632.69(15)
(15) Fraud prevention and control; fraudulent life settlement acts. 632.69(15)(a)(a) No person may commit a fraudulent life settlement act.
632.69(15)(b)
(b) No person may knowingly or intentionally interfere with the enforcement of this subsection or sub.
(13) or investigations of suspected or actual violations of this subsection or sub.
(13).
632.69(15)(c)
(c) No person in the business of life settlements may knowingly or intentionally permit any person convicted of a felony involving dishonesty or breach of trust to participate in the business of life settlements.
632.69(15)(d)1.1. Life settlement contracts, purchase agreements, and applications for life settlements, regardless of the form of transmission, shall contain the following statement or a substantially similar statement: “Any person who knowingly presents false information in an application for insurance, a life settlement, or a purchase agreement may be subject to civil and criminal penalties."
632.69(15)(d)2.
2. A person may not use the lack of the statement required under subd.
1. as a defense to any prosecution for a violation of this subsection or sub.
(13).
632.69(15)(e)1.1. Any person engaged in the business of life settlements having knowledge or a reasonable belief that a violation of this subsection or sub.
(13) is being, will be, or has been committed shall provide to the commissioner the information required by, and in a manner prescribed by, the commissioner.
632.69(15)(e)2.
2. Any other person having knowledge or a reasonable belief that a violation of this subsection or sub.
(13) is being, will be, or has been committed may provide to the commissioner the information required by, and in a manner prescribed by, the commissioner.
632.69(15)(f)1.1. In the absence of actual malice, no civil liability shall be imposed on and no cause of action shall arise from a person's furnishing information concerning suspected, anticipated, or completed violations of this subsection or sub.
(13) or suspected, anticipated, or completed fraudulent insurance acts, if the information is provided to or received from any of the following:
632.69(15)(f)1.a.
a. The commissioner or the commissioner's employees, agents, or representatives.
632.69(15)(f)1.b.
b. Federal, state, or local law enforcement or regulatory officials or their employees, agents, or representatives.
632.69(15)(f)1.c.
c. A person involved in the prevention and detection of fraud or that person's agents, employees, or representatives.
632.69(15)(f)1.d.
d. The National Association of Insurance Commissioners, the Financial Industry Regulatory Authority, the North American Securities Administrators Association, or their employees, agents, or representatives or other regulatory body overseeing life insurance, life settlements, securities, or investment fraud.
632.69(15)(f)1.e.
e. The life insurer that issued the policy covering the life of the insured.
632.69(15)(f)2.
2. This paragraph does not abrogate or modify common law or statutory privileges or immunities enjoyed by a person who supplies information concerning suspected, anticipated, or completed fraudulent acts related to life settlements or insurance.
632.69(15)(g)
(g) Information, documents, and evidence provided under par.
(e) or obtained by the commissioner in an investigation of suspected or actual violations of this subsection or sub.
(13) shall be privileged and confidential, shall not be a public record, and shall not be subject to discovery or subpoena in a civil or criminal action. The commissioner may release information, documents, and evidence provided under par.
(e) or obtained in an investigation of suspected or actual violations of this subsection or sub.
(13) in administrative or judicial proceedings to enforce laws administered by the commissioner, to federal, state, or local law enforcement or regulatory agencies, to an organization established for the purpose of detecting and preventing fraud related to life settlements, to the National Association of Insurance Commissioners, or, at the discretion of the commissioner, to a person in the business of life settlements that is aggrieved by a violation of this subsection or sub.
(13). Release by the commissioner of information, documents, and evidence as set forth in this paragraph does not abrogate, modify, or waive the privilege established in this paragraph.
632.69(15)(h)1.
1. Preempt the authority or relieve the duty of law enforcement or regulatory agencies other than the commissioner to investigate, examine, and prosecute suspected violations of law.
632.69(15)(h)2.
2. Prevent or prohibit a person from disclosing voluntarily information concerning life settlement fraud to a law enforcement or regulatory agency other than the commissioner.
632.69(15)(h)3.
3. Limit the powers granted elsewhere by the laws of this state to the commissioner to investigate and examine possible violations of law and to take appropriate action.
632.69(15)(i)1.1. Providers and brokers shall have in place antifraud initiatives reasonably calculated to detect, prosecute, and prevent violations of this subsection and sub.
(13). The commissioner may modify the antifraud initiatives from time to time as necessary to ensure an effective antifraud program and to accomplish the purpose of this paragraph.
632.69(15)(i)2.
2. Antifraud initiatives shall include having fraud investigators, who may be employees of the provider or broker or who may be independent contractors, and an antifraud plan, which the provider or broker shall submit to the commissioner and which shall include all of the following:
632.69(15)(i)2.a.
a. A description of the procedures that the provider or broker will use for detecting and investigating possible fraud and violations of this subsection and sub.
