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) Except as the commissioner may provide by rule under
sub. (5) and notwithstanding
subs. (1) and
(2) and
s. 631.36 (4), an insurer is not required to renew individual health benefit plan coverage that complies with all of the following:
632.7495(4)(a)
(a) The coverage is marketed and designed to provide short-term coverage as a bridge between coverages.
632.7495(4)(b)
(b) The coverage has a term of not more than 12 months.
632.7495(4)(c)
(c) The coverage term aggregated with all consecutive periods of the insurer's coverage of the insured by individual health benefit plan coverage not required to be renewed under this subsection does not exceed 18 months. For purposes of this paragraph, coverage periods are consecutive if there are no more than 63 days between the coverage periods.
632.7495(5)
(5) The commissioner shall promulgate rules governing disclosures related to, and may promulgate rules setting standards for, the sale of individual health benefit plans that an insurer is not required to renew under
sub. (4).
632.7495 History
History: 1997 a. 27,
237;
2009 a. 28.
632.7497
632.7497
Modifications at renewal. 632.7497(1)
(1) In this section, "individual major medical or comprehensive health benefit plan" includes coverage under a group policy that is underwritten on an individual basis and issued to individuals or families.
632.7497(2)
(2) An insurer that issues an individual major medical or comprehensive health benefit plan shall, at the time of a coverage renewal, at the request of an insured, permit the insured to do either of the following:
632.7497(2)(a)
(a) Change his or her coverage to any of the following:
632.7497(2)(a)1.
1. A different but comparable individual major medical or comprehensive health benefit plan currently offered by the insurer.
632.7497(2)(a)2.
2. An individual major medical or comprehensive health benefit plan currently offered by the insurer with more limited benefits.
632.7497(2)(a)3.
3. An individual major medical or comprehensive health benefit plan currently offered by the insurer with higher deductibles.
632.7497(2)(b)
(b) Modify his or her existing coverage by electing an optional higher deductible, if any, under the individual major medical or comprehensive health benefit plan.
632.7497(3)(a)(a) The insurer may not impose any new preexisting condition exclusion under the new or modified coverage under
sub. (2) that did not apply to the insured's original coverage and shall allow the insured credit under the new or modified coverage for the period of original coverage.
632.7497(3)(b)
(b) For the new or modified coverage, the insurer may not rate for health status other than on the insured's health status at the time the insured applied for the original coverage and as the insured disclosed on the original application.
632.7497(4)(a)(a) Annually, the insurer shall mail to each insured under an individual major medical or comprehensive health benefit plan issued by the insurer, a notice that includes all of the following information:
632.7497(4)(a)1.
1. That the insured has the right to elect alternative coverage as described in
sub. (2).
632.7497(4)(b)
(b) The insurer shall mail the notice under
par. (a) not more than 3 months nor less than 60 days before the renewal date of the insured's plan.
632.7497(5)(a)(a) Nothing in this section requires an insurer to issue alternative coverage under
sub. (2) if the insured's coverage may be nonrenewed or discontinued under
s. 632.7495 (2),
(3) (b), or
(4).
632.7497(5)(b)
(b) Notwithstanding
s. 600.01 (1) (b) 3. and
4., this section applies to a group health benefit plan described in
s. 600.01 (1) (b) 3. or
4. if that group health benefit plan is an individual major medical or comprehensive health benefit plan as defined in
sub. (1).
632.7497 History
History: 2009 a. 28.
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)(ac)1.1. Notwithstanding
par. (a), no claim or loss incurred or disability commencing after 12 months from the date of issue of an individual disability insurance policy, as defined in
s. 632.895 (1) (a), 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 the loss.
632.76(2)(ac)2.
2. Except as provided in
subd. 3., an individual disability insurance policy, as defined in
s. 632.895 (1) (a), other than a short-term policy subject to
s. 632.7495 (4) and
(5), may not define a preexisting condition more restrictively than a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within 12 months before the effective date of coverage.
632.76(2)(ac)3.
3. Except as the commissioner provides by rule under
s. 632.7495 (5), all of the following apply to an individual disability insurance policy that is a short-term policy subject to
s. 632.7495 (4) and
(5):
632.76(2)(ac)3.a.
a. The policy may not define a preexisting condition more restrictively than a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received before the effective date of coverage.
632.76(2)(ac)3.b.
b. The policy shall reduce the length of time during which a preexisting condition exclusion may be imposed by the aggregate of the insured's consecutive periods of coverage under the insurer's individual disability insurance policies that are short-term policies subject to
s. 632.7495 (4) and
(5). For purposes of this
subd. 3. b., coverage periods are consecutive if there are no more than 63 days between the coverage periods.
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. Notwithstanding
par. (ac) 2., 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.
632.76 Cross-reference
Cross-reference: See also s.
Ins 3.39, Wis. adm. code.
632.76 Annotation
A generic exclusion of all diseases or conditions diagnosed or treated before issuance of the policy does not constitute exclusion by "name or specific description" under sub. (2). Peterson v. Equitable Life Assurance Society,
57 F. Supp. 2d 692 (1999).
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 Health Insurance 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 employees 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 employees 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 employees 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 employees or members is terminated and immediately replaced by another policy or plan providing similar coverage to such employees 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.
632.79 Cross-reference
Cross-reference: See also s.
Ins 6.51, Wis. adm. code.
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 employees 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 employees for each working day in at least 20 calendar weeks in the current year or the preceding year.
