W. Va. Code R. § 114-10-6

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-10-6 - Advertisements Of Benefits Payable, Losses Covered Or Premiums Payable

6.1. Deceptive words, phrases or illustrations prohibited.

(a) No advertisement shall omit information or use words, phrases, statements, references or illustrations if the omission of such information or use of such words, phrases, statements, references or illustrations has the capacity, tendency or effect of misleading or deceiving purchasers or prospective purchasers as to the nature or extent of any policy benefit payable, loss covered or premium payable. The fact that the policy offered is made available to a prospective insured for inspection prior to consummation of the sale or an offer is made to refund the premium if the purchaser is not satisfied, does not remedy misleading statements.

(b) No advertisement shall contain or use words or phrases such as, "All"; "Full"; "Complete"; "Comprehensive"; "Unlimited"; "Up To"; "As High As"; "This policy will help pay your hospital and surgical bills"; "This policy will help fill some of the gaps that medicare and your present insurance leave out"; "This policy will help to replace your income" (when used to express loss of time benefits); or similar words and phrases, in a manner which exaggerates any benefits beyond the terms of the policy.

(c) An advertisement shall not contain descriptions of a policy limitation, exception or reduction, worded in a positive manner to imply that it is a benefit, such as, describing a waiting period as a "Benefit Builder," or stating "Even preexisting conditions are covered after two (2) years." Words and phrases used in an advertisement to describe such policy limitations, exceptions and reductions shall fairly and accurately describe the negative features of such limitations, exceptions and reductions in the policy offered.

(d) No advertisement of a benefit for which payment is conditional upon confinement in a hospital or similar facility shall use words or phrases such as "Tax Free"; "Extra Cash"; "Extra Income"; "Extra Pay"; or substantially similar words or phrases because such words and phrases have the capacity, tendency or effect of misleading the public into believing that the policy advertised will, in some way, enable them to make a profit from being hospitalized.

(e) No advertisement of a hospital or other similar facility confinement benefit shall advertise that the amount of the benefit is payable on a monthly or weekly basis when, in fact, the amount of the benefit payable is based upon a daily pro rata basis relating to the number of days of confinement. When the policy contains a limit on the number of days of coverage provided, such limit must appear in the advertisement.

(f) No advertisement of a policy covering only one disease or a list of specified diseases shall imply coverage beyond the terms of the policy. Synonymous terms shall not be used to refer to any disease so as to imply broader coverage than is the fact.

(g) An advertisement for a policy providing benefits for specified illnesses only, such as cancer or for specified accidents, shall clearly and conspicuously in prominent type state the limited nature of the policy. The statement shall be worded in language identical to or substantially similar to the following: "This is a Limited Policy"; "This is a Cancer Only Policy"; "This is an Automobile Accident Only Policy."

(h) An advertisement of a direct response insurance product shall not imply that because "No insurance agent will call and no commissions will be paid to agents" that it is "A Low Cost Plan," or use other similar words or phrases because the cost of advertising and servicing such policies is a substantial cost in the marketing of a direct response insurance product.

6.2. Exceptions, reductions and limitations.

(a) When an advertisement refers to either a dollar amount, or a period of time for which any benefit is payable, or the cost of the policy, or specific policy benefit, or the loss for which such benefit is payable, it shall also disclose those exceptions, reductions and limitations affecting the basic provisions of the policy without which the advertisement would have the capacity or tendency to mislead or deceive.

(b) When a policy contains a waiting, elimination, probationary or similar time period between the effective date of the policy and the effective date of coverage under the policy or a time period between the date a loss occurs and the date benefits begin to accrue for such loss, an advertisement which is subject to the requirements of Paragraph (a) of this section shall disclose the existence of such periods.

(c) An advertisement shall not use the words "Only"; "Just"; "Merely"; "Minimum" or similar words or phrases to describe the applicability of any exceptions and reductions, such as: "This policy is subject to the following minimum exceptions and reductions."

6.3. Preexisting conditions.

(a) An advertisement which is subject to the requirements of Section 6.2 of these rules, shall in negative terms, disclose the extent to which any loss is not covered if the cause of such loss is traceable to a condition existing prior to the effective date of the policy. The use of the term "Preexisting Condition" without an appropriate definition or description is prohibited.

(b) When a policy does not cover losses resulting from preexisting conditions, no advertisement of the policy shall state or imply that the applicant's physical condition or medical history will not affect the issuance of the policy or payment of a claim thereunder. This section prohibits the use of the phrase "No Medical Examination Required" and phrases of similar import, but does not prohibit explaining "Automatic Issue." If an insurer requires a medical examination for a specified policy, the advertisement shall disclose that a medical examination is required.

(c) When an advertisement contains an application form to be completed by the applicant and return by mail for a direct response insurance project, such application form shall contain a question or statement which reflects the preexisting condition provisions of the policy immediately preceding the blank space for the applicant's signature. For example, such an application form shall contain a question or statement substantially as follows:

"Do you understand that this policy will not pay benefits during the first _______ year (s) after the issue date for a disease or physical condition which you now have or have had in the past?" () YES

Or substantially the following statement:

"I understand that the policy applied for will not pay benefits for any loss incurred during the first _______ year (s) after the issue date on account of disease or physical condition which I now have or have had in the past."

W. Va. Code R. § 114-10-6