14 Va. Admin. Code § 5-90-30

Current through Register Vol. 40, No. 22, June 17, 2024

Section 14VAC5-90-30 - Definitions

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Advertisement" means

(i) printed and published material, audio visual material, and descriptive literature of an insurer used in direct mail, newspapers, magazines, radio scripts, television scripts, web sites and other Internet displays or communications, other forms of electronic communications, billboards, and similar displays;

(ii) descriptive literature and sales aids of all kinds issued by an insurer or agent for presentation to the insurance-buying public, including but not limited to circulars, leaflets, booklets, depictions, illustrations, and form letters; and

(iii) prepared sales talks, presentations and material for use by agents. "Advertisement" shall not include:

1. Material used in-house by insurers;

2. Communications within an insurer's own organization not intended for dissemination to the insurance-buying public; however, to the extent any communications are in fact disseminated to the insurance-buying public or utilized in a sales presentation to the insurance-buying public, the materials shall be considered to fall within the definition of "advertising";

3. Individual communications of a personal nature with current policyholders other than material urging the policyholder to increase, expand, terminate or purchase new coverages;

4. Correspondence between a prospective group or policyholder and an insurer in the course of negotiating a group contract other than material urging the policyholder to increase or expand coverages;

5. Court-approved material ordered by a court to be disseminated to policyholders;

6. A general announcement from a group policyholder to eligible individuals on an employment or membership list that a contract or program has been written or arranged, provided that the announcement clearly indicates that it is preliminary to the issuance of a booklet and that the announcement does not describe specific benefits under the contract or program nor describe advantages as to the purchase of the contract or program. This does not prohibit a general endorsement of the program by the sponsor;

7. Electronic communications devoted to electronic business transactions between existing members, providers, employers, and the insurer containing no materials relating to increasing, decreasing, terminating, or expanding coverages; or

8. Member newsletters or educational material sent to existing members, providers, or employers containing no materials relating to increasing, decreasing, terminating, or expanding coverages.

"Commission" means the Virginia State Corporation Commission.

"Exception" means any provision in a policy whereby coverage for a specified hazard is entirely eliminated; it is a statement of a risk not assumed under the policy.

"Institutional advertisement" means an advertisement having as its sole purpose the promotion of the reader's, viewer's, or listener's interest in the concept of accident and sickness insurance, or the promotion of the insurer as a seller of accident and sickness insurance.

"Insurer" means an individual, corporation, association, partnership, reciprocal exchange, inter-insurer, Lloyds, fraternal benefit society, health maintenance organization, and any other legal entity that is defined as an "insurer" in Title 38.2 of the Code of Virginia.

"Invitation to contract" means an advertisement that includes in any manner an application for insurance. It is not an invitation to inquire nor an institutional advertisement.

"Invitation to inquire" means an advertisement having as its objective the creation of a desire to inquire further about accident and sickness insurance and that is limited to a brief description of the loss for which benefits are payable and does not contain an application for coverage, but may contain (i) the dollar amount of benefits payable, and (ii) the period of time during which benefits are payable. An invitation to inquire may not refer to cost, except as otherwise permitted by this chapter.

"Limitation" means any provision that restricts coverage under the policy other than an exception or a reduction.

"Policy" means a policy, plan, certificate, contract, agreement, statement of coverage, rider or endorsement that provides accident or sickness benefits or medical, surgical or hospital expense benefits, whether on an indemnity, reimbursement, service or prepaid basis, except (i) when issued in connection with another kind of insurance other than life; and (ii) disability, waiver of premium, and double indemnity benefits included in life insurance and annuity contracts.

"Reduction" means any provision that reduces the amount of the benefit; a risk of loss is assumed but payment upon the occurrence of the loss is limited to some amount or period less than would be otherwise payable had such reduction not been used.

14 Va. Admin. Code § 5-90-30

Derived from Regulation 8, Case No. 19498, § 3, eff. June 1, 1975; amended, Virginia Register Volume 20, Issue 25, eff. August 4, 2004.

Statutory Authority

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