There shall be a provision as follows:
'Proofs of Loss: Written proof of loss must be furnished to the insurer at its said office in case of claim for loss for which this policy provides any periodic payment contingent upon continuing loss within 90 days after the termination of the period for which the insurer is liable and, in case of claim for any other loss, within 90 days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required.'
The purpose of this article is to promote the public interest, to promote the availability of long-term care insurance policies, to protect applicants for long-term care insurance, as defined, from unfair or deceptive sales or enrollment practices, to establish standards for long-term care insurance, to facilitate public understanding and comparison of long-term care insurance policies, and to facilitate flexibility and innovation in the development of long-term care insurance coverage. The Legislature recognizes the viability of a long-term care product funded through a life insurance vehicle, and this article is not intended to prohibit approval of this product.
The requirements of this article shall apply to policies delivered or issued for delivery in this state on or after August 1, 2000. This article is not intended to supersede the obligations of entities subject to this article to comply with the substance of other applicable insurance laws insofar as they do not conflict with this article, except that laws and regulations designed and intended to apply to Medicare supplement insurance policies shall not be applied to long-term care insurance. Entities subject to this article shall continue to comply with other applicable insurance legislation not in conflict with this article.
This article may be known and cited as the 'Alabama Long-Term Care Insurance Policy Minimum Standards Act.'
Unless the context requires otherwise, the definitions in this section apply throughout this article.
(1) APPLICANT. In the case of:
a. An individual long-term care insurance policy, the person who seeks to contract for benefits.
b. A group long-term care insurance policy, the proposed certificate holder.
(2) CERTIFICATE. Any certificate issued under a group long-term care insurance policy, which policy has been delivered or issued for delivery in this state.
(3) COMMISSIONER. The Alabama Commissioner of Insurance.
(4) GROUP LONG-TERM CARE INSURANCE. A long-term care insurance policy which is delivered or issued for delivery in this state and issued to any of the following:
a. One or more employers or labor organizations, or to a trust or to the trustees of a fund established by one or more employers or labor organizations, or a combination thereof, for employees or former employees or a combination thereof, or for members or former members or a combination thereof, of the labor organizations.
b. Any professional, trade, or occupational association for its members or former or retired members, or combination thereof, if the association meets both of the following requirements:
1. Is composed of individuals all of whom are or were actively engaged in the same profession, trade, or occupation.
2. Has been maintained in good faith for purposes other than obtaining insurance.
c. An association or a trust or the trustee or trustees of a fund established, created, or maintained for the benefit of members of one or more associations. Prior to advertising, marketing, or offering the policy within this state, the association or associations, or the insurer of the association or associations, shall file evidence with the commissioner that the association or associations have at the outset a minimum of 100 persons and have been organized and maintained in good faith for purposes other than that of obtaining insurance; have been in active existence for at least one year; and have a constitution and bylaws which provide all of the following:
1. The association or associations hold regular meetings, not less than annually, to further purposes of the members.
2. Except for credit unions, the association or associations collect dues or solicit contributions from members.
3. The members have voting privileges and representation on the governing board and committees. Thirty days after this filing, the association or associations shall be deemed to satisfy these organizational requirements, unless the commissioner makes a finding that the association or associations do not satisfy those organizational requirements.
d. A group, other than as described in paragraphs a., b., and c., subject to a finding by the commissioner that:
1. The issuance of the group policy is not contrary to the best interest of the public.
2. The issuance of the group policy would result in economies of acquisition or administration.
3. The benefits are reasonable in relation to the premiums charged.
(5) LONG-TERM CARE INSURANCE. Any insurance policy or rider advertised, marketed, offered, or designed to provide coverage for not less than 12 consecutive months for each covered person on an expense incurred, indemnity, prepaid or other basis for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services, provided in a setting other than an acute care unit of a hospital. This term includes group and individual annuities and life insurance policies or riders that provide directly or that supplement long-term care insurance. This term also includes a policy or rider that provides for payment of benefits based upon cognitive impairment or the loss of functional capacity. The term shall also include qualified long-term care insurance contracts. Long-term care insurance may be issued by insurers as follows: Fraternal benefit societies; nonprofit health, hospital, and medical service corporations; prepaid health plans; health maintenance organizations; or any similar organization to the extent they are otherwise authorized to issue life or health insurance. Long-term care insurance shall not include any insurance policy which is offered primarily to provide basic Medicare supplement coverage, basic hospital expense coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income or related asset-protection coverage, accident only coverage, specified disease or specified accident coverage, or limited benefit health coverage. With regard to life insurance, this term does not include life insurance policies which accelerate the death benefit specifically for one or more of the qualifying events of terminal illness, medical conditions requiring extraordinary medical intervention, or permanent institutional confinement, and which provide the option of a lump-sum payment for those benefits and in which neither the benefits nor the eligibility for the benefits is conditioned upon the receipt of long-term care. Notwithstanding any other provision contained herein, any product advertised, marketed, or offered as long-term care insurance shall be subject to the provisions of this article. The definition of long-term care insurance under this article is designed to allow maximum flexibility in benefit scope, intensity, and level, while assuring that the purchasers' reasonable expectations for a long-term care insurance policy are met. The article is intended to permit long-term care insurance policies to cover either diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services, or any combination thereof, and not to mandate coverage for each of these types of services. Pursuant to the definition, long-term care insurance may be either a group or individual insurance policy or a rider to a policy, for example, life or disability. The language in the definition concerning 'other than an acute care unit of a hospital' is intended to allow payment of benefits when a portion of a hospital has been designated for, and duly licensed or certified as, a long-term care provider or swing bed.
(6) POLICY. Any policy, contract, subscriber agreement, rider, or endorsement delivered or issued for delivery in this state by an insurer, fraternal benefit society, nonprofit health, hospital, or medical service corporation, prepaid health plan, health maintenance organization, or any similar organization.
