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.
632.77
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 mandatory 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 employes 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 employes 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 employes 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 employes or members is terminated and immediately replaced by another policy or plan providing similar coverage to such employes 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.
632.793
632.793
Notice of loss of primary insurance coverage due to age. 632.793(1)(1)
Notice to insured and employer. If an individual who is covered under a group disability insurance policy, as defined in
s. 632.895 (1) (a), that is purchased by or on behalf of an employer to provide coverage for employes will lose primary coverage under the policy upon reaching age 65, the insurer issuing the policy shall provide written notice of the change in coverage status by regular mail to the individual and shall send a copy of the notice by regular mail to the employer. The insurer shall provide the notice not less than 30 nor more than 60 days before the individual becomes 65 years of age. The notice shall specify the date on which the insurance coverage will no longer be primary and shall inform the individual that he or she will be eligible for coverage under the federal medicare program at age 65.
632.793(2)
(2) Applicability. Subsection (1) does not apply if the employer has at least 20 employes for each working day in at least 20 calendar weeks in the current year or the preceding year.
632.793 History
History: 1993 a. 108.
632.795
632.795
Open enrollment upon liquidation. 632.795(1)
(1)
Definition. In this section, "liquidated insurer" means an insurer ordered liquidated under
ch. 645 or under similar laws of another jurisdiction.
632.795(2)
(2) Coverage for group members. Except as provided in
sub. (5) and unless otherwise provided by rule or order of the commissioner, an insurer described in
sub. (3) shall permit insureds or enrolled participants of a liquidated insurer's group health care policy or plan to obtain coverage under a comprehensive group health care policy or plan offered by the insurer in the manner and under the terms required by
sub. (4).
632.795(3)
(3) Participating insurers. Subsection (2) applies to an insurer that participated in the most recent enrollment period in which the group members were able to choose among coverage offered by the liquidated insurer and coverage offered by one or more other insurers, if all of the following are satisfied:
632.795(3)(a)
(a) Coverage under a comprehensive group health care policy or plan offered by the insurer was selected by one or more members of the group in the most recent enrollment period.
632.795(3)(b)
(b) The most recent enrollment period occurred on or after July 1, 1989.
632.795(4)(a)(a) An insurer subject to
sub. (2) shall provide coverage under the same policy form and for the same premium as it originally offered in the most recent enrollment period, subject only to the medical underwriting used in that enrollment period. Unless otherwise prescribed by rule, the insurer may apply deductibles, preexisting condition limitations, waiting periods or other limits only to the extent that they would have been applicable had coverage been extended at the time of the most recent enrollment period and with credit for the satisfaction or partial satisfaction of similar provisions under the liquidated insurer's policy or plan. The insurer may exclude coverage of claims that are payable by a solvent insurer under insolvency coverage required by the commissioner or by the insurance regulator of another jurisdiction. Coverage shall be effective on the date that the liquidated insurer's coverage terminates.
632.795(4)(b)
(b) An insurer subject to
sub. (2) shall offer coverage to the group members, and the policyholder shall provide group members with the opportunity to obtain coverage, in the manner and within the time limits required by the commissioner by rule or order.
632.795(5)
(5) Medical assistance enrollees. This section does not apply to persons enrolled in a health care plan offered by a liquidated insurer if the persons are enrolled in that plan under a contract between the department of health and family services and the liquidated insurer under
s. 49.45 (2) (b) 2.
632.795 History
History: 1989 a. 23;
1995 a. 27 s.
9126 (19).
632.797
632.797
Disclosure of group health claims experience. 632.797(1)(a)(a) Except as provided in
subs. (2) and
(3), an insurer shall provide the policyholder of a group or blanket disability insurance policy, or an employer that provides health care coverage to its employes through a multiple-employer trust, with the policyholder's or the employer's aggregate group health claims experience for the current policy period, and for up to 2 policy periods immediately preceding the current policy period if the insurer provided coverage during those periods, upon request from the policyholder or employer.
632.797(1)(b)
(b) The insurer shall provide the information under
par. (a) no later than 30 days after receiving a request for that information from the policyholder or employer.
632.797(1)(c)
(c) The insurer may not charge the policyholder or the employer for providing the information under
par. (a) one time in a 12-month period.
632.797(2)
(2) An insurer is not required to provide the information under
sub. (1) unless the policyholder or employer requesting the information provides coverage under the policy for at least 50 individuals, exclusive of individuals who have coverage under the policy as a dependent of another individual.
632.797(3)
(3) Notwithstanding
sub. (1), an insurer is not required to provide health claims experience under
sub. (1) for any period of time that is before 18 months before the date on which the information is requested.
632.797(4)
(4) Subsection (1) does not require that an insurer provide the policyholder of a group or blanket disability insurance policy, or an employer that provides health care coverage to its employes through a multiple-employer trust, with the health claims experience of an individual employe or insured.
632.797(5)
(5) An insurer is not required under
sub. (1) to provide information that identifies an individual or that is confidential under
s. 146.82.
