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. 631.22(1)
(1) In this section "consumer insurance policy" means a life, disability, property or casualty insurance policy, or a certificate or a substitute for a certificate for group life, disability, property or casualty insurance coverage, which is issued to a person for a personal, family or household purpose and a copy of which is customarily, in the insurance industry, delivered or is required by law, rule or agreement to be delivered to the person obtaining insurance coverage.
631.22(2)
(2) An insurer may provide a consumer insurance policy which is delivered to a person obtaining insurance coverage and is not exempt under
sub. (5) only if the consumer insurance policy is coherent, written in commonly understood language, legible, appropriately divided and captioned by its various sections and presented in a meaningful sequence. The commissioner shall promulgate rules establishing standards for the determination of compliance with this subsection.
631.22(3)
(3) This section does not apply to specific language or format required by state or federal law, rule or regulation.
631.22(4)
(4) This section applies only to consumer insurance policies delivered on or after the date which is 6 months after May 8, 1980 except the commissioner may provide by rule that this section will not apply to specific types of consumer insurance policies until a later date which is not later than the date which is 2 years after May 8, 1980 if the commissioner determines that delayed application is necessary to prevent an unreasonable burden upon insurers issuing those types of consumer insurance policies.
631.22(5)
(5) The commissioner may by rule exempt a type of consumer insurance policy from the application of this section if the commissioner finds that type of consumer insurance policy is generally understood by persons to whom it is delivered or that those persons are otherwise adequately protected.
631.22(6)
(6) A violation of this section does not void or render voidable any portion of an insurance policy and is not a defense to an action under the insurance policy.
631.22 History
History: 1979 c. 218.
631.23
631.23
Authorized clauses for insurance forms. 631.23(1)(1)
Promulgation of clauses. The commissioner may not promulgate mandatory uniform clauses that preclude an insurer from filing its own forms for approval under
s. 631.20; the commissioner may only disapprove such forms on the basis of the criteria stated in that section. Subject thereto, the commissioner may promulgate authorized clauses by rule upon a finding that:
631.23(1)(a)
(a) Price or coverage competition is ineffective because diversity in language or content makes comparison difficult;
631.23(1)(b)
(b) Provision of language, content or form of specific clauses is necessary to provide certainty of meaning of those clauses;
631.23(1)(c)
(c) Regulation of contract forms would be more effective or litigation would be substantially reduced if there were increased standardization of certain clauses; or
631.23(1)(d)
(d) Reasonable minimum standards of insurance protection are needed for policies to serve a useful purpose.
631.23(2)
(2) Degree of specificity. Any rule creating an authorized clause may prescribe that to be treated as an authorized clause there must be verbatim or substantial adherence to prescribed language, that certain standards or criteria must be met, or that certain drafting principles must be followed. The rules may also permit liberalization of prescribed language. If the proposed rule prescribed verbatim adherence, the commissioner shall make a finding that substantial adherence to the prescribed language is not sufficient and that liberalization of prescribed language will frustrate the purposes of the prescription. If an insurer uses authorized clauses as part of filed forms the commissioner may only disapprove those clauses under
s. 631.20 upon a finding that improper combination of clauses makes them violate the criteria of
s. 631.20.
631.23 History
History: 1975 c. 375,
421;
1979 c. 221.
631.23 Cross-reference
Cross Reference: See also s.
Ins 6.76, Wis. adm. code.
631.24
631.24
Credit life and disability insurance. Section 631.20 does not apply to credit life and disability insurance forms which are subject to approval under
s. 424.209.
631.24 History
History: 1979 c. 102.
631.27
631.27
Rules of law as provisions of contracts. By rule, the commissioner may require an insurer to insert in a policy any rule of law stated in
chs. 600 to
646 and
655 that is applicable to the contents or interpretation of an insurance contract.
631.28
631.28
Notice of right to file complaint. 631.28(1)
(1)
Requirement to provide notice. Every insurer shall provide notice to its policyholders and its insureds of the right to file a complaint with the office in the manner prescribed by rule under
sub. (2).
