Ins 3.15(4)(a)1. 1. Volunteer fire departments.

Ins 3.15(4)(a)2. 2. National guard units.

Ins 3.15(4)(a)3. 3. Newspaper delivery carriers.

Ins 3.15(4)(a)4. 4. Dependents of students.

Ins 3.15(4)(a)5. 5. Volunteer civil defense organizations.

Ins 3.15(4)(a)6. 6. Volunteer auxiliary police organizations.

Ins 3.15(4)(a)7. 7. Law enforcement agencies.

Ins 3.15(4)(a)8. 8. Cooperatives organized under ch. 185, Stats., on a membership basis without capital stock.

Ins 3.15(4)(a)9. 9. Registered guests in a motel, hotel, or resort.

Ins 3.15(4)(a)10. 10. Members or members and advisors of fraternal organizations including women’s auxiliaries of such organizations and fraternal youth organizations.

Ins 3.15(4)(a)11. 11. Associations of sports officials.

Ins 3.15(4)(a)12. 12. Purchasers of protective athletic equipment.

Ins 3.15(4)(a)13. 13. Migrant workers.

Ins 3.15(4)(a)14. 14. Participants in racing meets.

Ins 3.15(4)(a)15. 15. Patrons or guests of a recreational facility or resort.

Ins 3.15(4)(a)16. 16. Veterans.

Ins 3.15(4)(b) (b) A company may submit any other risk or class of risks, subject to approval by the commissioner, which it believes is properly eligible for blanket accident and health insurance.

Ins 3.15(5) (5) Coverage requirements.

Ins 3.15(5)(a) (a) Surgical benefit provisions or schedules shall provide that the benefit for any covered surgical procedure not specifically listed in the schedule and not excluded by the provisions of the policy shall be determined by the company on a basis consistent with the benefit provided for a comparable listed procedure.

Ins 3.15(5)(b) (b) A policy which contains any provision under which the claimant may elect one benefit in lieu of another shall not limit to a specified period the time within which election may be made.

Ins 3.15 History History: Cr. Register, March, 1958, no. 27, eff. 4-1-58; am. (4) (a), cr. (5), Register, November, 1959, No. 47, eff. 12-1-59; am. (1), (3) and (4) (a), Register, October, 1961, No. 70, eff. 11-1-61; am. (4) (a), Register, April, 1963, No. 88, eff. 5-1-63; am. (4) (a), Register, June, 1963, No. 90, eff. 7-1-63; am. (4) (a), Register, October, 1963, No. 94, eff. 11-1-63; am. (4) (a), Register, August, 1964, No. 104, eff. 9-1-64; am. (4) (a), Register, August, 1968, No. 152, eff. 9-1-68; am. (4) (a), Register, March, 1969, No. 159, eff. 4-1-69; am. (4) (a), Register, August, 1970, No. 176, eff. 9-1-70; am. (4) (a), renum. (5) to be (5) (a), and cr. (b), Register, June, 1971, No. 186, eff. 7-1-71; emerg. am. (1), (3) and (4) (a), eff. 6-22-76; am. (1), (3) and (4) (a), Register, September, 1976, No. 249, eff. 10-1-76; r. (2), Register, January, 1980, No. 289, eff. 2-1-80; am. (1), Register, September, 1986, No. 369, eff. 10-1-86; corrections to (4) made under s. 13.93 (2m) (b) 5. and 7., Stats., Register, April, 1992, No. 436; CR 23-059: am. (4) (a) 15., cr. (4) (a) 16. Register June 2024 No. 822, eff. 7-1-24; correction in (4) (a) 1. to 15. made under s. 35.17, Stats., Register June 2024 No. 822.

Ins 3.17 Ins 3.17 Reserves for accident and sickness insurance policies.

Ins 3.17(1) (1) Purpose. This section establishes required minimum standards under ch. 623, Stats., for claim, premium and contract reserves of insurers writing accident and sickness insurance policies.

Ins 3.17(2) (2) Scope. This section applies to any insurer, including a fraternal benefit society, issuing a policy providing individual or group accident and sickness insurance coverages as classified under s. Ins 6.75 (1) (c) or (2) (c). This section does not apply to credit insurance as classified under s. Ins 6.75 (1) (c) 1. or (2) (c) 1.

Ins 3.17(3) (3) Definitions. In this section:

Ins 3.17(3)(a) (a) “Annual claim cost” means the net annual cost per unit of benefit before the addition of expenses, including claim settlement expenses, and a margin for profit or contingencies.

Ins 3.17 Note Note: For example, the annual claim cost for a $100 monthly disability benefit, for a maximum disability benefit period of one year, with an elimination period of one week, with respect to a male at age 35, in a certain occupation might be $12, while the gross premium for this benefit might be $18. The additional $6 would cover expenses and profit or contingencies.

Ins 3.17(3)(b) (b) “Claims accrued” means that portion of claims incurred on or prior to the valuation date which result in liability of the insurer for the payment of benefits for medical services which have been rendered on or prior to the valuation date, and for the payment of benefits for days of hospitalization and days of disability which have occurred on or prior to the valuation date, which the insurer has not paid as of the valuation date, but for which it is liable, and will have to pay after the valuation date.

Ins 3.17 Note Note: This liability is sometimes referred to as a liability for accrued benefits. A claim reserve, which represents an estimate of this accrued claim liability, must be established.