632.897(3)(c)
(c) If the right of the terminated insured to continue group policy coverage is terminated under
par. (a) 3. and the group member does not become eligible for coverage by a replacement group policy, the terminated insured has the right to convert to individual coverage under
sub. (4), unless
sub. (4) (d) applies.
632.897(3)(d)
(d) If the right of the terminated insured to continue group policy coverage is terminated under
par. (a) 1. the terminated insured, and a spouse or dependent of the terminated insured, if the terminated insured was eligible for continued group coverage under
sub. (2) (b) 2. and the spouse or dependent was covered under the group policy, have the right to convert to individual coverage under
sub. (4), unless
sub. (4) (d) applies.
632.897(3)(e)
(e) This subsection does not require coverage of expenses which are covered by medicare.
632.897(4)(a)(a) A terminated insured who elects conversion coverage under
sub. (2) (b) or
(3) (c) or
(d), the spouse or dependent of such a terminated insured, if the terminated insured is eligible under
sub. (2) (b) 2. and the spouse or dependent was covered under the group policy, and a terminated insured eligible under
sub. (9) and his or her dependents are entitled to have the insurer issue to them, without evidence of insurability, individual coverage reasonably similar to the terminated coverage under the group policy or individual policy. Any probationary or waiting periods required by such individual coverage shall be considered as being met to the extent such limitations have been met under the prior group policy or individual policy.
632.897(4)(b)
(b) The commissioner shall promulgate, by rule, 3 plans of individual coverage varying in degree of covered benefits to be offered as individual conversion policies. The insurer provides reasonably similar individual coverage if a person is offered his or her choice of the plans promulgated by the commissioner or is offered a high limit comprehensive plan of benefits regularly provided by the insurer for conversions and approved for this purpose by the commissioner. This paragraph does not apply if the policy being converted is a long-term care insurance policy.
632.897(4)(bm)
(bm) The commissioner shall specify, by rule, the minimum standards that an individual conversion policy must satisfy if the policy being converted is a long-term care insurance policy. An insurer provides reasonably similar individual coverage to a person converting a long-term care insurance policy if the person is offered an individual conversion policy that complies with the rules promulgated under this paragraph.
632.897(4)(c)
(c) If the first premium for conversion coverage is tendered to the insurer within 30 days after the notice of termination of group coverage, the individual conversion policy shall be issued with an effective date of the day following the termination of group or individual coverage.
632.897(4)(d)
(d) This subsection does not require individual coverage to be offered by an insurer offering group policies only. This subsection does not require an insurer to issue an individual conversion policy covering a terminated insured or his or her spouse or dependent if benefits provided or available to the covered person under
subds. 1. to
3., together with the converted policy's benefits, would result in overinsurance according to the insurer's standards for overinsurance, and these standards have been filed with and approved by the commissioner prior to use:
632.897(4)(d)1.
1. Similar benefits under another individual policy for which the terminated insured, spouse or dependent is eligible.
632.897(4)(d)2.
2. Similar benefits under a group policy for which the terminated insured, spouse or dependent is eligible.
632.897(4)(d)3.
3. Similar benefits for which the terminated insured, spouse or dependent is eligible by reason of any state or federal law.
632.897(5)
(5) A notification of the group continuation and individual conversion privileges shall be included in each certificate of coverage for a group policy as defined in
sub. (1) (c) 1.,
1m. or
3. and in any evidence of coverage provided by a group policy as defined in
sub. (1) (c) 2.
632.897(6)
(6) If the terminated insured elects to continue group coverage as provided in this section, the insurer may require conversion to individual coverage by the terminated insured and his or her spouse and dependents 18 months after the terminated insured elects the group coverage except as provided in
s. 103.10 (9) (d). The conditions, rights and procedures governing conversion under
sub. (4) (a) apply to this conversion.
632.897(8)
(8) Premium payments for continued group coverage required under this section shall be paid to the employer. The employer shall collect, and the insurer shall bill the employer for, those premiums. The insurer shall charge the claims experience of individuals covered under continued group coverage against the claims experience of the employer. An insurer is not required to issue a new certificate of insurance to an individual obtaining continued group coverage under this section.
632.897(9)(a)(a) No individual policy which provides coverage to the spouse of the insured may contain a provision for termination of coverage for the spouse solely as a result of a break in their marital relationship except by reason of the entry of a judgment of divorce or annulment of their marriage.
632.897(9)(b)
(b) Every individual policy which contains a provision for the termination of coverage of the spouse of the insured upon divorce or annulment shall contain a provision to the effect that upon divorce or annulment the former spouse has the right to obtain individual coverage under
sub. (4) and that coverage of the former spouse shall continue until he or she is notified of that right in accordance with
par. (c) if the premium for the coverage continues to be paid by or on behalf of the former spouse. This individual coverage shall provide to the former spouse the option to include dependent children previously covered.
