Code of Virginia

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Code of Virginia
Title 38.2. Insurance
Chapter 35. Accident and Sickness Insurance Policies
7/24/2021

Article 2. Individual Accident and Sickness Insurance Minimum Standards.

§ 38.2-3516. Purpose.

The purpose of this article is to authorize the Commission, pursuant to the authority granted in § 38.2-223, to issue rules and regulations to:

1. Provide reasonable standardization and simplification of terms and coverages of individual accident and sickness insurance policies;

2. Facilitate public understanding and comparison;

3. Eliminate provisions contained in individual accident and sickness insurance policies which may be misleading or unreasonably confusing in connection either with the purchase of coverages or with the settlement of claims; and

4. Provide for full disclosure in the sale of individual accident and sickness policies.

1980, c. 204, § 38.1-362.11; 1986, c. 562.

§ 38.2-3517. Definitions.

As used in this article:

"Form" means policies, contracts, riders, endorsements, and applications.

"Policy" means the entire contract between the insurer and the insured, including the policy riders, endorsements, and the application, if attached.

1980, c. 204, § 38.1-362.12; 1986, c. 562.

§ 38.2-3518. Standards for policy provisions.

A. Pursuant to the authority granted in § 38.2-223, the Commission may issue rules and regulations to establish specific standards, including standards of full and fair disclosure, for the sale of individual accident and sickness insurance policies. These rules and regulations shall be in addition to and in accordance with applicable laws of this Commonwealth, including Chapter 34 (§ 38.2-3400 et seq.) and Articles 1 (§ 38.2-3500 et seq.) and 2 (§ 38.2-3516 et seq.) of this chapter which may cover but shall not be limited to:

1. Terms of renewability;

2. Initial and subsequent conditions of eligibility;

3. Nonduplication of coverage provisions;

4. Coverage of dependents;

5. Coverage of persons eligible for Medicare by reason of age;

6. Preexisting conditions;

7. Termination of insurance;

8. Probationary periods;

9. Limitations;

10. Exceptions;

11. Reductions;

12. Elimination periods;

13. Requirements for replacement;

14. Recurrent conditions; and

15. Definition of terms including but not limited to the following: hospital, accident, sickness, injury, physician, accidental means, total disability, partial disability, nervous disorder, guaranteed renewable, and noncancellable.

For the purposes of this article, "licensed health care practitioners", to the extent required by law, shall be deemed physicians.

B. Pursuant to the authority granted in § 38.2-223, the Commission may issue rules and regulations that specify prohibited policies or policy provisions not otherwise specifically authorized by statute that in the opinion of the Commission are unjust, unfair, or unfairly discriminatory to the policyowner, beneficiary, or any person insured under the policy.

1980, c. 204, § 38.1-362.13; 1981, c. 575; 1986, c. 562.

§ 38.2-3519. Minimum standards for benefits.

A. Pursuant to the authority granted in § 38.2-223, the Commission may issue rules and regulations establishing minimum standards for benefits under each of the following categories of coverage in individual policies of accident and sickness insurance:

1. Basic hospital expense coverage;

2. Basic medical-surgical expense coverage;

3. Hospital confinement indemnity coverage;

4. Major medical expense coverage;

5. Disability income protection coverage;

6. Accident only coverage;

7. Specified disease or specified accident coverage;

8. Medicare supplement coverage; and

9. Limited benefit health coverage.

B. Nothing in this section shall preclude the issuance of any policy that combines two or more of the categories of coverage enumerated in subdivisions 1 through 6 of subsection A of this section.

C. No policy shall be delivered or issued for delivery in this Commonwealth that does not meet the prescribed minimum standards for the categories of coverage listed in subdivisions 1 through 9 of subsection A of this section or does not meet the requirements set forth in § 38.2-3501.

D. The Commission may prescribe the method of identification of policies based upon coverages provided.

1980, c. 204, § 38.1-362.14; 1986, c. 562.

§ 38.2-3520. Coverage of preexisting conditions.

A. Notwithstanding the provisions of § 38.2-3503, if an insurer elects to use a simplified application form, with or without a specific question as to the applicant's health, but without any detailed questions concerning the insured's health history or medical treatment history, the policy shall cover any loss occurring after twelve months from the effective date of coverage from any preexisting condition not specifically excluded from coverage by terms of the policy. Except as so provided, the policy shall not include wording that would permit a defense based upon preexisting conditions.

B. The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34.

1980, c. 204, § 38.1-362.15; 1981, c. 575; 1986, c. 562; 2013, c. 751.