631.08(1)
(1)
General. Except as otherwise provided in
chs. 600 to
646 and
655, general contract law applies to mistakes in insurance contracts.
631.08(2)
(2) Person to whom proceeds payable in property insurance. Mistake in designating the person to whom the insurance is payable in a policy of property insurance does not void the policy nor constitute a defense for the insurer unless the mistake was due to misrepresentation or concealment by the owner of the property or someone representing the owner in procuring the policy, or unless the company would not have issued or continued the policy if it had known the truth.
631.09
631.09
Knowledge and acts of agents. 631.09(1)
(1)
Imputation of knowledge. An insurer is deemed to know any fact material to the risk or which breaches a condition of the policy, if the agent who bound the insurer or issued the policy or transmitted the application to the insurer knew it at the time the agent acted, or if thereafter any of the insurer's agents with whom the policyholder is then dealing as agent of the insurer learns it in the course of the agent's dealing with the policyholder, and knows that it pertains to a policy written by the insurer.
631.09(2)
(2) Acts of agent. A failure by any policyholder or insured to perform an act required to perfect his or her rights under the policy, or failure to perform the act in the time and manner prescribed, does not affect the insurer's obligations under the policy if the failure was caused by an act, statement or representation or omission to perform a duty by an agent of the insurer who has apparent authority, whether or not the agent was within the actual scope of the agent's authority.
631.09(3)
(3) Effect of notice to agent. Notice given by or on behalf of the policyholder or insured to any authorized agent of the insurer with particulars sufficient to identify the policy is notice to the insurer.
631.09(4)
(4) Collusion. Subsections (1) and
(2) do not apply if the agent and the policyholder or insured acted in collusion to deceive or defraud the insurer, or if the policyholder or insured knew the agent was acting beyond the scope of the agent's authority.
631.09(5)
(5) Group policyholder not agent. No person is an agent of an insurer merely because the person is a policyholder of a group insurance policy.
631.09(6)
(6) Liability under common law. This section does not diminish any liability of the insurer that would exist under common law.
631.09 History
History: 1975 c. 375,
421.
631.09 Annotation
Absent proof that an agent knew, or should have known, of financial problems of a reinsurer from whom the agent procured insurance, the agent is not liable when the reinsurer later becomes insolvent. Master Plumbers Mut. Liab. v. Cormany & Bird,
79 Wis. 2d 308,
255 N.W.2d 533 (1977).
631.09 Annotation
When an insured elected to have open heart surgery after an agent indicated that the insurer would probably pay the bills, that action was sufficient reliance to estop the insurer from denying coverage. Nolden v. Mutual Benefit Life Insurance Co.
80 Wis. 2d 353,
259 N.W.2d 75 (1977).
631.11
631.11
Representations, warranties and conditions. 631.11(1)(1)
Effect of negotiations for contract. 631.11(1)(a)(a)
Statement or warranty. No statement, representation or warranty made by a person other than the insurer or an agent of the insurer in the negotiation for an insurance contract affects the insurer's obligations under the policy unless it is stated in any of the following:
631.11(1)(a)2.
2. A written application signed by the person, provided that a copy of the written application is made a part of the policy by attachment or endorsement.
631.11(1)(a)3.
3. A written communication provided by the insurer to the insured within 60 days after the effective date of the policy.
631.11(1)(b)
(b)
Misrepresentation or breach of affirmative warranty. No misrepresentation, and no breach of an affirmative warranty, that is made by a person other than the insurer or an agent of the insurer in the negotiation for or procurement of an insurance contract constitutes grounds for rescission of, or affects the insurer's obligations under, the policy unless, if a misrepresentation, the person knew or should have known that the representation was false, and unless any of the following applies:
631.11(1)(b)1.
1. The insurer relies on the misrepresentation or affirmative warranty and the misrepresentation or affirmative warranty is either material or made with intent to deceive.
631.11(1)(b)2.
2. The fact misrepresented or falsely warranted contributes to the loss.
631.11(3)
(3) Effect of failure of condition or breach of promissory warranty. No failure of a condition prior to a loss and no breach of a promissory warranty constitutes grounds for rescission of, or affects an insurer's obligations under, an insurance policy unless it exists at the time of the loss and either increases the risk at the time of the loss or contributes to the loss. This subsection does not apply to failure to tender payment of premium.
631.11(4)(a)(a)
Knowledge when policy issued. No misrepresentation made by or on behalf of a policyholder and no breach of an affirmative warranty or failure of a condition constitutes grounds for rescission of, or affects an insurer's obligations under, an insurance policy if at the time the policy is issued the insurer has either constructive knowledge of the facts under
s. 631.09 (1) or actual knowledge. If the application is in the handwriting of the applicant, the insurer does not have constructive knowledge under
s. 631.09 (1) merely because of the agent's knowledge.