(13) and for resolving material inconsistencies between medical records and insurance applications.
632.69(15)(i)2.b.
b. A description of the procedures that the provider or broker will use for reporting possible violations of this subsection and sub.
(13) to the commissioner.
632.69(15)(i)2.c.
c. A description of the plan that the provider or broker will follow for antifraud education and training of underwriters and other personnel.
632.69(15)(i)2.d.
d. A description or chart outlining the organizational arrangement of the antifraud personnel who are responsible for investigating and reporting possible violations of this subsection and sub.
(13) and investigating unresolved material inconsistencies between medical records and insurance applications.
632.69(15)(i)3.
3. Antifraud plans submitted to the commissioner are privileged and confidential, are not a public record, and are not subject to discovery or subpoena in a civil or criminal action.
632.69(16)
(16) Conflicts of law. If there is more than one owner on a single policy and the owners are residents of different states, a life settlement shall be governed by the law of the state in which the owner having the largest percentage ownership resides or, if the owners hold equal ownership, the state of residence of one owner agreed upon in writing by all owners.
632.69(17)
(17) Fraternal benefit societies. Nothing in this section shall prohibit a fraternal benefit society under ch.
614 from enforcing the terms of its bylaws or rules regarding permitted beneficiaries and owners.
632.69(18)
(18) Civil action. Any person damaged by a violation of this section may bring a civil action against the person committing the violation in a court of competent jurisdiction.
632.69(19)
(19) Penalties. Any person who violates this section is subject to the penalties provided under s.
601.64, suspension or revocation of a license or certificate of authority, and an order under s.
601.41.
632.69(20)
(20) Powers of commissioner. The commissioner may do any of the following:
632.69(20)(a)
(a) Adopt rules implementing and administering this section.
632.69(20)(b)
(b) Establish standards for evaluating the reasonableness of payments under life settlement contracts for persons who are terminally or chronically ill, including regulation of discount rates used to determine the amount paid in exchange for assignment, transfer, sale, devise, or bequest of a benefit under a policy insuring the life of a person who is terminally or chronically ill.
632.69(20)(c)
(c) Establish appropriate licensing requirements and standards for continued licensure for providers and brokers.
632.69(20)(d)
(d) Require a bond or other mechanism for financial accountability for providers and brokers.
632.69(20)(e)
(e) Adopt rules governing the relationship and responsibilities of insurers, providers, and brokers during settlement of a policy.
632.695
632.695
Applicability of general transfers at death provisions. Chapter
854 applies to transfers at death under life insurance policies and annuities.
632.695 History
History: 1997 a. 188.
632.697
632.697
Benefits subject to department's right to recover. Death benefits payable under a life insurance policy or an annuity are subject to the right of the department of health services to recover under s.
46.27 (7g), 2017 stats., or s.
49.496,
49.682, or
49.849 an amount equal to the medical assistance that is recoverable under s.
49.496 (3) (a), an amount equal to aid under s.
49.68,
49.683,
49.685, or
49.785 that is recoverable under s.
49.682 (2) (a) or
(am), or an amount equal to long-term community support services under s.
46.27, 2017 stats., that is recoverable under s.
46.27 (7g) (c) 1., 2017 stats., and that was paid on behalf of the deceased policyholder or annuitant.
632.697 History
History: 2013 a. 20;
2015 a. 55;
2019 a. 9; s. 35.17 correction.
DISABILITY INSURANCE
632.71
632.71
Estoppel from medical examination, assignability and change of beneficiary. Sections
632.47 to
632.50 apply to disability insurance policies.
632.71 History
History: 1975 c. 373,
375,
422.
632.715
632.715
Reports of action against health care provider. Every insurer that has taken any action against a person who holds a license granted by the medical examining board or an affiliated credentialing board attached to the medical examining board shall notify the board or affiliated credentialing board of the action taken against the person if the action relates to unprofessional conduct or negligence in treatment by the person who holds the license.
632.715 History
History: 1985 a. 340;
1993 a. 107.
632.72
632.72
Medical benefits or assistance; assignment. 632.72(1g)(a)
(a) “Department or contract provider" means the department of health services, the county providing the medical benefits or assistance or a health maintenance organization that has contracted with the department of health services to provide the medical benefits or assistance.
632.72(1g)(b)
(b) “Medical benefits or assistance" means health care services funded by a relief block grant, as defined in s.
49.001 (5p); medical assistance, as defined under s.
49.43 (8); or maternal and child health services under s.
253.05.
632.72(1r)
(1r) The providing of medical benefits or assistance constitutes an assignment to the department or contract provider. The assignment shall be, to the extent of the medical benefits or assistance provided, for benefits to which the recipient would be entitled under any policy of health and disability insurance.