631.28(2)
(2) Contents by rule. The commissioner shall promulgate rules specifying the contents of a notice that insurers must disseminate under
sub. (1), and when and in what manner the notice must be provided. The rules shall describe how a policyholder, insured or other person may make a complaint with the office about an insurer, an intermediary or other insurance matter. The rules may also specify the form, including the type size, in which insurers must present the notice.
631.28 History
History: 1991 a. 154.
631.28 Cross-reference
Cross Reference: See also s.
Ins 6.85, Wis. adm. code.
SPECIFIC CLAUSES IN CONTRACTS
631.31
631.31
Clauses required to be on first page. 631.31(1)
(1)
List of clauses. The following clauses of insurance policies shall appear on the first page of the policy:
631.31(1)(b)
(b)
Several liability. Information that 2 or more insurers undertake only several liability, as required by
s. 631.41;
631.31(1)(e)
(e)
Right to return policy. The right to return a disability insurance policy under
s. 632.73, except that this clause may be conspicuously attached to the first page rather than printed on it.
631.31(2)
(2) Manner of display. Clauses listed in
sub. (1) shall be displayed conspicuously and separately from any other clauses.
631.31 History
History: 1975 c. 375;
1981 c. 218.
631.36
631.36
Termination of insurance contracts by insurers. 631.36(1)(a)(a)
General. Except as otherwise provided in this section or in other statutes or by rule under
par. (c), this section applies to all contracts of insurance based on forms which are subject to filing and approval under
s. 631.20 (1) (a).
631.36(1)(b)
(b)
Contracts more favorable to policyholder. The contract may provide terms more favorable to policyholders than are required by this section.
631.36(1)(c)
(c)
Exemption by rule. The commissioner may by rule totally or partially exempt from this section classes or parts of classes of insurance contracts if the policyholders do not need protection against arbitrary or unannounced termination.
631.36(1)(d)
(d)
Other rights. The rights provided by this section are in addition to and do not prejudice any other rights the policyholder may have at common law or under other statutes.
631.36(1)(e)
(e)
Rescission or reformation. This section does not apply to the rescission or reformation of any insurance contract.
631.36(2)(a)(a)
Permissible grounds. Except as provided by
par. (c) and
sub. (3) and
s. 655.24 (2) (b), no insurance policy may be canceled by the insurer prior to the expiration of the agreed term except for failure to pay a premium when due or on grounds stated in the policy, which must be comprehended within one of the following classes:
631.36(2)(a)2.
2. Substantial change in the risk assumed, except to the extent that the insurer should reasonably have foreseen the change or contemplated the risk in writing the contract;
631.36(2)(a)3.
3. Substantial breaches of contractual duties, conditions or warranties; or
631.36(2)(a)4.
4. Attainment of the age specified as the terminal age for coverage, in which case the insurer may cancel by notice under
par. (b) accompanied by a tender of a proportional return of premium.
631.36(2)(b)
(b)
Notice. No cancellation under
par. (a) is effective until at least 10 days after the 1st class mailing or delivery of a written notice to the policyholder.
631.36(2)(c)
(c)
New policies. Paragraphs (a) and
(b) do not apply to any insurance policy that has not been previously renewed if the policy has been in effect less than 60 days at the time the notice of cancellation is mailed or delivered. No cancellation under this paragraph is effective until at least 10 days after the 1st class mailing or delivery of a written notice to the policyholder.
Subsections (6) and
(7) do not apply to such a policy.
631.36(3)
(3) Anniversary cancellation or alteration. A policy may be issued for a term longer than one year or for an indefinite term with a clause providing for cancellation by the insurer in the manner provided in
sub. (4) (a) for nonrenewals, except the notice must be given at least 60 days prior to any anniversary date and an insurer may not cancel a policy solely because of the termination of an insurance marketing intermediary's contract with the insurer unless the insurer complies with
sub. (4m). The clause may also provide for alteration of the terms or premium by the insurer as provided in
sub. (5) (c), except the clause must then permit cancellation by the policyholders as provided in
sub. (5) (c).
