Administrative Code

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Virginia Administrative Code
Title 14. Insurance
Agency 5. State Corporation Commission, Bureau of Insurance
Chapter 120. Rules Governing the Implementation of the Individual Accident and Sickness Insurance Minimum Standards Act with Respect to Specified Disease Policies

14VAC5-120-50. General policy requirements.

All specified disease policies must meet the following general requirements:

1. A "noncancellable," "guaranteed renewable," or "noncancellable and guaranteed renewable" policy shall not provide for termination of coverage of the spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than nonpayment of premium. The policy shall provide that in the event of the insured's death, the spouse of the insured, if covered under the policy, shall become the insured.

2. Policies containing specified disease coverage shall be at least guaranteed renewable. The renewability provisions "noncancellable," "guaranteed renewable" or "noncancellable and guaranteed renewable" shall not be used without further explanatory language in accordance with the disclosure requirements of 14VAC5-120-80 A.

3. If a policy contains a status type military service exclusion or a provision which suspends coverage during military service, the policy shall provide, upon receipt of written notice of military service, for refund of premiums as applicable to such person on a pro rata basis.

4. Policies providing convalescent or extended care benefits following hospitalization shall not condition such benefits upon admission to the convalescent or extended care facility within a period of less than 14 days after discharge from the hospital.

5. Any policy providing coverage for the recipient in a transplant operation shall also provide reimbursement of any medical expenses of a live donor to the extent that benefits remain and are available under the recipient's policy, after benefits for the recipient's own expenses have been paid.

6. A policy may contain a provision relating to recurrent disabilities; provided, however, that no such provision shall specify that a recurrent disability be separated by a period greater than six months.

7. Policies covering a single specified disease or combination of specified diseases may not be sold or offered for sale other than as specified disease coverage under this chapter (14VAC5-120-10 et seq.).

8. Any policy which conditions payment upon pathological diagnosis of a covered disease shall also provide that if such a pathological diagnosis is medically inappropriate, a clinical diagnosis will be accepted in lieu thereof.

9. Notwithstanding any other provision of this chapter specified disease policies shall not deny benefits to any covered person for the specified disease(s) nor for any other condition(s) or disease(s) directly caused or aggravated by the specified disease(s) or the treatment of the specified disease(s).

10. No policy shall contain a waiting or probationary period greater than 30 days.

11. Any application for specified disease coverage shall contain a statement above the signature of the applicant indicating that no person to be covered for specified disease is also covered by any Title XIX program (Medicaid or any similar name) (42 USC § 1396 et seq.). Such statement may be combined with any other statement for which the insurer may require the applicant's signature.

12. Payments may be conditioned upon a covered person's receiving medically necessary care, given in a medically appropriate location, under a medically accepted course of diagnosis or treatment.

13. Except for the uniform provision regarding other insurance with this insurer, benefits for specified disease coverage shall be paid regardless of other coverage available through other health insurance.

14. After the effective date of the coverage (or applicable waiting period, if any) benefits shall begin with the first day of care or confinement if such care or confinement is for a covered disease even though the diagnosis is made at some later date. The retroactive application of such coverage may not be less than ninety (90) days prior to such diagnosis.

Statutory Authority

§§ 38.2-514, 38.2-3516 through 38.2-3520 of the Code of Virginia.

Historical Notes

Derived from Regulation 21, INS810010, § 6, eff. June 1; 1981.

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