(7)a. QUALIFIED LONG-TERM CARE INSURANCE CONTRACT or FEDERALLY TAX-QUALIFIED LONG-TERM CARE INSURANCE CONTRACT. An individual or group insurance contract that meets the requirements of Section 7702B (b) of the Internal Revenue Code of 1986, as amended, as follows:
1. The only insurance protection provided under the contract is coverage of qualified long-term care services. A contract shall not fail to satisfy the requirements of this subparagraph by reason of payments being made on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate.
2. The contract does not pay or reimburse expenses incurred for services or items to the extent that the expenses are reimbursable under Title XVIII of the Social Security Act, as amended, or would be so reimbursable but for the application of a deduction or coinsurance amount. The requirements of this subparagraph do not apply to expenses that are reimbursable under Title XVIII of the Social Security Act only as a secondary payor. A contract shall not fail to satisfy the requirements of this subparagraph by reason of payments being made on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate.
3. The contract is guaranteed renewable, within the meaning of Section 7702B (b)(1)(C) of the Internal Revenue Code of 1986, as amended.
4. The contract does not provide for a cash surrender value or other money that can be paid, assigned, pledged as collateral for a loan, or borrowed, except as provided in subparagraph 5.
5. All refunds of premiums, and all policyholder dividends or similar amounts, under the contract are to be applied as a reduction in future premiums or to increase future benefits, except that a refund on the event of death of the insured or a complete surrender or cancellation of the contract cannot exceed the aggregate premiums paid under the contract.
6. The contract meets the consumer protection provisions set forth in Section 7702B (g) of the Internal Revenue Code of 1986, as amended.
b. QUALIFIED LONG-TERM CARE INSURANCE CONTRACT or FEDERALLY TAX-QUALIFIED LONG-TERM CARE INSURANCE CONTRACT. This term also means the portion of a life insurance contract that provides long-term care insurance coverage by rider or as part of the contract and that satisfies the requirements of Sections 7702B (b) and (e) of the Internal Revenue Code of 1986, as amended.
No group long-term care insurance coverage may be offered to a resident of this state under a group policy issued in another state to a group described in Section 27-19-103(4)d, unless this state or another state having statutory and regulatory long-term care insurance requirements substantially similar to those adopted in this state has made a determination that these requirements have been met.
(a) The commissioner may adopt regulations that include standards for full and fair disclosure setting forth the manner, content, and required disclosures for the sale of long-term care insurance policies, terms of renewability, initial and subsequent conditions of eligibility, nonduplication of coverage provisions, coverage of dependents, preexisting conditions, termination of insurance, continuation or conversion, probationary periods, limitations, exceptions, reductions, elimination periods, requirements for replacement, recurrent conditions, and definitions of terms. Regulations under this subsection should recognize the developing and unique nature of long-term care insurance and the distinction between group and individual long-term insurance policies.
(b) No long-term care insurance policy may do any of the following:
(1) Be cancelled, nonrenewed, or otherwise terminated on the grounds of the age or the deterioration of the mental or physical health of the insured individual or certificate holder.
(2) Contain a provision establishing a new waiting period in the event existing coverage is converted to or replaced by a new or other form within the same company, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder.
(3) Provide coverage for skilled nursing care only or provide significantly more coverage for skilled care in a facility than coverage for lower levels of care.
(c)(1) No long-term care insurance policy or certificate other than a policy or certificate thereunder issued to a group as defined in Section 27-19-103(4)a, shall use a definition of preexisting condition which is more restrictive than the following: Preexisting condition means a condition for which medical advice or treatment was recommended by, or received from, a provider of health care services, within six months preceding the effective date of coverage of an insured person.
(2) No long-term care insurance policy or certificate other than a policy or certificate thereunder issued to a group as defined in Section 27-19-103(4)a, may exclude coverage for a loss or confinement which is the result of a preexisting condition unless the loss or confinement begins within six months following the effective date of coverage of an insured person.
(3) The commissioner may extend the limitation periods set forth in subdivisions (1) and (2) as to specific age group categories in specific policy forms upon findings that the extension is in the best interest of the public.
(4) The definition of preexisting condition does not prohibit an insurer from using an application form designed to elicit the complete health history of an applicant, and, on the basis of the answers on that application, from underwriting in accordance with the underwriting standards established by the insurer. Unless otherwise provided in the policy or certificate, a preexisting condition, regardless of whether it is disclosed on the application, need not be covered until the waiting period described in subdivision (2) expires. No long-term care insurance policy or certificates may exclude or use waivers or riders of any kind to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions beyond the waiting period described in subdivision (2).
(d) Prior hospitalization or institutionalization standards:
(1) No long-term care insurance policy may be delivered or issued for delivery in this state if the policy does any one of the following:
a. Conditions eligibility for any benefits on a prior hospitalization requirement.
b. Conditions eligibility for benefits provided in an institutional care setting on the receipt of a higher level of institutional care.
c. Conditions eligibility for any benefits other than waiver of premium, post-confinement, post-acute care or recuperative benefits on a prior institutionalization requirement.
(2) a. A long-term care insurance policy containing post-confinement, post-acute care, or recuperative benefits shall clearly label in a separate paragraph of the policy or certificate entitled 'Limitations or Conditions on Eligibility for Benefits' the limitations or conditions, including any required number of days of confinement.
b. A long-term care insurance policy or rider which conditions eligibility of noninstitutional benefits on the prior receipt of institutional care shall not require a prior institutional stay of more than 30 days.
(3) No long-term care insurance policy or rider which provides benefits only following institutionalization shall condition the benefits upon admission to a facility for the same or related conditions within a period of less than 30 days after discharge from the institution.
(e) The commissioner may adopt regulations establishing loss ratio standards for long-term care insurance policies provided that a specific reference to long-term care insurance policies is contained in the regulation.
(f) Long-term care insurance applicants shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason. Long-term care insurance policies and certificates shall have a notice prominently printed on the first page or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, other than a certificate issued pursuant to a policy issued to a group, as defined in Section 27-19-103(4)a., the applicant is not satisfied for any reason.
