W. Va. Code R. § 114-39-4

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

Section 114-39-4 - Prohibited Policy Provisions

4.1. No policy may exclude coverage for a loss due to a preexisting condition for a period greater than twelve (12) months following an individual's enrollment date. For a health benefit plan issued in connection with a group health plan, a waiting period or affiliation period elected by a health maintenance organization pursuant to WV 114CSR54 "Group Accident and Sickness Insurance Issuance, Portability and Marketing Requirements," prior to an insured's eligibility for benefits must run concurrently with a preexisting condition exclusion period.

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

4.3. For a health benefit plan issued in connection with a group health plan, a health insurer may impose a preexisting condition exclusion only as provided in WV 114CSR54 "Group Accident and Sickness Insurance Issuance, Portability and Marketing Requirements."

4.4. For policies other than a health benefit plan issued in connection with a group health plan, 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.

4.5. 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 determined 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. § 114-39-4