Repealed or Renumbered
There may be a provision as follows:
'Unpaid Premiums: Upon the payment of a claim under this policy, a premium then due and unpaid or covered by a note or written order may be deducted from it.'
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 that which the premium paid would have purchased at the correct age.'
There may be a provision as follows:
'Intoxicants and Narcotics: The insurer shall not be liable for a loss sustained or contracted in consequence of the insured's being intoxicated or under the influence of a narcotic unless administered on the advice of a physician.'
There may be a provision as follows:
'Illegal Occupation: The insurer shall not be liable for a 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:
'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 that date is amended to conform to the minimum requirements of the statutes.'
The word 'insured,' as used in this chapter, may not prevent 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 a policy to any indemnities, benefits, and rights provided in the policy.
A health care insurer that offers a health care insurance plan in the individual market shall comply with the guaranteed renewability requirements established under 42 U.S.C. 300gg-42 and shall comply with the certification of coverage requirements established under 42 U.S.C. 300gg-43.
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 at law or in equity shall be brought to recover on this policy before the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of this policy. No action shall be brought after the expiration of three years after the written proof of loss is required to be furnished.'
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 the approval is 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:
'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 a 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.)
There shall be a provision as follows:
'Claim Forms: The insurer, within 10 working days after receipt of a notice of claim, will furnish to the claimant forms that are usually furnished by it for filing proofs of loss. If the forms are not furnished within 10 days after the giving of notice, the claimant shall be considered 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.'
There shall be a provision as follows:
'Time of Payment of Claims: Indemnities payable under this policy for a loss other than loss for which this policy provides a periodic payment will be paid within 30 days after receipt of due written proof of the 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 beginning within 30 days after receipt of due written proof.'
(a) A policy of a foreign or alien insurer, when delivered or issued for delivery to a person in this state, may contain any provision that is not less favorable to the insured or the beneficiary than the provisions of this chapter and that is prescribed or required by the law of the state or country under which the insurer is organized.
(b) A policy of a domestic insurer may, when issued for delivery in another state or country, contain any provision permitted or required by the laws of the other state or country.
(a) A policy provision that is not subject to this chapter may not make a policy, or any portion of a policy, less favorable to the insured or the beneficiary than the provisions of the policy that are subject to this chapter.
(b) A policy delivered or issued for delivery to a person in this state in violation of this chapter shall be held valid but shall be construed as provided in this chapter. When a provision in a policy subject to this chapter is in conflict with a provision of this chapter, the rights, duties, and obligations of the insurer, the insured and the beneficiary shall be governed by the provisions of this chapter.
There shall be a provision as follows:
'Proofs of Loss: Written proof of loss must be furnished to the insurer at its office in case of claim for loss for which this policy provides 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 that loss. Failure to furnish proof within the time required shall not invalidate or reduce a claim if it was not reasonably possible to give proof within that time, provided that the 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.'
If the 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 the date falls within a period for which premium is accepted by the insurer or if the insurer accepts a premium after that date, the coverage provided by the policy will continue in force until the end of the period for which premium has been accepted. If 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 before the acceptance of the premium or premiums, 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.
In this chapter,
(1) 'health care insurance plan' has the meaning given in AS 21.54.500;
(2) 'health care insurer' has the meaning given in AS 21.54.500 ;
(3) 'individual market' means the market for health care insurance offered to individuals other than in connection with a health benefit plan as defined in AS 21.54.500 .
Health insurance policies, other than accident insurance only policies, in which the insurer reserves the right to refuse renewal on an individual basis, must provide in substance in a provision or in an endorsement or rider attached to it that, subject to the right to terminate the policy upon nonpayment of premium when due, the right to refuse renewal may not be exercised to take effect before the renewal date occurring on or after and nearest each policy anniversary, or in the case of lapse and reinstatement, at the renewal date occurring on or after and nearest each anniversary of the last reinstatement, and a refusal of renewal shall be without prejudice to any claim originating while the policy is in force. The parenthetic reference to lapse and reinstatement may be omitted at the insurer's option.
The provisions that are the subject of AS 21.51.040 - 21.51.260, or any corresponding provisions that are used in lieu thereof in accordance with these sections, shall be printed in the consecutive order of the provisions in the sections or, at the option of the insurer, the 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 may 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) 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.'