632.897(9)(c)
(c) When the insurer is notified that the coverage of a spouse may be terminated because of a divorce or annulment, the insurer shall provide the former spouse written notification of the right to obtain individual coverage under
sub. (4), the premium amounts required and the manner, place and time in which premiums may be paid. This notice shall be given not less than 30 days before the former spouse's coverage would otherwise terminate. The premium shall be determined in accordance with the insurer's table of premium rates applicable to the age and class of risk of every person to be covered and to the type and amount of coverage provided. If the former spouse tenders the first monthly premium to the insurer within 30 days after the notice provided by this paragraph,
sub. (4) shall apply and the former spouse shall receive individual coverage commencing immediately upon termination of his or her coverage under the insured's policy.
632.897(10)(a)(a) No group policy or individual policy which provides coverage to dependent children of the group member or insured may deny eligibility for coverage to any child, or set a premium for any child which is different from that which is set for other dependent children, based solely on any of the following:
632.897(10)(a)1.
1. The fact that the child does not reside with the group member or insured or is dependent on another parent rather than the group member or insured.
632.897(10)(a)2.
2. The proportion of the child's support provided by the group member or insured.
632.897(10)(a)3.
3. The fact that the group member or insured does not claim the child as an exemption for federal income tax purposes under
26 USC 151 (c) (1) (B), or as an exemption for state income tax purposes under
s. 71.07 (8) (b) or under the laws of another state, if a court order under
s. 767.25 (4m) or the laws of another state assigns responsibility for the child's health care expenses to the group member or insured.
632.897(10)(a)5.
5. The fact that the child resides outside the insurer's geographical service area.
632.897(10)(am)
(am) If a court orders an individual to provide coverage for health care expenses for a child of the individual and the individual is eligible for family coverage under a group policy or individual policy, the insurer shall do all of the following:
632.897(10)(am)1.
1. Provide family coverage under the group policy or individual policy for the individual's child, if eligible for coverage, without regard to any enrollment period restrictions that may apply under the policy.
632.897(10)(am)2.
2. Provide family coverage under the group policy or individual policy for the individual's child, if eligible for coverage, upon application by the individual, the child's other parent, the department of workforce development or the county child support agency under
s. 59.53 (5).
632.897(10)(am)3.
3. After the child is covered under the group policy or individual policy, and as long as the individual is eligible for family coverage under the policy, continue to provide coverage for the child unless the insurer receives satisfactory written evidence that the court order is no longer in effect or that the child has coverage under another group policy or individual policy that provides comparable health care coverage.
632.897(10)(b)
(b) Paragraphs (a) and
(am) do not prohibit an insurer from determining the eligibility of a group member's or insured's child for coverage under the group policy or individual policy, or the premium for that coverage, based on factors that are not prohibited by
par. (a) 1. to
5. and that the insurer applies generally to determine the eligibility of children for coverage, and the premium for coverage, under the group policy or individual policy.
632.897(10)(bf)
(bf) If an insurer provides coverage under a group policy or an individual policy for a child of a group member or an insured who is not the custodial parent of the child, the insurer shall do all of the following:
632.897(10)(bf)1.
1. Provide to the custodial parent of the child information related to the child's enrollment.
632.897(10)(bf)2.
2. Permit the custodial parent of the child, a health care provider that provides services to the child or the department of health and family services to submit claims for covered services without the approval of the parent who is the group member or insured.
632.897(10)(bf)3.
3. Pay claims directly to the health care provider, the custodial parent of the child or the department of health and family services, as appropriate.
632.897(10)(c)
(c) This subsection applies to any group policy that would otherwise be exempt under
s. 600.01 (1) (b) 3. if at least 25 of the certificate holders or insureds are residents of this state.
632.897 Cross-reference
Cross-reference: See s.
49.45 (20) concerning exemption from continuation of group coverage.
632.897 Cross-reference
Cross Reference: See also ss.
Ins 3.41,
3.43,
3.44, and
6.51, Wis. adm. code.
632.897 Annotation
The federal employee retirement income security act (ERISA) preempts any state law that relates to employee benefit plans. General Split Corp. v. Mitchell,
523 F. Supp. 427 (1981).
632.897 Annotation
Wisconsin health insurance continuation/conversion law. Michal, WBB February 1982.
632.899
632.899
Medical savings accounts study. If the federal government enacts legislation providing for a federal income tax exemption for amounts deposited in a medical savings account and for any interest, dividends or other gain that accrues in the account if redeposited in the account, the commissioner shall conduct a study, to be completed within 4 years after the enactment of the federal legislation, of individuals and groups that had coverage under a high cost-share health plan, as defined in s.
632.898 (1) (c), 1995 stats., and that terminated that coverage in order to enroll in a health benefit plan that was not a high cost-share health plan, as defined in s.
632.898 (1) (c), 1995 stats. The commissioner shall submit a report of all findings, conclusions and recommendations to the appropriate standing committees in the manner provided under section
13.172 (3) of the statutes.