This subsection shall also apply to denials of applications and any refund must be made within 30 days of the return or denial.
(g)(1) An outline of coverage shall be delivered to a prospective applicant for long-term care insurance at the time of initial solicitation through means which prominently direct the attention of the recipient to the document and its purpose.
a. The commissioner shall prescribe a standard format, including style, arrangement, and overall appearance, and the content of an outline of coverage.
b. In the case of agent solicitations, an agent shall deliver the outline of coverage prior to the presentation of an application or enrollment form.
c. In the case of direct response solicitations, the outline of coverage shall be presented in conjunction with any application or enrollment form.
(2) The outline of coverage shall include all of the following:
a. A description of the principal benefits and coverage provided in the policy.
b. A statement of the principal exclusions, reductions, and limitations contained in the policy.
c. A statement of the terms under which the policy or certificate, or both, may be continued in force or discontinued, including any reservation in the policy of a right to change premium. Continuation or conversion provisions of group coverage shall be specifically described.
d. A statement that the outline of coverage is a summary only, not a contract of insurance, and that the policy or group master policy contains governing contractual provisions.
e. A description of the terms under which the policy or certificate may be returned and premium refunded.
f. A brief description of the relationship of cost of care and benefits.
g. A statement that discloses to the policyholder or certificateholder whether the policy is intended to be a federally tax-qualified long-term care insurance contract under 7702B (b) of the Internal Revenue Code of 1986, as amended.
(h) A certificate issued, pursuant to a group long-term care insurance policy, which policy is delivered or issued for delivery, in this state shall include all of the following:
(1) A description of the principal benefits and coverage provided in the policy.
(2) A statement of the principal exclusions, reductions, and limitations contained in the policy.
(3) A statement that the group master policy determines governing contractual provisions.
(i) If an application for a long-term care insurance contract or certificate is approved, the issuer shall deliver the contract or certificate of insurance to the applicant no later than 30 days after the date of approval.
(j) At the time of policy delivery, a policy summary shall be delivered for an individual life insurance policy which provides long-term care benefits within the policy or by rider. In the case of direct response solicitations, the insurer shall deliver the policy summary upon the applicant's request, but regardless of request shall make the delivery no later than at the time of policy delivery. In addition to complying with all applicable requirements, the summary shall also include all of the following:
(1) An explanation of how the long-term care benefit interacts with other components of the policy, including deductions from death benefits.
(2) An illustration of the amount of benefits, the length of benefit, and the guaranteed lifetime benefits if any, for each covered person.
(3) Any exclusions, reductions, and limitations on benefits of long-term care.
(4) A statement that any long-term care inflation protection option required by regulations promulgated by the commissioner is not available under this policy.
(5) If applicable to the policy type, the summary shall also include all of the following:
a. A disclosure of the effects of exercising other rights under the policy.
b. A disclosure of guarantees related to long-term care costs of insurance charges.
c. Current and projected maximum lifetime benefits.
(6) The provisions of the policy summary listed above may be incorporated into a basic illustration required to be delivered in accordance with regulations promulgated by the commissioner or into the life insurance policy summary which is required to be delivered in accordance with regulations promulgated by the commissioner.
(k) Any time a long-term care benefit, funded through a life insurance vehicle by the acceleration of the death benefit, is in benefit payment status, a monthly report shall be provided to the policyholder. The report shall include all of the following:
(1) Any long-term care benefits paid out during the month.
(2) An explanation of any changes in the policy, for example, death benefits or cash values, due to long-term care benefits paid out.
(3) The amount of long-term care benefits existing or remaining.
(l) If a claim under a long-term care insurance contract is denied, the issuer, within 60 days of the date of a written request by the policyholder or certificateholder, or a representative thereof, shall do both of the following:
(1) Provide a written explanation of the reasons for the denial.
(2) Make available all information directly related to the denial.
(m) Any policy or rider advertised, marketed, or offered as long-term care or nursing home insurance shall comply with this article.
(a) For a policy or certificate that has been in force for less than six months an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is material to the acceptance for coverage.
(b) For a policy or certificate that has been in force for at least six months but less than two years an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is both material to the acceptance for coverage and which pertains to the condition for which benefits are sought.
(c) After a policy or certificate has been in force for two years it is not contestable upon the grounds of misrepresentation alone but may be contested only upon a showing that the insured knowingly and intentionally misrepresented relevant facts relating to the insured's health.
(d)(1) No long-term care insurance policy or certificate may be field issued based on medical or health status.
(2) For purposes of this section, 'field issued' means a policy or certificate issued by an agent or a third-party administrator pursuant to the underwriting authority granted to the agent or third-party administrator by an insurer.
(e) If an insurer has paid benefits under the long-term care insurance policy or certificate, the benefit payments may not be recovered by the insurer in the event that the policy or certificate is rescinded.
(f) In the event of the death of the insured, this section shall not apply to the remaining death benefit of a life insurance policy that accelerates benefits for long-term care. In this situation, the remaining death benefits under these policies shall be governed by Section 27-15-18. In all other situations, this section shall apply to life insurance policies that accelerate benefits for long-term care.
(a) Except as provided in subsection (b), a long-term care insurance policy may not be delivered or issued for delivery in this state unless the policyholder or certificateholder has been offered the option of purchasing a policy or certificate including a nonforfeiture benefit. The offer of a nonforfeiture benefit may be in the form of a rider that is attached to the policy. In the event the policyholder or certificateholder declines the nonforfeiture benefit, the insurer shall provide a contingent benefit upon lapse that shall be available for a specified period of time following a substantial increase in premium rates.
(b) When a group long-term care insurance policy is issued, the offer required in subsection (a) shall be made to the group policyholder. However, if the policy is issued as group long-term care insurance, as defined in Section 27-19-103(4)d., other than to a continuing care retirement community or other similar entity, the offering shall be made to each proposed certificateholder.