(b) A policy in which the insurer reserves the right to refuse renewal shall have, at the beginning of the provision in (a) of this section,
'Unless not less than 30 days before the premium due date the insurer has delivered to the insured or has mailed to the last address of the insured 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.'
Nothing in this chapter applies to or affects
(1) a policy of liability or workers' compensation insurance with or without supplementary expense coverage;
(2) a group or blanket policy;
(3) life insurance, endowment or annuity contracts, or supplemental contracts that contain only those provisions relating to health insurance that
(A) provide additional benefits in case of death or dismemberment or loss of sight by accident or accidental means; or
(B) operate to safeguard the contracts against lapse, or to give a special surrender value or special benefit or an annuity in the event that the insured or annuitant becomes totally and permanently disabled, as defined by the contract or supplemental contract;
(4) reinsurance.
Except as provided in AS 21.51.030 (b), a policy delivered or issued for delivery to a person in this state may not contain provisions respecting the matters set out in AS 21.51.170 - 21.51.260 unless the 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 the provision a corresponding provision of different wording approved by the director that is not less favorable in any respect to the insured or the beneficiary. The provision contained in the policy shall be preceded individually by the appropriate caption or, at the option of the insurer, by the appropriate individual or group captions or subcaptions as the director may approve.
(a) 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 is 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 the excess shall be returned to the insured or to the estate of the insured.'
(b) In lieu of the provision in (a) of this section, there may be a provision as follows:
'Insurance effective at any one time on the insured under a like policy or policies in this insurer is limited to the one policy elected by the insured, the beneficiary or the estate of the insured, as the case may be, and the insurer will return all premiums paid for all other such policies.'
(a) Except as provided in (b) of this section, each policy delivered or issued for delivery to a person in this state must contain the provisions specified in AS 21.51.040 - 21.51.150, in the words in which the same appear; except, that the insurer may, at its option, substitute for one or more of the provisions corresponding provisions of different wording approved by the director that are in each instance not less favorable in any respect to the insured or the beneficiary. Each provision shall be preceded individually by the applicable caption shown, or, at the option of the insurer, by the appropriate individual or group captions or subcaptions as the director may approve.
(b) If the 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 director shall omit from the policy any inapplicable provision or part of a provision and shall modify the inconsistent provision or part of a provision in a manner that makes the provision as contained in the policy consistent with the coverage provided by the policy.
(a) Health insurance on a franchise plan is that form of health insurance issued to
(1) five or more employees of a corporation, copartnership, or individual employer or a governmental corporation, agency, or department of them; or
(2) 10 or more members, employees, or employees of members of a trade or professional association or of a labor union or of any other association having had an active existence for at least two years if the association or union has a constitution or bylaws and is formed in good faith for purposes other than that of obtaining insurance.
(b) If these persons, with or without their dependents, are issued the same form of an individual policy varying only in amounts and kinds of coverage applied for by the persons under an arrangement whereby the premiums on the 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 the employer, association, or union, the term 'employees' as used herein may be considered to include the officers, managers, and employees and retired employees of the employer and the individual proprietor or partners if the employer is an individual proprietor or partnership.
There may be a provision as follows:
'Change of Occupation: If the insured is injured or contracts sickness after changing occupations 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 the portion of the indemnities provided in this policy which the premium paid would have purchased at the rates and within the limits fixed by the insurer for the more hazardous occupation. If the insured changes occupations to one classified by the insurer as less hazardous than that stated in this policy, the insurer, upon receipt of proof of the 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 the proof, whichever is the more recent. In applying this provision, the classification of occupational risk and the premium rates shall be those which have been last filed by the insurer before the occurrence of the loss for which the insurer is liable or before the 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 the filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the insurer in the state before the occurrence of the loss or before the date of proof of change in occupation.'
(a) 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 a 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 the office which the insurer designates for the purpose), or to an authorized agent of the insurer, with information sufficient to identify the insured, shall be considered notice to the insurer.'