631.11(4)(b)
(b)
Knowledge acquired after policy issued. If after issuance of an insurance policy an insurer acquires knowledge of sufficient facts to constitute grounds for rescission of the policy under this section or a general defense to all claims under the policy, the insurer may not rescind the policy and the defense is not available unless the insurer notifies the insured within 60 days after acquiring such knowledge of its intention to either rescind the policy or defend against a claim if one should arise, or within 120 days if the insurer determines that it is necessary to secure additional medical information.
631.11(4m)(a)(a)
Copy of application to be made available. The policyholder under a life or disability insurance policy and any person whose life or health is insured under the policy may request in writing a copy of the application if he or she did not receive the policy or a copy of it, or if the policy has been reinstated or renewed without attachment of a copy of the original application. If the insurer does not deliver or mail a copy as requested within 15 working days after receipt of the request by the insurer or its agent or, in the case of a group policy certificate holder, does not inform such person within the same period how he or she may inspect the policy and application during normal business hours at a place reasonably convenient to the certificate holder, nothing in the application affects the insurer's obligations under the policy to the person making the request. A person whose life or health is insured under a group life or disability insurance policy has the same right to request a copy of any document specified in
par. (b), including the certificate.
631.11(4m)(b)
(b)
Statement or warranty. No statement, representation or warranty made by or on behalf of a particular certificate holder under a group life or disability insurance policy affects the insurer's obligations under the certificate unless it is stated in the certificate, or in a written document signed by the certificate holder, a copy of which is supplied to the certificate holder or the beneficiary whose rights would be affected.
631.11 History
History: 1975 c. 375,
421;
1977 c. 339 s.
44; Stats. 1977 s. 641.11;
1983 a. 189 s.
329 (25);
1995 a. 259.
631.11 Annotation
If a question on a form calls for the applicant's judgment or opinion as a lay person, any ambiguity should be construed against the insurer. Nolden v. Mutual Benefit Life Ins. Co.
80 Wis. 2d 353,
259 N.W.2d 75 (1977).
631.11 Annotation
An insured's contradictory statements constituted a breach of the contractual duties of notice and cooperation. Dietz v. Hardware Dealers Mut. Fire Ins. Co.
88 Wis. 2d 496,
276 N.W.2d 808 (1979).
631.11 Annotation
Third parties may recover against an insurer even though the insured's fraudulent application voided the policy under s. 631.11. Rauch v. American Family Insurance Co.
115 Wis. 2d 257,
340 N.W.2d 478 (1983).
631.11 Annotation
Sub. (2) applies a reliance test to misrepresentations made in the negotiation or application for insurance, and not to statements made in proof of loss forms. Tempelis v. Aetna Casualty & Surety Co.
164 Wis. 2d 17,
473 N.W.2d 549 (Ct. App. 1991).
631.11 Annotation
In order to make a written application form a part of an insurance policy by endorsement, the insurer must specifically write across the application itself that it is an endorsement and part of the policy. Smith v. Dodgeville Mutual Insurance Co.
212 Wis. 2d 226,
568 N.W.2d 31 (Ct. App. 1997),
96-3352.
631.11 Annotation
Sub. (3) only applies to conditions subsequent to a policy becoming effective, not conditions precedent. Conditions to the making of the contract, conditions precedent, cannot be implicated by the statute because the policy has not yet come into existence. Fox v. Catholic Knights Ins. Society, 2003 WI 87,
263 Wis. 2d 207,
665 N.W.2d 181,
01-1469.
631.13
631.13
Incorporation by reference. No insurance contract may contain any agreement or incorporate any provision not fully set forth in the policy or in an application or other document attached to and made a part of the policy at the time of its delivery except that:
631.13(1)
(1) Rates. Any policy may by reference incorporate rate schedules and classifications of risks and short-rate tables filed with the commissioner; and
631.13(2)
(2) Complex contracts. By rule or order or by approval of a form the commissioner may authorize for complex contracts incorporation by reference of provisions for administrative arrangements, premium schedules and payment procedures.
631.13 History
History: 1975 c. 375.
631.15
631.15
Contract rights under noncomplying policies. 631.15(1)(1)
Enforcement of policy terms. Except as otherwise specifically provided by statute, a policy is enforceable against the insurer according to its terms, even if it exceeds the authority of the insurer.
631.15(3m)
(3m) Enforcement of statute and rule requirements. A policy that violates a statute or rule is enforceable against the insurer as if it conformed to the statute or rule.
631.15(4)
(4) Reformation of contract. Upon written request of the policyholder or an insured whose rights under the policy are continuing and not transitory, an insurer shall reform and reissue its written policy to comply with the requirements of the law existing at the date of issue or last renewal of the policy.
631.15 History
History: 1975 c. 375;
1987 a. 247.
631.15 Annotation
When uninsured motorist coverage in the amount of $25,000 was contracted for, in violation of the requirement for $50,000 coverage under s. 632.32 (4m) (d), the higher level of coverage was read into the policy under sub. (3m), even though it was not reflected in the premium paid. Brunson v. Ward, 2001 WI 89,
245 Wis. 2d 163,
629 N.W.2d 140,
98-3002.