(c) The commissioner shall promulgate regulations specifying the type or types of nonforfeiture benefits to be offered as part of long-term care insurance policies and certificates, the standards for nonforfeiture benefits, and the rules regarding contingent benefit upon lapse, including a determination of the specified period of time during which a contingent benefit upon lapse will be available and the substantial premium rate increase that triggers a contingent benefit upon lapse as described in subsection (a).
The commissioner shall issue reasonable regulations to promote premium adequacy and to protect the policyholder in the event of substantial rate increases, and to establish minimum standards for marketing practices, agent compensation, agent testing, penalties, and reporting practices for long-term care insurance.
In addition to any other penalties provided by the laws of this state, any insurer and any agent found to have violated any requirement of this state relating to the regulation of long-term care insurance or the marketing of this insurance shall be subject to a fine of up to three times the amount of any commissions paid for each policy involved in the violation or up to ten thousand dollars ($10,000), whichever is greater.
There shall be a provision as follows:
'Time of Payment of Claims: Indemnities payable under this policy for any loss, other than loss for which this policy provides periodic payment, will be paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment will be paid _____ (insert period for payment which must not be less frequently than monthly) and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof.'
Regulations promulgated pursuant to this article shall be subject to Chapter 2.
There shall be a provision as follows:
'Payment of Claims: Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to the estate of the insured. Any other accrued indemnities unpaid at the insured's death may, at the option of the insurer, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the insured.'
The following provisions, or either of them, may be included with the foregoing provision at the option of the insurer:
'If any indemnity of this policy shall be payable to the estate of the insured or to an insured or beneficiary who is a minor or otherwise not competent to give a valid release, the insurer may pay such indemnity, up to an amount not exceeding $ _____ (insert an amount which shall not exceed $1,000.00), to any relative by blood or connection by marriage of the insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any payment made by the insurer in good faith pursuant to this provision shall fully discharge the insurer to the extent of such payment.'
'Subject to any written direction of the insured in the application or otherwise, all, or a portion of any, indemnities provided by this policy on account of hospital, nursing, medical or surgical services may, at the insurer's option and unless the insured requests otherwise in writing not later than the time of filing proof of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the service be rendered by a particular hospital or person.'
There shall be a provision as follows:
'Physical Examinations and Autopsy: The insurer at its own expense shall have the right and opportunity to examine the person of the insured when, and as often as, it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law.'
There shall be a provision as follows:
'Legal Actions: No action shall be brought to recover on this policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished.'
There shall be a provision as follows:
'Change of Beneficiary: Unless the insured makes an irrevocable designation of beneficiary, the right to change a beneficiary is reserved to the insured and the consent of the beneficiary, or beneficiaries, shall not be requisite to surrender or assignment of this policy or to any change of beneficiary, or beneficiaries, or to any other changes in this policy.'
(The first clause of this provision, relating to the irrevocable designation of beneficiary, may be omitted at the insurer's option.)
Except as provided in subsection (b) of Section 27-19-3, no such policy delivered, or issued for delivery, to any person in this state shall contain provisions respecting the matters set forth in Sections 27-19-17 through 27-19-26 unless such provisions are in the words in which the same appear in the applicable section; except, that the insurer may, at its option, use in lieu of any such provision a corresponding provision of different wording approved by the commissioner which is not less favorable in any respect to the insured or the beneficiary. Any such provision contained in the policy shall be preceded individually by the appropriate caption or, at the option of the insurer, by such appropriate individual, or group captions or subcaptions as the commissioner may approve.
There may be a provision as follows:
'Change of Occupation: If the insured be injured or contract sickness after having changed his occupation to one classified by the insurer as more hazardous than that stated in this policy or while doing for compensation anything pertaining to an occupation so classified, the insurer will pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for such more hazardous occupation. If the insured changes his occupation to one classified by the insurer as less hazardous than that stated in this policy, the insurer, upon receipt of proof of such change of occupation, will reduce the premium rate accordingly, and will return the excess pro rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent. In applying this provision, the classification of occupational risk and the premium rates shall be such as have been last filed by the insurer prior to the occurrence of the loss for which the insurer is liable or prior to date of proof of change in occupation with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued; but if such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the insurer in such state prior to the occurrence of the loss or prior to the date of proof of change in occupation.'
There may be a provision as follows:
'Misstatement of Age: If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age.'
There may be a provision as follows:
'Other Insurance in This Insurer: If an accident or sickness or accident and sickness policy, or policies, previously issued by the insurer to the insured be in force concurrently herewith, making the aggregate indemnity for _____ (insert type of coverage or coverages) in excess of $ _____ (insert maximum limit of indemnity or indemnities), the excess insurance shall be void and all premiums paid for such excess shall be returned to the insured or to his estate.'
Or, in lieu thereof:
'Insurance effective at any one time on the insured under a like policy, or policies, in this insurer is limited to the one such policy elected by the insured, his beneficiary or his estate, as the case may be, and the insurer will return all premiums paid for all other such policies.'
(a) There may be a provision as follows:
'Insurance with Other Insurers: If there be other valid coverage, not with this insurer, providing benefits for the same loss on a provision of service basis or on an expense-incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability under any expense-incurred coverage of this policy shall be for such proportion of the loss as the amount which would otherwise have been payable hereunder plus the total of the like amounts under all such other valid coverages for the same loss of which this insurer had notice bears to the total like amounts under all valid coverages for such loss, and for the return of such portion of the premiums paid as shall exceed the pro rata portion for the amount so determined. For the purpose of applying this provision when other coverage is on a provision of service basis, the 'like amount' of such other coverage shall be taken as the amount which the services rendered would have cost in the absence of such coverage.'