(b) 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 provision in (a) of this section:
'Subject to the qualifications set out below, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least two years, the insured 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 a filing of proof by the insured or a payment by the insurer on account of the claim or a denial of liability in whole or in part by the insurer shall be excluded in applying this provision. Delay in the giving of notice shall not impair the insured's right to indemnity which would otherwise have accrued during the period of six months preceding the date on which the notice is actually given.'
(a) There shall be a provision as follows:
'Reinstatement: If (1) a renewal premium is not paid within the time granted the insured for payment, (2) a subsequent acceptance of premium by the insurer or by an agent authorized by the insurer to accept the premium occurs, without requiring in connection therewith an application for reinstatement, and (3) the insurer issues a conditional receipt for the premium tendered, the policy will be reinstated upon approval of the application by the insurer or, lacking approval, upon the 45th day following the date of the conditional receipt unless the insurer has previously notified the insured in writing of its disapproval of the application. The reinstated policy shall cover only loss resulting from the accidental injury that may be sustained after the date of reinstatement and loss due to the sickness that may begin more than 10 days after that date. In all other respects, the insured and 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. A premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to a period more than 60 days before the date of reinstatement.'
(b) The last sentence of the provision in (a) of this section may be omitted from a policy that 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:
'Time Limit on Certain Defenses: (1) After three years from the date of issue of this policy no misstatements, except fraudulent misstatements, made by the applicant in the application for the 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 the three-year period.'
(A) 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 the initial three-year period, or to limit the application of AS 21.51.170 - 21.51.210 in the event of misstatement with respect to age or occupation or other insurance.
(B) A policy that the insured has the right to continue in force subject to its terms by the timely payment of premium (i) until at least age 50 or (ii) 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 three years during the lifetime of the insured (excluding any period 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 three 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 before the effective date of coverage of this policy.'
(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 the average monthly earnings of the insured 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 the proportionate amount of the benefits under this policy that the amount of the monthly earnings or the average monthly earnings of the insured bears to the total amount of monthly benefits for the same loss under all the coverage upon the insured at the time disability commences and for the return of the part of the premiums paid during the two years which 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 the coverage upon the insured below the sum of $200 or the sum of the monthly benefits specified in the coverages, whichever is the lesser, or operate to reduce benefits other than those payable for loss of time.'
(b) The policy provision in (a) of this section may be inserted only in a policy that 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 director, 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 another state of the United States or a province of Canada, or to any other coverage that may be approved for inclusion by the director or a combination of these coverages. In the absence of this definition the term may not include coverage provided for the insured under a compulsory benefit statute, including a workers' compensation or employer's liability statute, or benefits provided by union welfare plans or by employer or employee benefit organizations.
(a) There may be a provision as follows:
'Insurance With Other Insurers: If there is 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 before the occurrence or commencement of loss, the only liability for the benefits under this policy shall be for the proportion of the indemnities otherwise provided hereunder for the loss that the like indemnities of which the insurer has notice (including the indemnities under this policy) bear to the total amount of all like indemnities for the loss, and for the return of the portion of the premium paid which exceeds the pro rata portion for the indemnities thus determined.'
(b) If the policy provision in (a) of this section is included in a policy that also contains the policy provision set out in AS 21.51.200 , 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 director, 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 a province of Canada, and to any other coverage the inclusion of which may be approved by the director. In the absence of this definition the 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 an insured, an amount of benefit provided for such insured under any compulsory benefit statute (including any workers' compensation or employer's liability statute), whether provided by a governmental agency or otherwise, shall in all cases be considered 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 policy of health insurance may not be delivered or issued for delivery to a person in this state unless it otherwise complies with this title, and complies with the following:
(1) the entire money and other considerations must be expressed in the policy;
(2) the time the insurance takes effect and terminates must be expressed in the policy;
(3) it must insure only one person, except that a policy may insure, originally or by subsequent amendment, upon the application of an adult member of a family, who shall be considered the policyholder, any two or more eligible members of that family, including husband, wife, dependent children, or any children under a specified age, which shall not exceed 23 years, and any other person dependent upon the policyholder;
(4) the style, arrangement, and over-all appearance of the policy must give no undue prominence to any portion of the text, and every printed portion of the text of the policy and of endorsements or attached papers must be plainly printed in light-faced type of a style in general use, the size of which must be uniform and not less than 10 point with a lower case unspaced alphabet length not less than 120 point; in this paragraph, text includes all printed matter except the name and address of the insurer, name or title of the policy, the brief description, if any, and captions and subcaptions;
(5) the exceptions and reductions of indemnity must be set out in the policy and, other than those contained in AS 21.51.040 - 21.51.260, must be printed, at the insurer's option, either included with the benefit provision to which they apply, or under an appropriate caption such as 'Exceptions,' or 'Exceptions and Reductions,' except that if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of the exception or reduction must be included with the benefit provision to which it applies;
(6) each form, including riders and endorsements, must be identified by a form number in the lower left-hand corner of the first page;
(7) the policy may not contain a provision making a portion of the charter, rules, constitution, or bylaws of the insurer a part of the policy unless the portion is set out in full in the policy; this paragraph does not apply to the incorporation of, or reference to, a statement of rates or classification of risks, or short-rate table filed with the director.