632.72(2)
(2) An insurer may not impose on the department or contract provider, as assignee of a person who is covered under the policy of health and disability insurance and who is eligible for medical benefits or assistance, requirements that are different from those imposed on any other agent or assignee of a person who is covered under the policy of health and disability insurance.
632.725
632.725
Standardization of health care billing and insurance claim forms. 632.725(2)
(2) Rules for standardization of forms. The commissioner, in consultation with the department of health services, shall, by rule, do all of the following:
632.725(2)(a)
(a) Establish a standardized billing format for health care services and require that a health care provider that provides health care services in this state use, by July 1, 1993, the standardized format for all printed billing forms.
632.725(2)(b)
(b) Establish a standardized claim format for health care insurance benefits and require that an insurer that provides health care coverage to one or more residents of this state use, by July 1, 1993, the standardized format for all printed claim forms.
632.725(2)(c)
(c) Establish a standardized explanation of benefits format for health care insurance benefits and require that an insurer that provides health care coverage to one or more residents of this state use, by July 1, 1993, the standardized format for all printed forms that contain an explanation of benefits. The rule shall also require that benefits be explained in easily understood language.
632.725(2)(d)
(d) Establish a uniform statewide patient identification system in which each individual who receives health care services in this state is assigned an identification number. The standardized billing format established under par.
(a) and the standardized claim format established under par.
(b) shall provide for the designation of an individual's patient identification number.
632.725(3)
(3) Proposals for legislation. The commissioner shall develop proposals for legislation for the use of the patient identification system established under sub.
(2) (d) and for the implementation of the proposed uses, including any proposals for safeguarding patient confidentiality.
632.725 Cross-reference
Cross-reference: See also ss.
Ins 3.65 and
3.651, Wis. adm. code.
632.726
632.726
Current procedural terminology code changes. 632.726(1)(1)
In this section, “current procedural terminology code" means a number established by the American Medical Association that a health care provider puts on a health insurance claim form to describe the services that he or she performed.
632.726(2)
(2) If an insurer changes a current procedural terminology code that was submitted by a health care provider on a health insurance claim form, the insurer shall include on the explanation of benefits form the reason for the change to the current procedural terminology code and shall cite on the explanation of benefits form the source for the change.
632.726 History
History: 2007 a. 20.
632.729
632.729
Prohibiting discrimination based on COVID-19. 632.729(1)(a)
(a) “COVID-19” means an infection caused by the SARS-CoV-2 coronavirus.
632.729(2)(a)
(a) An insurer that offers an individual or group health benefit plan, a pharmacy benefit manager, or a self-insured health plan may not establish rules for the eligibility of any individual to enroll, for the continued eligibility of any individual to remain enrolled, or for the renewal of coverage under the plan based on a current or past diagnosis or suspected diagnosis of COVID-19.
632.729(2)(b)
(b) An insurer that offers a group health benefit plan, a pharmacy benefit manager, or a self-insured health plan may not establish rules for the eligibility of any employer or other group to enroll, for the continued eligibility of any employer or group to remain enrolled, or for the renewal of an employer's or group's coverage under the plan based on a current or past diagnosis or suspected diagnosis of COVID-19 of any employee or other member of the group.
632.729(3)
(3) Cancellation. An insurer that offers an individual or group health benefit plan, a pharmacy benefit manager, or a self-insured health plan may not use as a basis for cancellation of coverage during a contract term a current or past diagnosis of COVID-19 or suspected diagnosis of COVID-19.
632.729(4)
(4) Rates. An insurer that offers an individual or group health benefit plan, a pharmacy benefit manager, or a self-insured health plan may not use as a basis for setting rates for coverage a current or past diagnosis of COVID-19 or suspected diagnosis of COVID-19.
632.729(5)
(5) Premium grace period. An insurer that offers an individual or group health benefit plan, a pharmacy benefit manager, or a self-insured health plan may not refuse to grant to an individual, employer, or other group a grace period for the payment of a premium based on an individual's, employee's, or group member's current or past diagnosis of COVID-19 or suspected diagnosis of COVID-19 if a grace period for payment of premium would generally be granted under the plan.
632.729 History
History: 2019 a. 185.
632.73
632.73
Right to return policy. 632.73(1)(1)
Right of return. A policyholder may return an individual or franchise disability policy within 10 days after receipt. If the policyholder does so, the contract is void, and all payments made under it shall be refunded. This subsection does not apply to medicare supplement policies, medicare replacement policies or long-term care insurance policies subject to sub.
(2m).
632.73(2)
(2) Notification. Subsection
(1) shall in substance be conspicuously printed on the first page of each such policy or conspicuously attached thereto.