(b) If the foregoing policy provision is included in a policy which also contains the policy provision set out in Section 27-19-21 there shall be added to the caption of the foregoing provision the phrase '-Expense-Incurred Benefits.' The insurer may, at its option, include in this provision a definition of 'other valid coverage,' approved as to form by the commissioner, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this, or any other, state of the United States or any province of Canada, and by hospital or medical service organizations and to any other coverage the inclusion of which may be approved by the commissioner. In the absence of such definition, such term shall not include group insurance, automobile medical payments insurance or coverage provided by hospital, or medical service organizations, or by union welfare plans or employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute, including any workmen's compensation or employer's liability statute, whether provided by a governmental agency or otherwise, shall, in all cases, be deemed to be 'other valid coverage' of which the insurer has had notice. In applying the foregoing policy provision, no third party liability coverage shall be included as 'other valid coverage.'
(a) There may be a provision as follows:
'Insurance with Other Insurers: If there be other valid coverage, not with this insurer, providing benefits for the same loss on other than an expense-incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability for such benefits under this policy shall be for such proportion of the indemnities otherwise provided hereunder for such loss as the like indemnities of which the insurer had notice (including the indemnities under this policy) bear to the total amount of all like indemnities for such loss and for the return of such portion of the premium paid as shall exceed the pro rata portion for the indemnities thus determined.'
(b) If the foregoing policy provision is included in a policy which also contains the policy provision set out in Section 27-19-20, there shall be added to the caption of the foregoing provision the phrase '-Other Benefits.' The insurer may, at its option, include in this provision a definition of 'other valid coverage,' approved as to form by the commissioner, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this, or any other, state of the United States or any province of Canada and to any other coverage the inclusion of which may be approved by the commissioner. In the absence of such definition, such term shall not include group insurance or benefits provided by union welfare plans, or by employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute, including any workmen's compensation or employer's liability statute, whether provided by a governmental agency or otherwise, shall, in all cases, be deemed to be 'other valid coverage' of which the insurer has had notice. In applying the foregoing policy provision, no third party liability coverage shall be included as 'other valid coverage.'
(a) There may be a provision as follows:
'Relation of Earnings to Insurance: If the total monthly amount of loss of time benefits promised for the same loss under all valid loss of time coverage upon the insured, whether payable on a weekly or monthly basis, shall exceed the monthly earnings of the insured at the time disability commenced or his average monthly earnings for the period of two years immediately preceding a disability for which claim is made, whichever is the greater, the insurer will be liable only for such proportionate amount of such benefits under this policy as the amount of such monthly earnings or such average monthly earnings of the insured bears to the total amount of monthly benefits for the same loss under all such coverage upon the insured at the time such disability commences and for the return of such part of the premiums paid during such two years as shall exceed the pro rata amount of the premiums for the benefits actually paid hereunder; but this shall not operate to reduce the total monthly amount of benefits payable under all such coverage upon the insured below the sum of $200.00 or the sum of the monthly benefits specified in such coverages, whichever is the lesser, nor shall it operate to reduce benefits other than those payable for loss of time.'
(b) The foregoing policy provision may be inserted only in a policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums:
(1) Until at least age 50; or
(2) In the case of a policy issued after age 44, for at least five years from its date of issue.
The insurer may, at its option, include in this provision a definition of 'valid loss of time coverage,' approved as to form by the commissioner, which definition shall be limited in subject matter to coverage provided by governmental agencies or by organizations subject to regulation by insurance law or by insurance authorities of this, or any other, state of the United States or any province of Canada, or to any other coverage the inclusion of which may be approved by the commissioner or any combination of such coverages. In the absence of such definition, such term shall not include any coverage provided for such insured pursuant to any compulsory benefit statute including any workmen's compensation or employer's liability statute, or benefits provided by union welfare plans or by employer or employee benefit organizations.
There may be a provision as follows:
'Unpaid Premiums: Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom.'
There may be a provision as follows:
'Conformity with State Statutes: Any provision of this policy which, on its effective date, is in conflict with the statutes of the state in which the insured resides on such date is hereby amended to conform to the minimum requirements of such statutes.'
There may be a provision as follows:
'Illegal Occupation: The insurer shall not be liable for any loss to which a contributing cause was the insured's commission of, or attempt to commit, a felony or to which a contributing cause was the insured's being engaged in an illegal occupation.'
There may be a provision as follows:
'Intoxicants and Narcotics: The insurer shall not be liable for any loss sustained or contracted in consequence of the insured's being intoxicated or under the influence of any narcotic unless administered on the advice of a physician.'
The provisions which are the subject of Sections 27-19-4 through 27-19-26, or any corresponding provisions which are used in lieu thereof in accordance with such sections, shall be printed in the consecutive order of the provisions in such sections or, at the option of the insurer, any such provision may appear as a unit in any part of the policy with other provisions to which it may be logically related, provided that the resulting policy shall not be, in whole or in part, unintelligible, uncertain, ambiguous, abstruse or likely to mislead a person to whom the policy is offered, delivered or issued.
(a) No policy of health, sickness or accident insurance delivered, or issued for delivery, in this state, including both individual and group policies, which provide coverage for psychiatric treatment or mental illness shall exclude hospitalization benefits for mental patients in tax-supported institutions of the State of Alabama, or any county or municipality thereof.
(b) The provisions of this section shall not apply to any policy of insurance in effect prior to September 20, 1971, nor shall the provisions of this section apply to any employee benefit plan providing hospital benefits for mental patients where such employee benefit plan is established by the employer and contributions to the plan are provided by the employer and the employee, or either of them, and such plan is not evidenced by individual, or group or blanket policies of health, sickness or accident insurance issued by an insurance company.
The word 'insured,' as used in this article, shall not be construed as preventing a person other than the insured with a proper insurable interest from making application for and owning a policy covering the insured or from being entitled under such a policy to any indemnities, benefits and rights provided therein.
(a) Except as provided in subsection (b) of this section, each such policy delivered, or issued for delivery, to any person in this state shall contain the provisions specified in Sections 27-19-4 through 27-19-15, in the words in which the same appear; except, that the insurer may, at its option, substitute for one or more of such provisions corresponding provisions of different wording approved by the commissioner which are in each instance not less favorable in any respect to the insured or the beneficiary. Each such provision shall be preceded individually by the applicable caption shown or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the commissioner may approve.
