Ins 3.42(2)(g)2. 2. The minimum benefits for group policies described in s. 632.89 (2) (d), Stats.

Ins 3.42(3) (3) Plan 3—major medical expense coverage. Plan 3 major medical expense coverage shall consist of benefits for hospital, surgical and medical expenses incurred either in or out of a hospital of the following:

(Same as Plan 2 except that maximum benefit is $100,000 and deductible is $1,000 for an individual and $2,000 for a family.)

Ins 3.42 History History: Cr. Register, April, 1981, No. 304, eff. 5-1-81; am. (2) (b) and (e), cr. (2) (f) and (g), Register, October, 1982, No. 322, eff. 11-1-82.

Ins 3.43 Ins 3.43 High limit comprehensive plan of benefits.

Ins 3.43(1) (1) A policy form providing a high limit comprehensive plan of benefits may be approved as an individual conversion policy as provided by s. 632.897 (4) (b), Stats., if it provides comprehensive coverage of expenses of hospital, surgical and medical services of not less than the following:

Ins 3.43(1)(a) (a) A lifetime maximum benefit of $250,000.

Ins 3.43(1)(b) (b) Payment of benefits at the rate of 80% of covered hospital, medical, and surgical expenses which are in excess of the deductible, until 20% of such expenses in a benefit period reaches $1,000, after which benefits shall be paid at 100% for the remainder of the benefit period; provided, however, benefits for outpatient treatment of mental illness, if covered by the policy, may be limited as provided in par. (g), and surgical expenses shall be covered at a usual, customary and reasonable level.

Ins 3.43(1)(c) (c) A deductible for each benefit period of at least $250 and not more than $500 except that the deductible shall be at least $250 and not more than $1,000 for each benefit period for a policy insuring members of a family. All covered expenses of any insured family member may be applied to satisfy the deductible.

Ins 3.43(1)(d) (d) A “benefit period” shall be defined as a calendar year.

Ins 3.43(1)(e) (e) Payment for all services covered under the contract by any licensed health care professional qualified to provide the services; except payment for psychologists’ services may be conditioned upon referral or supervision by a physician.

Ins 3.43(1)(f) (f) Payment of benefits for maternity, subject to the limitations in pars. (a), (b), and (c), if maternity was covered under the prior policy.

Ins 3.43(1)(g) (g) Benefits for outpatient treatment of mental illness, if provided by the policy, may be limited to either of the following coverages at the option of the insurer:

Ins 3.43(1)(g)1. 1. At least 50% of usual, customary and reasonable expenses which are in excess of the policy deductible, subject to the policy lifetime maximum.

Ins 3.43(1)(g)2. 2. The minimum benefits for group policies described in s. 632.89 (2) (d), Stats.

Ins 3.43(2) (2) The filing procedures of s. Ins 6.05, shall apply to policy forms filed as individual conversion policies.

Ins 3.43 History History: Cr. Register, April, 1981, No. 304, eff. 5-1-81; am. (1) (b) and (e), cr. (1) (f) and (g), Register, October, 1982, No. 322, eff. 11-1-82; correction in (2) made under s. 13.93 (2m) (b) 7., Stats., Register, January, 1999, No. 517.

Ins 3.44 Ins 3.44 Effective date of s. 632.897, Stats.

Ins 3.44(1) (1) Section 632.897, Stats., applies to group policies issued or renewed on or after May 14, 1980, or if a policy is not renewed within 2 years after the effective date of the act, s. 632.897, Stats., is effective at the end of 2 years from May 14, 1980.

Ins 3.44(2) (2) 

Ins 3.44(2)(a) (a) A group policy as defined in s. 632.897 (1) (c) 1. or 3., Stats., shall be considered to have been renewed on any date specified in the policy as a renewal date or on any date on which the insurer or the insured changed the rate of premium for the group policy.

Ins 3.44(2)(b) (b) A group policy as defined in s. 632.897 (1) (c) 2., Stats., shall be considered to have been renewed on any date on which an underlying collective bargaining agreement or other underlying contract is renewed, or on which a significant change is made in benefits.

Ins 3.44(3) (3) Section 632.897, Stats., applies to individual policies issued or renewed after May 14, 1980, except that it shall not apply to any individual policy in force on May 13, 1980, in which the insurer does not have the option of changing premiums.

Ins 3.44 History History: Cr. Register, April, 1981, No. 304, eff. 5-1-81.

Ins 3.45 Ins 3.45 Conversion policies by insurers offering group policies only. Section 632.897 (4) (d), Stats., (first sentence), establishes that an insurer offering group policies only is not required to offer individual coverage. Since the insurer has no individual conversion policies which it may offer, it may not require a terminated insured who elected to continue coverage under s. 632.897 (2), Stats., to convert to individual coverage under s. 632.897 (6), Stats., after 12 months. The terminated person may continue group coverage except as provided in s. 632.897 (3) (a), Stats.

Ins 3.45 History History: Cr. Register, April, 1981, No. 304, eff. 5-1-81.

Ins 3.455 Ins 3.455 Long-term care, nursing home and home health care policies; loss ratios; rating practices; continuation and conversion, reserves.

Ins 3.455(1) (1) Findings.

Ins 3.455(1)(a) (a) The commissioner finds that long-term care policies and life insurance-long-term care coverage are offered and marketed to a population which is particularly susceptible to pressure sales tactics and misleading or fraudulent sales activities. These products are also complex and difficult for most purchasers to analyze and understand.