W. Va. Code R. § 114-39-1

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 114-39-1 - General

1.1. Scope and Applicability. -- This rule applies to all group accident and sickness insurance policies, all group subscriber contracts of hospital, medical, dental and health service corporations, health care corporations and fraternal benefit societies and all enrollee agreements or contracts of health maintenance organizations, issued in connection with a group health plan and delivered or issued for delivery in this state on and after the effective date hereof, except that it does not apply to:

a. Individual policies or contracts issued pursuant to a conversion privilege under a policy or contract of group insurance;

b. Individual policies or contracts issued to eligible individuals.

c. Credit accident and sickness insurance subject to WV 114CSR6 "Regulation of Credit Life Insurance and Credit Accident and Sickness Insurance;"

d. Medicare supplement insurance policies subject to WV 114CSR24 "Medicare Supplement Insurance; "

e. Long-term care insurance policies subject to WV 114CSR32 "Long-Term Care Insurance; "

f. Coverage under the West Virginia Public Employees Insurance Act (W. Va. Code §§ 5-16-1 et seq.): Provided, That this rule applies to a health benefit plan issued by a health insurer to provide medical care under the West Virginia Public Employees Insurance Act;

g. Coverage under Medicare or Medicaid: Provided, That this rule applies to a health benefit plan issued by a health insurer to provide medical care under Medicare or Medicaid;

h. Coverage under any automobile no-fault, workers' compensation, employer's liability, occupational disease or similar law;

i. Basic Hospital and Medical-Surgical Expense Coverage; and

j. Individual limited benefits. "Limited benefits policy" means any individual or group accident and sickness insurance policy, including all riders thereto (and certificates in the case of a group policy), that covers one or more residents of this state and that is not required to offer or provide all benefits mandated by any other applicable provision of this chapter. Such policies include, but are not limited to, accident only, sickness only disability, sickness only, accident only disability, hospital indemnity, specified disease and travel accident insurance policies:

Provided, that the following types of policies and certificates are excluded from the definition of "limited benefits policy:"

1. Credit accident and sickness insurance;

2. Long-term care insurance;

3. Medicare supplement insurance;

4. Minimum benefits accident and sickness insurance issued pursuant to section fifteen, article fifteen of this chapter or article sixteen-c of this chapter;

5. Accident and sickness policies which provide benefits for loss of income due to disability;

6. Major medical policies;

7. Dental policies; and

8. Vision policies.

k. Disability income insurance

1.2. Sections 7, 8 and 9 of this rule apply only to group major medical expense coverage.

The requirements contained in this rule are in addition to WV 114CSR54 "Group Accident and Sickness Insurance Issuance, Portability and Marketing Requirements" and any other applicable rules previously adopted.

1.3. Authority. -- W. Va. Code §§ 33-2-10, 33-16-3(f), 33-16-17 and 33-16D-6.

1.4. Filing Date. -- April 3, 2003.

1.5. Effective Date. -- April 3, 2003.

1.6. Purpose. -- The purpose of this legislative rule is to provide reasonable standardization of coverage and simplification of terms and benefits of group accident and sickness insurance policies, subscriber contracts of hospital, medical, dental and health service corporations, health care corporations, fraternal benefit societies and enrollee agreements and contracts of health maintenance organizations, which are issued in connection with a group health plan; to facilitate public understanding and comparison of such policies, contracts and agreements, to eliminate provisions contained in such policies, contracts and agreements which may be misleading or confusing in connection with either their purchase or the settlement of claims; to provide for full disclosure in the sale of such policies, contracts and agreements; and to implement standards set forth in 1997 W. Va. Acts 109 and the federal Health Insurance Portability and Accountability Act of 1996 ( P.L. 104-191 ), as amended by the Newborns' and Mothers' Health Protection Act of 1996 and the Mental Health Parity Act of 1996 ( P.L. 104-204 ).

W. Va. Code R. § 114-39-1