632.899 History
History: 1997 a. 27.
FRATERNAL INSURANCE
Subch. VII of ch. 632 Cross-reference
Cross Reference: See also ch.
Ins 1, Wis. adm. code.
632.91
632.91
Definition. In this subchapter:
632.91(1)
(1) "Insured employee" means an employee of a fraternal or of a subsidiary or other affiliate of a fraternal who is provided insurance benefits by the fraternal under
s. 614.10 (2) (c) 2. but is not a member of the fraternal.
632.91(2)
(2) "Owner" means the owner of a policy or certificate issued by a fraternal in accordance with
s. 614.10.
632.93
632.93
The fraternal contract. 632.93(1)
(1)
Issuance of certificate. A fraternal shall issue to each owner a policy or certificate specifying the benefits provided and containing at least in substance all sections of the laws of the fraternal which might result in the termination of coverage or the reduction of benefits. The policy or certificate, any riders or endorsements attached thereto, the laws of the fraternal, and the application and declarations made in connection therewith and signed by the applicant, constitute the agreement between the fraternal and the owner, and the policy or certificate shall so state.
632.93(2)
(2) Changes in laws of fraternals. Except as provided in
s. 614.24 (1m), any changes in the laws of a fraternal made subsequent to the issuance of a policy or certificate bind the owner and any beneficiary under the policy or certificate as if they had been in force at the time of the application, so long as they do not destroy or diminish benefits promised in the policy or certificate.
632.93(3)
(3) Proof of terms. Copies of any documents mentioned in
subs. (1) and
(2), certified by the secretary or corresponding officer of the fraternal, are evidence of the terms and conditions of the contract.
632.93(5)
(5) Grace period. Every fraternal certificate shall contain a provision entitling the owner to a grace period of not less than one month, or 30 days at the fraternal's option, for the payment of any premium due except the first, during which the death benefit shall continue in force. A fraternal may specify in the grace period provision that the overdue premium will be deducted from the death benefit in the event of death before it is paid.
632.93(6)
(6) Compliance with other provisions. If a fraternal's laws provide for expulsion or suspension of a member for any reason other than nonpayment of premium or under
s. 632.46, the fraternal's insurance certificate shall contain a provision that if a member is expelled or suspended for any reason other than nonpayment of premium or under
s. 632.46, the expelled member, or other owner who was provided insurance benefits under
s. 614.10 on the application of the expelled member, has the right to maintain the policy in force by continuing payment of the required premium.
632.93(7)
(7) Scope of application. This section applies to all contracts made by a fraternal beginning 6 months after December 18, 1979. A fraternal may elect to have this section apply at an earlier date, so long as it applies simultaneously to all such contracts and the fraternal gives the commissioner at least 30 days' notice of intention to adopt this section.
632.95
632.95
Fraud in obtaining membership. Subject to
s. 632.46, any certificate of membership secured by misrepresentation in or with reference to any application for membership or documentary or other proof for the purpose of obtaining membership in or noninsurance benefit from the fraternal is void, if the fraternal relied on it and it is either material or fraudulent.
632.95 History
History: 1975 c. 373.
632.95 Annotation
Legislative Council Note, 1975: This section continues the contractual portion of s. 208.38, edited with a change in meaning, to include nonfraudulent but material misrepresentation, and also to subject the provision to the rule of incontestability provided in s. 632.46. [Bill 643-S]
632.96
632.96
Beneficiaries in fraternal contracts. 632.96(1)
(1) Any owner may designate as beneficiary any person permitted by the laws of the fraternal. Those laws shall authorize the designation of the estate of a member or insured employee as beneficiary.
632.96 Annotation
Legislative Council Note, 1975: Sub. (1) states a rule slightly more restrictive of the range of permitted beneficiaries than for commercial life insurance; this reflects the nature of the fraternal. Sub. (2) applies the general provision for life insurance, subject to sub. (1). [Bill 643-S]
MISCELLANEOUS
632.97
632.97
Application of proceeds of credit insurance policy. Payment to a creditor of any amounts insured under the terms of a credit insurance policy reduces the debt proportionately. This rule does not apply to an insurance policy on which the debtor pays no part of the premium, directly or indirectly.
632.97 History
History: 1975 c. 375.
632.98
632.98
Worker's compensation insurance. Sections 102.31 and
102.62 apply to worker's compensation insurance.
632.98 History
History: 1975 c. 375,
421;
1979 c. 102.
632.99
632.99
Certifications of disability. Every insurer doing a health or disability insurance business in this state shall afford equal weight to a certification of disability signed by a physician with respect to matters within the scope of the physician's professional license and to a certification of disability signed by a chiropractor with respect to matters within the scope of the chiropractor's professional license for the purpose of insurance policies they issue. This section does not require an insurer to treat any certification of disability as conclusive evidence of disability.
632.99 History
History: 1981 c. 55.