(b) If any such provision is, in whole or in part, inapplicable to, or inconsistent with, the coverage provided by a particular form of policy, the insurer, with the approval of the commissioner, shall omit from such policy any inapplicable provision, or part of a provision, and shall modify any inconsistent provision, or part of a provision, in such manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.
(a) Any policy of a foreign or alien insurer, when delivered or issued for delivery to any person in this state, may contain any provision which is not less favorable to the insured or the beneficiary than the provisions of this article and which is prescribed or required by the law of the state or country under which the insurer is organized.
(b) Any policy of a domestic insurer may, when issued for delivery in any other state or country, contain any provision permitted or required by the laws of such other state or country.
(a) Every individual policy of insurance providing hospital, medical or surgical benefits in which an insurer reserves the right to refuse renewal on an individual basis shall provide, in substance, in a provision thereof, or in an endorsement thereon or in a rider attached thereto that, subject to the right to terminate the policy upon nonpayment of premium when due, such right to refuse renewal shall not be exercised before the renewal date occurring on, or after and nearest, each policy anniversary or, in the case of lapse and reinstatement, before the renewal date occurring on, or after and nearest, each anniversary of the last reinstatement and that any refusal of renewal shall be without prejudice to any claim originating while the policy is in force. Subject to the right to terminate for nonpayment of premium, the right to refuse renewal by an insurer shall only be exercised after having given the insured no less than 30 days' notice in writing of the intent not to renew.
(b) Every individual disability insurance policy which is subject to renewal at the option of the insurer shall so indicate in a prominently captioned statement on the first page of such policy.
Every individual disability insurance policy, except single premium nonrenewable policies or contracts, issued for delivery in the State of Alabama shall have printed thereon, or attached thereto, a notice stating in substance that the person to whom the policy is issued shall be permitted to return the policy within 10 days of its delivery to such purchaser and to have the premium paid refunded if, after examination of the policy, the purchaser is not satisfied with it for any reason. If a policyholder or purchaser, pursuant to such notice, returns the policy or contract to the insurer at its home or branch office or to the agent through whom it was purchased, it shall be void from the beginning and the parties shall be in the same position as if no policy or contract has been issued.
Any insurer writing disability insurance policies may, with approval of the commissioner, add endorsements or riders to existing policies of such insurance, with or without increase in premium, provided there is shown separately on the endorsement or rider a stated premium charge for additional coverage.
The requirements of this article may be complied with by the insurer by attaching to the policy such rider or endorsement as may be necessary for the purpose.
(a) No policy provision which is not subject to this article shall make a policy, or any portion thereof, less favorable in any respect to the insured or the beneficiary than the provisions thereof which are subject to this article.
(b) A policy delivered, or issued for delivery, to any person in this state in violation of this article shall be held valid but shall be construed as provided in this article. When any provision in a policy subject to this article is in conflict with any provision of this article, the rights, duties and obligations of the insurer, the insured and the beneficiary shall be governed by the provisions of this article.
If any such policy contains a provision establishing, as an age limit or otherwise, a date after which the coverage provided by the policy will not be effective and if such date falls within a period for which premium is accepted by the insurer or if the insurer accepts a premium after such date, the coverage provided by the policy will continue in force subject to any right of cancellation until the end of the period for which premium has been accepted. In the event the age of the insured has been misstated and if, according to the correct age of the insured, the coverage provided by the policy would not have become effective or would have ceased prior to the acceptance of such premium, or premiums, then the liability of the insurer shall be limited to the refund, upon request, of all premiums paid for the period not covered by the policy.
Disability insurance on a franchise plan is hereby declared to be that form of disability insurance issued to:
(1) Three or more employees of any corporation, copartnership or individual employer, or any governmental corporation, agency or department thereof; or
(2) Ten or more members, employees or employees of members of any trade or professional association, or of a labor union or of any other association having had an active existence for at least two years where such association or union has a constitution or bylaws and is formed in good faith for purposes other than that of obtaining insurance where such persons, with or without their dependents, are issued the same form of an individual policy varying only as to amounts and kinds of coverage applied for by such persons under an arrangement whereby the premiums on such policies may be paid to the insurer periodically by the employer, with or without payroll deductions, or by the association for its members or by some designated person acting on behalf of such employer or association or union. The term 'employees' as used in this section may be deemed to include the officers, managers, employees and retired employees of the employer and the individual proprietor or partners if the employer is an individual proprietor or partnership.
(a) All individual and group health insurance policies providing coverage on an expense-incurred basis and individual and group service or indemnity type contracts issued by a nonprofit service corporation which provide coverage for a family member of the insured or subscriber shall, as to such family members' coverage, also provide that the health insurance benefits applicable for children shall be payable with respect to a newly born child of the insured or subscriber from the moment of birth.
(b) The coverage for newly born children shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities, but need not include benefits for routine well-baby care.
(c) The requirements of this section shall apply to all insurance policies and subscriber contracts renewed, delivered or issued for delivery in this state, 60 days after April 24, 1975.
Whenever any policy of insurance or any medical service plan or hospital service contract or hospital and medical service contract provides for reimbursement for any visual service in Alabama which is within the lawful scope of practice of a duly licensed optometrist, as defined in Section 34-22-1, the insured or other person entitled to benefits under such policy shall be entitled to reimbursement for such services, whether such services are performed by a duly licensed physician or by a duly licensed optometrist, whichever the insured selects, notwithstanding any provision to the contrary in any statute or in such policy, plan or contract. Duly licensed optometrists shall be entitled to participate in such policies, plans or contracts providing for visual services to the same extent as fully licensed physicians.
There shall be a provision as follows:
'Entire Contract; Changes: This policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the insurer and unless such approval be endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions.'
There shall be a provision as follows:
'Time Limit on Certain Defenses: (1) After two years from the date of issue of this policy, no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or to deny a claim for loss incurred or disability (as defined in the policy) commencing after the expiration of such two-year period.'
