Optional Policy Provisions

  1. Law
  2. Georgia Code
  3. Insurance
  4. Individual Accident and Sickness Insurance
  5. Optional Policy Provisions

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  1. No accident and sickness policy delivered or issued for delivery in this state shall contain provisions respecting the matters set forth in this Code section unless such provisions are in the words in which the same appear in subsection (b) of this Code section, except that the insurer may, at its option, use in lieu of any such provision a corresponding provision of different wording approved by the Commissioner which is not less favorable in any respect to the insured or the beneficiary. Any such provision contained in the policy shall be preceded individually by the appropriate caption appearing in this Code section or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the Commissioner may approve. If any such provision is in whole or in part inapplicable to or inconsistent with the coverage provided by a particular form of policy, the insurer, with the approval of the Commissioner, shall omit from the policy any inapplicable provision or part of a provision and shall modify any inconsistent provision or part of a provision in such a manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.
    1. CHANGE OF OCCUPATION. If the insured is injured or contracts sickness after having changed his or her occupation to one classified by the insurer as more hazardous than that stated in this policy or while doing for compensation anything pertaining to an occupation so classified, the insurer shall pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for such more hazardous occupation.If the insured changes his or her occupation to one classified by the insurer as less hazardous than that stated in this policy, the insurer, upon receipt of proof of such change of occupation, shall reduce the premium rate accordingly and shall return the excess pro rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent.In applying this provision, the classification of occupational risk and the premium rates shall be such as have been last filed by the insurer, prior to the occurrence of the loss for which the insurer is liable or prior to date of proof of change in occupation, with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued. If, however, such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the insurer in the state prior to the occurrence of the loss or prior to the date of proof of change in occupation.
    2. MISSTATEMENT OF AGE. If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age.
      1. If an accident or sickness or accident and sickness policy or policies previously issued by the insurer to the insured is in force concurrently herewith, making the aggregate indemnity for ____________ (insert type of coverage or coverages) in excess of $____________ (insert maximum limit of indemnity or indemnities), the excess insurance shall be void and all premiums paid for the excess shall be returned to the insured or to his or her estate;

        or, in lieu thereof:

      2. Insurance effective at any one time on the insured under a like policy or policies with this insurer is limited to the one such policy elected by the insured, his or her beneficiary, or his or her estate, as the case may be, and the insurer will return all premiums paid for all other policies.
      3. If the total monthly amount of loss of time benefits promised for the same loss under all valid loss of time coverage upon the insured, whether payable on a weekly or monthly basis, shall exceed the monthly earnings of the insured at the time disability commenced or his or her average monthly earnings for the period of two years immediately preceding a disability for which claim is made, whichever is the greater, the insurer will be liable only for such proportionate amount of such benefits under this policy as the amount of the monthly earnings or the average monthly earnings of the insured bears to the total amount of monthly benefits for the same loss under all such coverage upon the insured at the time such disability commences and for the return of that part of the premiums paid during such two years which exceeds the pro rata amount of the premiums for the benefits actually paid hereunder; but this shall not operate to reduce the total monthly amount of benefits payable under all the coverage upon the insured below the sum of $200.00 or the sum of the monthly benefits specified in the coverages, whichever is the lesser, nor shall it operate to reduce benefits other than those payable for loss of time.
      4. The policy provision of subparagraph (A) of this paragraph may be inserted only in a policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums until at least age 60 or, in the case of a policy issued after age 54, for at least five years from its date of issue. The insurer may, at its option, include in this provision a definition of "valid loss of time coverage," approved as to form by the Commissioner, which definition shall be limited in subject matter to coverage provided by governmental agencies or by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, or to any other coverage the inclusion of which may be approved by the Commissioner or any combination of such coverages. In the absence of that definition the term shall not include any coverage provided for the insured pursuant to any compulsory benefit statute, including any workers' compensation or employer's liability statute, or benefits provided by union welfare plans or by employer or employee benefit organizations.

        UNPAID PREMIUM. Upon the payment of a claim under this policy, any premiums then due and unpaid or covered by any note or written order may be deducted therefrom.

        CANCELLATION OF TRAVEL ACCIDENT POLICIES. With respect only to travel accident insurance policies, the following optional provisions may be inserted in the policy:

        INTOXICANTS AND NARCOTICS. The insurer shall not be liable for any loss sustained or contracted in consequence of the insured being intoxicated or under the influence of any narcotic unless administered on the advice of a physician.

        ILLEGAL OCCUPATION. The insurer shall not be liable for any loss to which a contributing cause was the insured's commission of or attempt to commit a felony or to which a contributing cause was the insured's being engaged in an illegal occupation.

        CONFORMITY WITH STATE STATUTES. Any provision of this policy which, on its effective date, is in conflict with the statutes of the state, District of Columbia, or territory in which the insured resides on such date is amended to conform to the minimum requirements of such statutes.

        RETURN OF PREMIUM ON CANCELLATION. If the insured cancels this policy, the earned premium shall be computed by the use of the short-rate table last filed with the state official having supervision of insurance in the state where the insured resided when the policy was issued. Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation.