631.36(4)(a)(a)
Notice required. Subject to
subs. (2) and
(3), a policyholder has a right to have the policy renewed, on the terms then being applied by the insurer to similar risks, for an additional period of time equivalent to the expiring term if the agreed term is one year or less, or for one year if the agreed term is longer than one year, unless at least 60 days prior to the date of expiration provided in the policy a notice of intention not to renew the policy beyond the agreed expiration date is mailed or delivered to the policyholder, or with respect to failure timely to pay a renewal premium a notice is given, not more than 75 days nor less than 10 days prior to the due date of the premium, which states clearly the effect of nonpayment of premium by the due date.
631.36(4)(am)
(am)
Prohibited nonrenewals. Notwithstanding
par. (a) an insurer may not refuse to renew a policy solely because of the termination of an insurance marketing intermediary's contract with the insurer unless the insurer complies with
sub. (4m).
631.36(4)(b)
(b)
Exceptions. This subsection does not apply if the policyholder has insured elsewhere, has accepted replacement coverage or has requested or agreed to nonrenewal, or if the policy is expressly designated as nonrenewable.
631.36(4m)
(4m) Policy cancellation. An insurer may refuse to renew or may cancel a policy under
sub. (3) or
(4) solely because of the termination of an insurance marketing intermediary's contract with the insurer only if the notice of nonrenewal or cancellation contains an offer to continue or renew the policy with the insurer if the insurer receives a written request from the policyholder prior to the cancellation or renewal date. The insurer shall continue or renew the policy if a timely request is received unless the policyholder does not meet normal underwriting criteria.
631.36(5)(a)(a)
General. Subject to
pars. (b) and
(d), if the insurer offers or purports to renew the policy but on less favorable terms or at higher premiums, the new terms or premiums take effect on the renewal date if the insurer sent by 1st class mail or delivered to the policyholder notice of the new terms or premiums at least 60 days prior to the renewal date. If the insurer notifies the policyholder within 60 days prior to the renewal date, the new terms or premiums do not take effect until 60 days after the notice is mailed or delivered, in which case the policyholder may elect to cancel the renewal policy at any time during the 60-day period. The notice shall include a statement of the policyholder's right to cancel. If the policyholder elects to cancel the renewal policy during the 60-day period, return premiums or additional premium charges shall be calculated proportionately on the basis of the old premiums. If the insurer does not notify the policyholder of the new premiums or terms as required by this subsection prior to the renewal date, the insurer shall continue the policy for an additional period of time equivalent to the expiring term and at the same premiums and terms of the expiring policy, except as permitted under
sub. (2) or
(3).
631.36(5)(b)
(b)
Exception. Paragraph (a) does not apply if the only change that is adverse to the policyholder is a premium increase and if either of the following applies to the premium increase:
631.36(5)(b)1.
1. The premium increase is less than 25% and is generally applicable to the class of business to which the policy belongs.
631.36(5)(b)2.
2. The premium increase results from a change based on action by the insured that alters the nature or extent of the risk insured against, including but not limited to a change in the classification or the units of exposure or increased policy coverage.
631.36(5)(c)
(c)
Anniversary alteration. Subject to
par. (d), an insurer may alter the terms or premium of a policy issued for a term longer than one year or for an indefinite term on the anniversary date only if notice of less favorable terms or premiums is sent by 1st class mail or delivered to the policyholder at least 60 days prior to the anniversary date. If the insurer notifies the policyholder within 60 days prior to the anniversary date, the new terms or premiums do not take effect until 60 days after the notice is mailed or delivered, in which case the policyholder may elect to cancel the policy at any time during the 60-day period. The notice shall include a statement of the policyholder's right to cancel. If the policyholder elects to cancel the policy during the 60-day period, return premiums or additional premium charges shall be calculated proportionately on the basis of the old premiums. If the insurer does not notify the policyholder of the new premiums or terms as required by this subsection prior to the anniversary date, the insurer shall continue the policy until the next anniversary date or the renewal date, whichever is earlier, at the same premiums and terms as for the previous period, except as permitted under
sub. (2) or
(3).
