W. Va. Code R. § 114-12-4

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

Section 114-12-4 - Prohibited Policy Provisions

4.1. No policy may utilize an initial premium which is less than a pro rata portion of the applicable annual premium.

4.2. No policy may contain a provision establishing a probationary or waiting period during which no coverage is provided under the policy: Provided, That a policy may contain a probationary or waiting period not to exceed ninety (90) days for specified diseases or conditions. Accident policies may not contain probationary or waiting periods.

a. An insurer offering accident and sickness insurance coverage, other than excepted benefits, in the individual market may not, with respect to an eligible individual desiring to enroll in individual accident and sickness insurance coverage, impose any preexisting condition exclusion with respect to such coverage.

4.3. No policies or riders for additional coverage may be issued as a dividend, unless an equivalent cash payment is offered to the policyholder as an alternative to the dividend policy or rider. No dividend policy or rider may be issued for an initial term of less than six (6) months.

4.4. No policy may exclude coverage for a loss due to a preexisting condition for a period greater than twelve (12) months following issuance of the policy. Provided, That an insurer offering accident and sickness insurance coverage, other than excepted benefits, in the individual market may not, with respect to an eligible individual desiring to enroll in individual accident and sickness coverage, impose any preexisting condition with respect to such coverage.

4.5. A disability income policy may contain a "return of premium" or "cash value benefit" so long as:

a. The return of premium or cash value benefit is not reduced by an amount greater than the aggregate of any claims paid under the policy; and

b. The insurer demonstrates that the reserve basis for the policies is adequate.

4.6. Policies providing hospital confinement indemnity coverage may not contain provisions excluding coverage because of confinement in a hospital operated by the state or federal government.

4.7. Except as otherwise prohibited by W. Va. Code '33-15-2b, this rule does not impair or limit the use of waivers to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases, physical conditions or extra-hazardous activity. Where waivers are required as a condition of policy issuance, renewal or reinstatement, signed acceptance by the insured is required unless on initial issuance of the policy, the full text of the waiver is contained either on the first page or the specification page.

4.8. Policy provisions expressly precluded in this section shall in no way be construed as a limitation on the authority of the Commissioner to disapprove other policy provisions including, but not limited to, provisions respecting limitations, exceptions, reductions or eliminations of coverage, not otherwise specifically authorized by statute or rule, which policy provisions are considered by the Commissioner to be unjust, unfair, unreasonable or unfairly discriminatory either to the policyholder, subscriber, beneficiary or any person insured under the policy.

W. Va. Code R. § 114-12-4