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Authority to Issue Blanket Accident and Sickness Policies; Filing of Form; Required Provisions; Applicability of Code Section to Similar Entities

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Any insurance company authorized to write accident and sickness insurance in this state shall have the power to issue blanket accident and sickness insurance. No blanket policy may be issued or delivered in this state unless a copy of the form of the blanket policy shall have been filed in accordance with Code Section 33-24-9.
Every blanket and group policy, certificate of insurance, or by whatever name called shall contain provisions which in the opinion of the Commissioner are at least as favorable to the policyholder and the individual insured as the following:
1. A provision that the policy and the application shall constitute the entire contract between the parties, and that all statements made by the policyholder shall, in absence of fraud or intentional misrepresentation of material fact in applying for or procuring coverage under the terms of the group policy or contract, be deemed representations and not warranties, and that no such statements shall be used in defense to a claim under the policy, unless contained in a written application;
2. A provision that written notice of sickness or of injury must be given to the insurer within 20 days after the date when such sickness or injury occurred. Failure to give notice within that time shall neither invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to give the notice and that notice was given as soon as was reasonably possible;
3. A provision that the insurer will furnish to the policyholder such forms as are usually furnished by it for filing proof of loss. If the forms are not furnished before the expiration of ten working days after the giving of notice, the claimant shall be deemed to have complied with the requirements of the policy as to proof of loss upon submitting, within the time fixed in the policy for filing proof of loss, written proof covering the occurrence, character, and extent of the loss for which claim is made;
4. A provision that in the case of claim for loss of time for disability, written proof of the loss must be furnished to the insurer within 30 days after the commencement of the period for which the insurer is liable, and that subsequent written proofs of the continuance of the disability must be furnished to the insurer at such intervals as the insurer may reasonably require, and that in the case of claim for any other loss, written proof of the loss must be furnished to the insurer within 90 days after the date of the loss. Failure to furnish the proof within such time shall neither invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to furnish the proof and that the proof was furnished as soon as was reasonably possible;
5. A provision incorporating and restating the substance of the provisions of subsections (b) and (c) of Code Section 33-24-59.5, relating to time limits for payment of claims for benefits under health benefit policies and sanctions for failure to pay timely. If a policy provides benefits for loss of time, such policy shall also provide that, subject to proof of such loss, all accrued benefits payable under the policy for loss of time will be paid not later than at the expiration of each period of 30 days during the continuance of the period for which the insurer is liable and any balance remaining unpaid at the termination of such period will be paid immediately upon receipt of such proof;
6. A provision that the insurer, at its own expense, shall have the right and opportunity to examine the person of the insured when and so often as it may reasonably require during the pendency of a claim under the policy and shall also have the right and opportunity to make an autopsy in case of death, if an autopsy is not prohibited by law;
7. A provision that no action at law or in equity shall be brought to recover under the policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of the policy, and that no action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished; and
8. A provision that, with respect to termination of benefits for, or coverage of, any person who is a dependent child of an insured, the child shall continue to be insured up to and including age 25 so long as the coverage of the insured parent or guardian continues in effect, the child remains a dependent of the parent or guardian, and the child, in each calendar year since reaching any age specified for termination of benefits as a dependent, has been enrolled for five months or more as a full-time student at a postsecondary institution of higher learning or, if not so enrolled, would have been eligible to be so enrolled and was prevented from being so enrolled due to illness or injury.
The provisions of this Code section shall also apply to group and blanket accident and sickness insurance policies issued by a fraternal benefit society, a health care corporation, a health maintenance organization, or any other similar entity.

(Code 1933, § 56-3105, enacted by Ga. L. 1960, p. 289, § 1; Ga. L. 1978, p. 1149, § 3; Ga. L. 1982, p. 1678, §§ 3, 6; Ga. L. 1984, p. 22, § 33; Ga. L. 1995, p. 745, § 2.9; Ga. L. 1999, p. 289, § 5; Ga. L. 2005, p. 481, § 12/HB 291; Ga. L. 2017, p. 164, § 47/HB 127.)

Code Commission notes.

- Pursuant to Code Section 28-9-5, in 1999, a semicolon was substituted for a period at the end of paragraph (b)(5).

JUDICIAL DECISIONS

Policies from outside state.

- Former Code 1933, § 56-3105 (see O.C.G.A. § 33-30-6) was not applicable when a policy was solicited, written, and delivered outside of this state and did not expressly contemplate coverage of the insured in this state when written, pursuant to subsection (d) of former Code 1933, § 56-302 (see O.C.G.A. § 33-3-2). Sloan v. Continental Cas. Co., 131 Ga. App. 377, 205 S.E.2d 925 (1974).

Claim for prejudgment interest not preempted by ERISA.

- Claim of a plan beneficiary under O.C.G.A. § 33-30-6 to recover prejudgment interest on unpaid benefits was not preempted by the Employee Retirement Income Security Act, 29 U.S.C. § 1001 et seq. Boyer v. Metropolitan Life Ins. Co., 889 F. Supp. 496 (S.D. Ga. 1995).

Cited in Thompson v. Metropolitan Life Ins. Co., 115 Ga. App. 724, 155 S.E.2d 728 (1967).

RESEARCH REFERENCES

ALR.

- Limit of liability of members of insurance associations, 10 A.L.R. 750.

Accident insurance: when insured deemed to be totally and continuously unable to transact all business duties, 24 A.L.R. 203.

Forfeiture of life or accident insurance for nonpayment of premium due to failure or neglect of one authorized by insured pay same, 67 A.L.R. 180.

Constitutionality, construction, and application of statutes relating to contractual time limitation provisions of insurance policies, 112 A.L.R. 1288.

Burden of proof, in action upon an accident policy or accident feature of life policy, as regards conditions which, by the terms of the policy, limit or exclude coverage, 142 A.L.R. 742.

Right of insurer to restitution of payments made under mistake, 167 A.L.R. 470.

Effect of failure to give notice, or delay in giving notice or filing of proofs of loss, upon fidelity bond or insurance, 23 A.L.R.2d 1065.

Physician's duties and liabilities to person examined pursuant to physician's contract with such person's prospective or actual employer or insurer, 10 A.L.R.3d 1071.

Beneficiary's ignorance of existence of life or accident policy as excusing failure to give notice, make proofs of loss, or bring action within time limited by policy or statute, 28 A.L.R.3d 292.

Construction and effect of "visible sign of injury" and similar clauses in accident provision of insurance policy, 28 A.L.R.3d 413.

Heart attack following exertion or exercise as within terms of accident provision of insurance policy, 1 A.L.R.4th 1319.

What constitutes total disability within coverage of disability insurance policy issued to lawyer, 6 A.L.R.4th 422.

Termination of employee's individual coverage under group policy for nonpayment of premiums, 22 A.L.R.4th 321.

Modern status of rules requiring liability insurer to show prejudice to escape liability because of insured's failure or delay in giving notice of accident or claim, or in forwarding suit papers, 32 A.L.R.4th 141.

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