(The foregoing policy provision shall not be so construed as to affect any legal requirement for avoidance of a policy or denial of a claim during such initial two-year period nor to limit the application of Sections 27-19-17 through 27-19-21 in the event of misstatement with respect to age or occupation or other insurance.)
(A policy which the insured has the right to continue in force subject to its terms by the timely payment of premium:
(1) Until at least age 50; or
(2) In the case of a policy issued after age 44, for at least five years from its date of issue may contain in lieu of the foregoing the following provision, from which the clause in parentheses may be omitted at the insurer's option, under the caption 'Incontestable':
'After this policy has been in force for a period of two years during the lifetime of the insured, excluding any period during which the insured is disabled, it shall become incontestable as to the statements contained in the application.)'
'(2) No claim for loss incurred or disability (as defined in the policy) commencing after two years from the date of issue of this policy shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss had existed prior to the effective date of coverage of this policy.'
This article shall be known and may be cited as the 'Alabama Medicare Supplement Minimum Standards Act.'
The purpose of this article is to establish certain definitions, policy provisions, anticipated loss ratio standards and disclosure requirements applicable to group and individual Medicare supplement disability policies and to authorize the implementation of these requirements through regulations promulgated by the Commissioner of Insurance consistent with the uniform standards developed by the National Association of Insurance Commissioners to meet the standards enacted in Public Law 96-265 (Laws 1980).
(a) Except as otherwise specifically provided, this article shall apply to both of the following:
(1) All Medicare supplement policies delivered or issued for delivery in this state on or after August 1, 2000.
(2) All certificates issued under group Medicare supplement policies, which certificates have been delivered or issued for delivery in this state.
(b) This article shall not apply to a policy of one or more employers or labor organizations, or of the trustees of a fund established by one or more employees or labor organizations, or combination thereof, for employees or former employees or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.
(c) Except as otherwise specifically provided in subsection (d) of Section 27-19-56, this article is not intended to prohibit or apply to insurance policies or health care benefit plans, including group conversion policies, provided to Medicare eligible persons which policies are not marketed or held to be Medicare supplement policies or benefit plans.
For purposes of this article, the following terms shall have the meaning indicated herein:
(1) APPLICANT. Includes either of the following:
a. In the case of an individual Medicare supplement policy or subscriber contract, the person who seeks to contract for insurance benefits.
b. In the case of a group Medicare supplement policy or subscriber contract, the proposed certificate holder.
(2) CERTIFICATE. Any certificate issued under a group Medicare supplement policy, which policy has been delivered or issued for delivery in this state.
(3) CERTIFICATE FORM. The form on which the certificate is delivered or issued for delivery by the issuer.
(4) ISSUER. Insurance companies, fraternal benefit societies, health care service plans, health maintenance organizations, and any other entity delivering or issuing for delivery in this state Medicare supplement policies or certificates.
(5) MEDICARE. The 'Health Insurance for the Aged Act,' Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.
(6) MEDICARE SUPPLEMENT POLICY. A group or individual policy of disability insurance or a nonprofit hospital and medical plan contract or a subscriber contract of a health maintenance organization, other than a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act (42 U.S.C. Section 1395, et seq.), or an issued policy under a demonstration project specified in 42 U.S.C. Section 1395ss (g)(1), which is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare.
(7) POLICY FORM. The form on which the policy is delivered or issued for delivery by the issuer
(a) The commissioner shall issue reasonable regulations to establish specific standards for policy provisions of Medicare supplement policies and certificates. The standards shall be in addition to and in accordance with applicable laws of this state, including Article 1 and Chapter 20. No requirement of this title relating to minimum required policy benefits, other than the minimum standards contained in this article, shall apply to Medicare supplement policies and certificates. The standards may cover but shall not be limited to the following:
(1) Terms of renewability.
(2) Initial and subsequent conditions of eligibility.
(3) Nonduplication of coverage.
(4) Probationary periods.
(5) Benefit limitations, exceptions and reductions.
(6) Elimination periods.
(7) Requirements for replacement.
(8) Recurrent conditions.
(9) Definition of terms.
(b) The commissioner may issue reasonable regulations that specify prohibited policy provisions not otherwise specifically authorized by statute which, in the opinion of the commissioner, are unjust, unfair or unfairly discriminatory to any person insured or proposed to be insured under a Medicare supplement policy or certificate.
(c) Notwithstanding any other provisions of law of this state, a Medicare supplement policy shall not exclude or limit benefits for loss incurred more than six months from the effective date of coverage because it involved a pre-existing condition. The policy may not define a pre-existing condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of coverage.
(d) No Medicare supplement policy or certificate in force in the state shall contain benefits that duplicate benefits provided by Medicare.
(a) The commissioner shall issue reasonable regulations to establish minimum standards for benefits, claims payment, marketing practices, compensation arrangements, and reporting practices, for Medicare supplement policies and certificates.
For the purposes of this section, the term compensation arrangements shall not include payment methods, fee schedules or other compensation arrangements between licensed health care providers and purchasers of health care services.
(b) The commissioner may, from time to time, adopt reasonable regulations as are necessary to conform Medicare supplement policies and certificates to the requirements of federal law and regulations promulgated thereunder, including, but not limited to, the following:
(1) Requiring refunds or credits if the policies or certificates do not meet loss ratio requirements.
(2) Establishing a uniform methodology for calculating and reporting loss ratios.
(3) Assuring public access to policies, premiums, and loss ratio information of issuers of Medicare supplement insurance.
(4) Establishing a process for approving or disapproving policy forms and certificate forms and proposed premium increases.
(5) Establishing a policy for holding public hearings prior to approval of premium increases.
(6) Establishing standards for Medicare Select policies and certificates.
Medicare supplement policies shall return to policyholders benefits which are reasonable in relation to the premium charged. The commissioner shall issue reasonable regulations to establish minimum standards for loss ratios of Medicare supplement policies on the basis of incurred claims experience, or incurred health care expenses where coverage is provided by a health maintenance organization on a service rather than reimbursement basis, and earned premiums in accordance with accepted actuarial principles and practices.