(a) There may be a provision as follows:
'Insurance With Other Insurers: If there is 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 before the occurrence or commencement of loss, the only liability under an expense incurred coverage of this policy shall be for the proportion of the loss that the amount that would otherwise have been payable hereunder plus the total of the like amounts under all the other valid coverages for the same loss of which this insurer had notice bears to the total like amounts under all valid coverages for the loss and for the return of the portion of the premiums paid that 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 the other coverage shall be taken as the amount which the services rendered would have cost in the absence of the coverage.'
(b) If the policy provision in (a) of this section is included in a policy that also contains the policy provision set out in AS 21.51.210 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 director, 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 a province of Canada, and by hospital or medical service organizations, and to any other coverage the inclusion of which may be approved by the director. In the absence of this definition the term may 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 an insured, an amount of benefit provided for the insured under a compulsory benefit statute (including a workers' compensation or employer's liability statute), whether provided by a governmental agency or otherwise, shall in all cases be considered 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) A health insurance policy delivered or issued for delivery must contain the following provisions:
(1) indemnity for loss of life shall be paid according to the beneficiary designation and payment provisions contained in the policy that are effective at the time of payment; if a beneficiary has not been designated, indemnity shall be paid to the estate of the insured; accrued indemnities unpaid at the insured's death shall be paid to either the beneficiary or the estate, at the option of the insurer; all other indemnities shall be paid to the insured;
(2) the insurer may, and upon written request of the insured shall, within 30 working days after receiving a proof of loss statement, pay indemnities for hospital, nursing, medical, dental, or surgical services directly to the provider of the services; an insurer who pays indemnities to an insured, after the insured has given the insurer written notice in the proof of loss statement of an election of direct payment of indemnities to the provider of the services, shall also pay indemnities to the provider of the services; this paragraph does not require that services be provided by a particular hospital or person;
(3) a covered person may revoke an election of direct payment of indemnities made under this subsection by giving written notice of the revocation to the insurer and to the provider of the services; the written notice of revocation given to the insurer must certify that the covered person has given written notice of revocation to the provider of the services; revocation of an election of direct payment is not effective until the notice of revocation is received by the insurer and the provider of the services;
(4) the right of the insured to request payment of indemnities for hospital, nursing, medical, dental, or surgical services directly to the provider of the services or to another person may be transferred to a person who is not the insured by a qualified domestic relations order; rights under the qualified domestic relations order do not take effect until the order is received by the insurer; in this paragraph, 'qualified domestic relations order' means an order or judgment in a divorce or dissolution action under AS 25.24 that designates a person to determine to whom indemnities for a named beneficiary should be paid under a health insurance policy.
(b) A health insurance policy delivered or issued for delivery may, at the option of the insurer, require that an indemnity in an amount not to exceed $1,000 that is payable to the estate of the insured, an insured or beneficiary who is a minor, or an insured who is not competent to give a valid release, be paid to a relative by blood or marriage, or a beneficiary that the insured determines is equitably entitled to the payment. A good faith payment by the insurer under this subsection fully discharges the insurer to the extent of the payment.
(c) This section does not apply to payments made under a provider contract that holds the covered person harmless from charges for services except copayments, coinsurance, and deductibles.
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