Every health care expense payments contract issued under this article shall be in writing and comply with requirements and contain provisions in substance as follows:
A. a provision that the policy, the application of the policyholder (if it or a copy thereof is attached to the policy) and the individual applications, if any, submitted in connection with such policy by the employees or members, constitutes the entire contract between the parties, that no statement therein is a warranty in the absence of fraud and that no such statement shall avoid the obligation of the health care plan provided in the policy or reduce benefits thereunder unless contained in a written application for such contract, attached to and made part of the policy;
B. if such contract is a group contract, a provision that the health care plan will furnish to the subscriber, for delivery to each employee or member of any covered group, an individual certificate, or an identification card, or other evidence of such coverage, setting forth in summary form a statement of the essential features of the contract of all persons included in the coverage;
C. if such contract is a group contract, a provision that eligible new employees or members or dependents, as the case may be, may be added from time to time to the group originally covered, in accordance with the terms of the contract;
D. the amount payable to the health care plan by the subscriber, and the time at which and manner in which such amount is to be paid;
E. the nature of the benefits which will be furnished and the period during which they will be furnished and, if there are any benefits to be excepted, a detailed statement of such exceptions;
F. any specific term or condition to the effect that the contract may be canceled or otherwise terminated by the health care plan, including the manner and time of such termination; provided a contract may not be canceled during the period for which the premium has been paid unless written notice is delivered to the insured, or mailed to his last address as shown by the records of the health care plan, stating when, not less than five days thereafter such cancellation shall be effective;
G. that the contract includes the endorsements thereon and attached papers, if any, and constitutes the entire contract;
H. that after two years no statement (except a fraudulent statement) by the subscriber in the application for a contract shall void the contract or be used against the subscriber in any legal action or proceedings relating to the contract unless such application or a true copy thereof is included in or attached to such contract; a statement that no change in the contract shall be valid until approved by an executive officer of the health care plan and unless such approval and countersignature be endorsed on or attached to such contract; and a statement that no agent has authority to change the contract or waive any of its provisions. No claim for loss incurred or disability (as defined in the policy) shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or a specific description effective on the date of loss had existed prior to the effective date of coverage of such policy;
I. that if the subscriber defaults in making any payment under the contract, the subsequent acceptance of an application for reinstatement and accompanying payment or its failure to take any action with respect thereto within thirty days following receipt of such application for reinstatement, by such health care plan or any duly authorized agent thereof reinstates the contract. The reinstated policy shall cover only loss resulting from such accidental injury as may [be] sustained after the date of reinstatement and loss due to such sickness as may begin more than ten days after such date. In all other respects the subscriber and the health care plan shall have the same rights thereunder as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions endorsed thereon or attached thereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which a premium has not been previously paid, but not to any period more than sixty days prior to the date of reinstatement. (The last sentence of the above provision may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums (1) until at least age fifty (50) or (2) in the case of a policy issued after age forty-four (44), for at least five (5) years from the date of its issue); and
J. the period of grace which will be allowed the subscriber for making any payment due under the contract, which period shall not be less than ten (10) days.
History: Laws 1984, ch. 127, § 879.22.
ANNOTATIONSBracketed material. — The bracketed material was inserted by the compiler and it is not a part of the law.