(a) In order to provide for full and fair disclosure in the sale of Medicare supplement policies, no Medicare supplement policy shall be delivered or issued for delivery in this state and no certificate shall be delivered pursuant to a group Medicare supplement policy delivered or issued for delivery in this state unless an outline of coverage is delivered to the applicant at the time application is made.
(b) The commissioner shall prescribe the format and content of the outline of coverage required by subsection (a) of this section. For purposes of this section, 'format' means style, arrangements and overall appearance, including, but not limited to, the size, color, and prominence of type and the arrangement of text and captions. This outline of coverage shall include all of the following:
(1) A description of the principal benefits and coverage provided in the policy
(2) A statement of the renewal provisions including any reservation by the insurer of a right to change the premiums and disclosure of the existence of any automatic renewal premium increases based on the policyholder's age.
(3) A statement that the outline of coverage is a summary of the policy issued or applied for and that the policy should be consulted to determine governing contractual provisions.
(c) The commissioner may prescribe by regulation a standard form and the contents of an informational brochure for persons eligible for Medicare, which is intended to improve the buyer's ability to select the most appropriate coverage and improve the buyer's understanding of Medicare. Except in the case of direct response insurance policies, the commissioner may require by regulation that the informational brochure be provided to any prospective insurers eligible for Medicare concurrently with delivery of the outline of coverage. With respect to direct response insurance policies, the commissioner may require by regulation that the prescribed brochure be provided upon request to any prospective insurers eligible for Medicare, but in no event later than the time of policy delivery.
(d) The commissioner may adopt regulations for captions or notice requirements, determined to be in the public interest and designed to inform prospective insurers that particular insurance coverages are not Medicare supplement coverages, for all disability insurance policies sold to persons eligible for Medicare, other than any of the following:
(1) Medicare supplement policies;
(2) Disability income policies;
(3) Basic, catastrophic, or major medical expense policies;
(4) Single premium, nonrenewable policies; or
(5) Other policies defined in subdivision (6) of Section 27-19-52.
(e) The commissioner may adopt reasonable regulations to govern the full and fair disclosure of the information in connection with the replacement of accident and sickness policies, subscriber contracts or certificates by persons eligible for Medicare.
(f) The commissioner may promulgate reasonable regulations to govern the full and fair disclosure of the information in connection with the replacement of accident and sickness policies, subscriber contracts, or certificates by persons eligible for Medicare.
Every issuer of Medicare supplement insurance policies or certificates in this state shall provide a copy of any Medicare supplement advertisement intended for use in this state whether through written, radio, or television medium to the Commissioner of Insurance of this state for review or approval by the commissioner to the extent it may be required under state law.
In addition to any other applicable penalties for violations of the insurance code, the commissioner may require issuers violating this article or regulations promulgated pursuant to this article to cease marketing any Medicare supplement policy or certificate in this state which is related directly or indirectly to a violation or may require the issuer to take actions necessary to comply with the provisions of this article, or both.
Medicare supplement policies or certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason. Any refund made pursuant to this section shall be paid directly to the applicant by the issuer in a timely manner.
Regulations promulgated pursuant to this article shall be subject to the provisions of Chapter 2 of this title.
In addition to any other penalties provided by the laws of this state, any insurer and any agent found to have violated any requirement of this state relating to the regulation of Medicare supplement insurance or the marketing of this insurance shall be subject to a fine of up to three times the amount of any commissions paid for each policy involved in the violation or up to ten thousand dollars ($10,000), whichever is greater.
There shall be a provision as follows:
'Grace Period: A grace period of _____ (insert a number not less than '7' for weekly premium policies, '10' for monthly premium policies and '31' for all other policies) days will be granted for the payment of each premium falling due after the first premium, during which grace period the policy shall continue in force.'
A policy in which the insurer reserves the right to refuse any renewal shall have, at the beginning of the above provision,
'Unless not less than 30 days prior to the premium due date the insurer has delivered to the insured or has mailed to his last address as shown by the records of the insurer written notice of its intention not to renew this policy beyond the period for which the premium has been accepted.'
There shall be a provision as follows:
'Reinstatement: If any renewal premium be not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any agent duly authorized by the insurer to accept such premium, without requiring in connection therewith an application for reinstatement, shall reinstate the policy; provided, however, that if the insurer or such agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy will be reinstated upon approval of such application by the insurer or, lacking such approval, upon the forty-fifth day following the date of such conditional receipt unless the insurer has previously notified the insured in writing of its disapproval of such application. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than 10 days after such date. In all other respects, the insured and the insurer shall have the same rights thereunder as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions endorsed hereon or attached hereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than 60 days prior to the date of reinstatement.'
The last sentence of the above provision may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums:
(1) Until at least age 50; or
(2) In the case of a policy issued after age 44, for at least five years from its date of issue.
There shall be a provision as follows:
'Notice of Claim: Written notice of claim must be given to the insurer within 20 days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible. Notice given by, or on behalf of, the insured or the beneficiary to the insurer at _____ (insert the location of such office as the insurer may designate for the purpose), or to any authorized agent of the insurer, with information sufficient to identify the insured, shall be deemed notice to the insurer.'
In a policy providing a loss-of-time benefit which may be payable for at least two years, an insurer may, at its option, insert the following between the first and second sentences of the above provision:
'Subject to the qualifications set forth below, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least two years, he shall, at least once in every six months after having given notice of the claim, give to the insurer notice of continuance of the disability, except in the event of legal incapacity. The period of six months following any filing of proof by the insured or any payment by the insurer on account of such claim or any denial of liability, in whole or in part, by the insurer shall be excluded in applying this provision. Delay in the giving of such notice shall not impair the insured's right to any indemnity which would otherwise have accrued during the period of six months preceding the date on which such notice is actually given.'
There shall be a provision as follows:
'Claim Forms: The insurer, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within 15 days after the giving of such notice, the claimant shall be deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made.'
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