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Virginia Administrative Code
Title 14. Insurance
Agency 5. State Corporation Commission, Bureau of Insurance
Chapter 130. Rules Governing the Filing of Rates for Individual and Group Accident and Sickness Insurance
11/23/2024

14VAC5-130-65. Reasonableness of benefits in relation to initial premiums.

A. Benefits shall be deemed reasonable in relation to premiums provided the anticipated loss ratio of the policy form, including riders and endorsements, is at least as great as specified in this subsection:

1. If the expected average annual premium is at least $200 but less than $1,000:

Type of Coverage

Renewal Clause

OR

CR

GR

NC

Other

Hospital Confinement Indemnity

n/a

n/a

55%

50%

n/a

Disability Income Protection, Accident Only, Specified Disease and Other, whether paid on an expense incurred or indemnity basis

60%

55%

50%

45%

60%

Short-term Limited Duration

n/a

n/a

n/a

n/a

60%

Definitions of renewal clause:

OR - Optionally renewable: individual policy renewal is at the option of the insurance company.

CR - Conditionally renewable: renewal can be declined by the insurance company only for stated reasons other than deterioration of health or renewal can be declined on a geographic territory basis.

GR - Guaranteed renewable: renewal cannot be declined by the insurance company for any reason, but the insurance company can revise rates on a class basis.

NC - Noncancellable: renewal cannot be declined nor can rates be revised by the insurance company.

Other - Any other renewal or nonrenewal clauses.

2. If the expected average annual premium is $100 or more but less than $200, subtract five percentage points from the numbers in the table in subdivision 1 of this subsection.

3. If the expected average annual premium is less than $100, subtract 10 percentage points from the numbers in the table in subdivision 1 of this subsection.

4. If the expected average annual premium is $1,000 or more, add five percentage points to the numbers in the table in subdivision 1 of this subsection.

5. For individual or group Medicare supplement policies, the loss ratios are identified in 14VAC5-170-120 A.

6. Notwithstanding subdivisions 1 through 4 of this subsection, all individual health insurance coverage shall be originally priced to meet a minimum 75% loss ratio and, except for student health insurance coverage such coverage shall be guaranteed renewable or noncancellable.

7. Notwithstanding subdivisions 1 through 4 of this subsection, all small employer group health insurance coverage shall be originally priced to meet a minimum 75% loss ratio and shall be guaranteed renewable or noncancellable.

The above anticipated loss ratio standards do not apply to a type of coverage where such standards are in conflict with specific statutes or regulations.

B. The expected average annual premium per policy and per member shall be computed by the insurer based on an anticipated distribution of business by all applicable criteria having a price difference, such as age, sex, amount, dependent status, rider frequency, etc., except assuming an annual mode for all policies (i.e., the fractional premium loading shall not affect the average annual premium or anticipated loss ratio calculation).

Statutory Authority

§§ 12.1-13 and 38.2-223 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 29, Issue 20, eff. July 1, 2013; amended, Virginia Register Volume 32, Issue 9, eff. January 1, 2016; Volume 36, Issue 5, eff. January 1, 2020.

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