631.17
631.17
Written reason for coverage denial. 631.17(2)
(2) An insurer that denies coverage under an individual or group life or disability insurance policy or a certificate of group life or disability insurance shall advise the applicant or proposed insured in writing of the reasons for the denial.
631.17 History
History: 1999 a. 95.
APPROVAL OF FORMS
631.20
631.20
Filing and approval of forms. 631.20(1)(a)(a) No form subject to
s. 631.01 (1), except as exempted under
s. 631.01 (2) to
(5) or by rule under
par. (b), may be used unless it has been filed with and approved by the commissioner and unless the insurer certifies that the form complies with
chs. 600 to
655 and rules promulgated under
chs. 600 to
655. It is deemed approved if it is not disapproved within 30 days after filing, or within a 30-day extension of that period ordered by the commissioner prior to the expiration of the first 30 days.
631.20(1)(b)
(b) Subject to
s. 655.24 (1), the commissioner may by rule exempt certain classes of policy forms from prior filing and approval.
631.20(2)
(2) Grounds for disapproval. The commissioner may disapprove a form upon a finding:
631.20(2)(a)
(a) That it is inequitable, unfairly discriminatory, misleading, deceptive, obscure or encourages misrepresentation, including cases where the form:
631.20(2)(a)1.
1. Is misleading because its benefits are too restricted to achieve the purposes for which the policy is sold;
631.20(2)(a)2.
2. Contains provisions whose natural consequence is to obscure or lessen competition;
631.20(2)(a)4.
4. Is misleading, deceptive or obscure because of such physical aspects as format, typography, style, color, material or organization;
631.20(2)(b)
(b) That it provides benefits or contains other provisions that endanger the solidity of the insurer;
631.20(2)(c)
(c) That in the case of the policy, though not of riders and endorsements, it fails to provide the exact name of the insurer and the full address of its home office; or
631.20(2)(d)
(d) That it violates a statute or a rule promulgated by the commissioner, or is otherwise contrary to law.
631.20(2)(f)
(f) In the case of a policy form under
ch. 149, that any of the following applies:
631.20(2)(f)1.
1. The benefit design is not comparable to a typical comprehensive individual health insurance policy offered in the private sector market in this state.
631.20(2)(f)2.
2. The benefit levels are not generally reflective of and commensurate with comprehensive health insurance coverage offered in the private individual market in the state.
631.20(2)(f)3.
3. The copayments, deductibles, and coinsurance are not actuarially equivalent to comprehensive individual plans and would create undue financial hardship.
631.20(2)(f)4.
4. It is inconsistent with the purpose of providing health care coverage to those unable to obtain coverage in the private market.
631.20(3)
(3) Subsequent disapproval. Whenever the commissioner finds, after a hearing, that a form approved or deemed to be approved under
sub. (1) (a) would be disapproved under
sub. (2) if newly filed, the commissioner may order that on or before a date not less than 30 nor more than 90 days after the order the use of the form shall be discontinued or appropriate changes shall be made.
631.20(4)
(4) Contents of order of disapproval. The commissioner's disapproval must be in writing and constitutes an order. It must state the reasons for disapproval sufficiently explicitly that the insurer is provided reasonable guidance in reformulating its proposals.
631.20(5)
(5) Explicit approval of certain clauses. General approval of a form under this section, or failure to disapprove, does not constitute approval of clauses specified in
s. 631.21.
631.20(6)
(6) Approved form which violates statute or rule. 631.20(6)(a)(a) The penalties under
s. 601.64 (3) to
(5) may not be imposed against an insurer for using a form that does not comply with a statute or rule if the statute or rule was in effect on the date the form was approved or deemed to be approved under
sub. (1) (a).
631.20(6)(b)
(b) Use of a form that does not comply with a statute or rule which takes effect after the date the form was approved or deemed to be approved under
sub. (1) (a) is a violation of the statute or rule, and the penalties under
s. 601.64 may be imposed against the insurer using the form.
631.20 Cross-reference
Cross Reference: See also ss.
Ins 6.05,
6.07, and
6.76, Wis. adm. code.
631.21
631.21
Explicit approval required. 631.21(1)
(1)
Required approval. Despite the general approval of a form under
s. 631.20, the following clauses are not approved even if contained in the form unless the commissioner gives explicit approval to them:
631.21(1)(a)
(a)
Expeditious notice. Clauses requiring more expeditious notice than 1st class mail, as provided in
s. 631.81 (2).
631.21(1)(c)
(c)
Reinstatement fees. A schedule of reinstatement fees under
s. 632.74, if made a part of the policy. Such a schedule need not be included in the contract but may be given approval as a separate document specifically made applicable to particular classes of policies.
631.21(2)
(2) Effect of failure to obtain explicit approval. If an insurer fails to obtain explicit approval from the commissioner for the clauses under
sub. (1), the clauses shall be null and void.
631.21 History
History: 1975 c. 375;
1985 a. 280.
631.21 Cross-reference
Cross Reference: See also ss.
Ins 6.05 and
6.07, Wis. adm. code.
631.22
631.22
Consumer insurance policy readability.
