W. Va. Code R. agency 114, tit. 114, ser. 114-12, app C
[COMPANY NAME]
BASIC HOSPITAL AND MEDICAL-SURGICAL EXPENSE 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) Basic Hospital and Medical-Surgical Expense Coverage. -- Policies of this category are designed to provide, to persons insured, coverage for hospital and medical-surgical expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, hospital outpatient services, surgical services, anesthesia services and in-hospital medical services, subject to any limitations, deductibles and copayment requirements set forth in the policy. Coverage is not provided for unlimited hospital or medical-surgical 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 and number of days' duration where applicable, contained in this policy, in the following order:
(a) Daily hospital room and board;
(b) Miscellaneous hospital services;
(c) Hospital outpatient services;
(d) Surgical services;
(e) Anesthesia services;
(f) In-hospital medical services; and
(g) Other benefits, if any.]
(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 C