W. Va. Code R. agency 114, tit. 114, ser. 114-12, app H
[COMPANY NAME]
[SPECIFIED DISEASE] [SPECIFIED ACCIDENT] COVERAGE
OUTLINE OF COVERAGE
(1) Read Your Policy Carefully. -- This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance policy, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurer. It is, therefore, important that you Read Your Policy Carefully!
(2) [Specified Disease] [Specified Accident] Coverage. -- Policies of this category are designed to provide, to persons insured, restricted coverage paying benefits only when certain losses occur as a result of [specified diseases] [specified accidents], subject to any limitations, deductibles or copayment requirements set forth in the policy. Coverage is not provided for basic hospital, basic medical-surgical or major medical expenses. [Note: Final sentence may be appropriately modified, if necessary, to reflect coverage provided.]
(3) [A brief specific description of the benefits, including dollar amounts, contained in this policy.]
(4) [A description of any policy provisions which exclude, eliminate, restrict, reduce, limit, delay or in any other manner operate to qualify payment of the benefits described in paragraph (3) above.]
(5) [A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.]
NOTE: In the outline of coverage forms that follow, only the material appearing in brackets is to be composed by the insurer in language appropriate for the coverage provided. All other material shall appear in exactly the form set forth in this rule.
W. Va. Code R. agency 114, tit. 114, ser. 114-12, app H