW (2d) 689 (Ct. App. 1988).
628.46 Annotation
See note to 807.01, citing Upthegrove v. Lumbermans Ins. Co. 152 W (2d) 7, 447 NW (2d) 367 (Ct. App. 1989).
628.46 Annotation
This section makes no distinction between payment of claims based on judgment and all other claims; a claim may be due under sub. (2) far in advance of a judgment or award. Fritsche v. Ford Motor Credit Co. 171 W (2d) 280, 491 NW (2d) 119 (Ct. App. 1992).
628.46 Annotation
Whether to assess 12% interest is dependent on whether insurer had reasonable proof establishing it was not responsible for payment. U.S. Fire Ins. Co. v. Good Humor Corp. 173 W (2d) 804, 496 NW (2d) 730 (Ct. App. 1993).
628.46 Annotation
This section applies to all insurers. Allison v. Ticor Title Ins. Co. 979 F (2d) 1187 (1992).
628.46 Annotation
Excess liability insurance. Griffin. 62 MLR 375 (1979).
628.48
628.48
Risk retention groups. 628.48(1)
(1)
Prohibited marketing. A risk retention group may not do any of the following:
628.48(1)(a)
(a) Solicit or sell insurance to any person who is not eligible for membership in the risk retention group.
628.48(1)(b)
(b) Solicit or sell insurance or otherwise operate if the risk retention group is in a hazardous financial condition or is financially impaired.
628.48(2)
(2) Notice in policies. A risk retention group may not issue an insurance policy unless the following notice, in 10-point type, is included on the front page and declarations page of the policy:
Notice
This policy is issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws and regulations of your state. State insurance insolvency guaranty funds are not available for your risk retention group.
628.48 History
History: 1987 a. 247.
628.49
628.49
Regulation of managing general agents, reinsurance brokers and managers and controlling producers. After considering the applicable model acts adopted by the national association of insurance commissioners, the commissioner may promulgate rules that are reasonably necessary to regulate the business practices and transactions of the following:
628.49(4)
(4) Intermediaries that control an insurer.
628.49 History
History: 1991 a. 269.
COMPENSATION OF INTERMEDIARIES
628.51
628.51
Controlled business. No intermediary may receive any compensation from an insurer for effecting insurance upon the intermediary's property, life or other risk unless during the preceding 12 months the intermediary had effected other insurance with the same insurer with aggregate premiums exceeding the premiums on the intermediary's risks.
628.51 History
History: 1975 c. 371,
421.
628.61
628.61
Sharing commissions. 628.61(1)(1)
Prohibition. No intermediary or insurer may pay any consideration, nor reimburse out-of-pocket expenses, to any natural person for services performed within this state as an intermediary if he or she knows or should know that the payee is not licensed under
s. 628.04 or
628.09. No natural person may accept compensation for service performed as an intermediary unless the natural person is licensed under
s. 628.04 or
628.09.
628.61(2)
(2) Exceptions. This section does not prohibit:
628.61(2)(a)
(a) The payment of deferred commissions to formerly licensed agent and broker intermediaries or their assignees; or
628.61(2)(b)
(b) The proper exchange of business between agent and broker intermediaries lawfully licensed in this state.
628.77
628.77
Bonuses prohibited. 628.77(1)(1)
General. No life insurer or representative of a life insurer may provide any bonus, prize or award or similar additional compensation on insurance business transacted in this state, as a result of a contest or competition among intermediaries, except that awards may be given not primarily as compensation but as recognition of merit, if no such award has a cost in excess of $150 and if the aggregate cost of all such awards in any calendar year does not exceed 1.5% of the insurer's total first year life insurance premium income derived from sales in this state, excluding single premium income.
628.77(2)
(2) Business or educational conferences. Payment may be made to cover reasonable actually incurred expenses in connection with any educational conference, meeting or training course of an insurer or intermediary held for bona fide business or educational purposes.