        "The insurer reserves the right to cancel this policy under the provisions set forth in Code Section 33-24-44."

(3) O THER INSURANCE WITH THIS INSURER.

(4) R ELATION OF EARNINGS TO INSURANCE.

(Code 1933, § 56-3005, enacted by Ga. L. 1960, p. 289, § 1; Ga. L. 1981, p. 1009, § 1; Ga. L. 1982, p. 3, § 33; Ga. L. 1983, p. 3, § 24; Ga. L. 1985, p. 149, § 33; Ga. L. 1988, p. 1760, § 3; Ga. L. 2019, p. 386, § 91/SB 133.)

The 2019 amendment, effective July 1, 2019, inserted "or her" throughout subsection (b); in paragraph (b)(1), substituted "shall" for "will" once in the first sentence and twice in the second sentence, in the third sentence, substituted "insurer" for "insured" and substituted "was issued. If, however," for "was issued; but, if" in the middle.

Editor's notes.

- Ga. L. 1981, p. 1009, § 3, not codified by the General Assembly, provided that the amendment to this section shall apply to policies issued, delivered, issued for delivery, renewed, or amended in this state on or after July 1, 1981.

Law reviews.

- For article surveying developments in Georgia insurance law from mid-1980 through mid-1981, see 33 Mercer L. Rev. 143 (1981).

JUDICIAL DECISIONS

Health insurance policy exclusion for injuries resulting from being "drunk" did not apply to injuries sustained by the insured in a traffic accident although the insured's blood alcohol content was .19 percent at the time of the accident and the insured pled guilty to driving under the influence of alcohol. Vulcan Life Ins. Co. v. Davenport, 191 Ga. App. 79, 380 S.E.2d 751, cert. denied, 191 Ga. App. 923, 380 S.E.2d 751 (1989).

Insured's social security disability benefits did not constitute benefits derived from "valid loss of time coverage" under a "relation of earnings to insurance" clause which was intended to be utilized to compute monthly benefits only when the insured was receiving benefits under more than one disability insurance policy. Walters v. Time Ins. Co., 738 F. Supp. 493 (M.D. Ga. 1990), aff'd, 932 F.2d 978 (11th Cir. 1991).

Cited in Life & Cas. Ins. Co. v. Hulsey, 109 Ga. App. 15, 134 S.E.2d 880 (1964).

RESEARCH REFERENCES

Am. Jur. 2d.

- 44 Am. Jur. 2d, Insurance, § 719 et seq.

C.J.S.

- 44 C.J.S., Insurance, § 474 et seq. 45 C.J.S., Insurance, §§ 877, 881, 1067, 1092. 46 C.J.S., Insurance, § 1564.

ALR.

- Death or injury resulting from insured's voluntary act as caused by accident or accidental means, 35 A.L.R. 1191; 42 A.L.R. 243; 45 A.L.R. 1528, 71 A.L.R. 1437, 111 A.L.R. 628.

Prorating life or accident insurance, 50 A.L.R. 1380.

Applicability of option provisions to double indemnity and disability features of life or accident insurance, 91 A.L.R. 1064; 128 A.L.R. 552.

Validity, construction, and effect of provisions in life or accident policy in relation to military service, 137 A.L.R. 1263; 36 A.L.R.2d 1018.

Insurer's liability for loss which is within coverage of its policy unless excluded because it is within the more specific coverage of the policy of another insurer, 150 A.L.R. 636.

Apportionment or contribution as between specific and blanket insurance policies, 169 A.L.R. 387.

Accident insurance policy provisions for diminution of indemnity where insured engages in, or does act pertaining to, a more hazardous occupation, 8 A.L.R.2d 481.

Clause in life, accident, or health policy excluding or limiting liability in case of insured's use of intoxicants or narcotics, 13 A.L.R.2d 987.

Apportionment of losses among automobile liability insurers under policies containing pro rata clauses, 21 A.L.R.2d 611.

Injury to or death of insured while assaulting another as due to accident or accidental means, 26 A.L.R.2d 399.

Liability under accident policy, or accident feature of life policy, for injury or death from freezing or exposure to cold, 4 A.L.R.3d 1177.

Coverage of policy insuring against liability under dramshop acts, 14 A.L.R.3d 858.

Insured's receipt of or right to workmen's compensation benefits as affecting recovery under accident, hospital, or medical expense policy, 40 A.L.R.3d 1012.

Liability under life or accident policy not containing a "violation of the law" clause, for death or injury resulting from violation of law by insured, 43 A.L.R.3d 1120.

Liability insurance: failure or refusal of insured to attend trial or to testify as breach of cooperation clause, 9 A.L.R.4th 218.

Resolution of conflicts, in non-automobile liability insurance policies, between excess or pro-rata "other insurance" clauses, 12 A.L.R.4th 993.

Accident insurance: death or disability incident to partaking of food or drink as within provision as to external, violent, and accidental means, 29 A.L.R.4th 1230.

Death or injury from taking illegal drugs or narcotics as accidental or result of accidental means within insurance coverage, 32 A.L.R.5th 629.


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