Sec. 38a-483. (Formerly Sec. 38-167). Standard provisions of individual health policy.
Sec. 38a-483. (Formerly Sec. 38-167). Standard provisions of individual
health policy. (a) Except as provided in subsection (c) of this section, each individual
health insurance policy delivered or issued for delivery to any person in this state shall
contain the provisions specified in this subsection in the words in which the same appear
in this section; provided the insurer may, at its option, substitute for one or more of such
provisions corresponding provisions of different wording approved by the commissioner which are in each instance not less favorable in any respect to the insured or the
beneficiary. Such provisions shall be preceded individually by the caption appearing in
this subsection or, at the option of the insurer, by such appropriate individual or group
captions or subcaptions as the commissioner may approve. Such provisions to be contained in such policy shall be:
(1) A provision as follows: "ENTIRE CONTRACT: CHANGES: This policy, including the endorsements and the attached papers, if any, constitutes the entire contract
of insurance. No change in this policy shall be valid until approved by an executive
officer of the insurer and unless such approval be endorsed hereon or attached hereto.
No agent has authority to change this policy or to waive any of its provisions."
(2) A provision as follows: "TIME LIMIT ON CERTAIN DEFENSES: This policy
shall be incontestable, except for nonpayment of premium, after it has been in force for
two years from its date of issue."
(3) A provision as follows: "GRACE PERIOD: A grace period of .... (insert a number not less than seven for weekly premium policies, ten for monthly premium policies
and thirty-one for all other policies) days will be granted for the payment of each premium falling due after the first premium, during which grace period the policy shall
continue in force." A policy which contains a cancellation provision may add, at the
end of the above provision, "subject to the right of the insurer to cancel in accordance
with the cancellation provision hereof." A policy in which the insurer reserves the right
to refuse any renewal may have, at the beginning of the above provision, "Unless not
less than five days prior to the premium due date the insurer has delivered to the insured
or has mailed to his last address as shown by the records of the insurer written notice
of its intention not to renew this policy beyond the period for which the premium has
been accepted."
(4) A provision as follows: "REINSTATEMENT: If any renewal premium is not
paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any agent duly authorized by the insurer to accept such
premium, without requiring in connection therewith an application for reinstatement,
shall reinstate the policy; provided, if the insurer or such agent requires an application
for reinstatement and issues a conditional receipt for the premium tendered, the policy
shall be reinstated upon approval of such application by the insurer or, lacking such
approval, upon the forty-fifth day following the date of such conditional receipt unless
the insurer has previously notified the insured, in writing, of its disapproval of such
application. 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 insured and
insurer 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 hereon
or attached hereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which 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 or (2), in the case of a policy issued
after age forty-four, for at least five years from its date of issue.
(5) A provision as follows: "NOTICE OF CLAIM: Written notice of claim must
be given to the insurer within twenty days after the occurrence or commencement of
any loss covered by the policy, or as soon thereafter as is reasonably possible. Notice
given by or on behalf of the insured or the beneficiary to the insurer at .... (insert the
location of such office as the insurer may designate for the purpose), or to any authorized
agent of the insurer, with information sufficient to identify the insured, shall be deemed
notice to the insurer." In a policy providing a loss-of-time benefit which may be payable
for at least two years, an insurer may, at its option, insert the following between the first
and second sentences of the above provision: "Subject to the qualifications set forth
below, if the insured suffers loss of time on account of disability for which indemnity
may be payable for at least two years, he shall, at least once in every six months after
having given notice of claim, give to the insurer notice of continuance of said disability,
except in the event of legal incapacity. The period of six months following any filing
of proof by the insured or any payment by the insurer on account of such claim or any
denial of liability in whole or in part by the insurer shall be excluded in applying this
provision. Delay in the giving of such notice shall not impair the insured's right to
any indemnity which would otherwise have accrued during the period of six months
preceding the date on which such notice is actually given."
(6) A provision as follows: "CLAIM FORMS: The insurer, upon receipt of a notice
of claim, shall furnish to the claimant such forms as are usually furnished by it for filing
proofs of loss. If such forms are not furnished within fifteen days after the giving of
such notice, the claimant shall be deemed to have complied with the requirements of
this policy as to proof of loss, upon submitting, within the time fixed in the policy for
filing proofs of loss, written proof covering the occurrence, the character and the extent
of the loss for which claim is made."
(7) A provision as follows: "PROOFS OF LOSS: Written proof of loss shall be
furnished to the insurer at its said office in case of claim for loss for which this policy
provides any periodic payment contingent upon continuing loss within ninety days after
the termination of the period for which the insurer is liable and in case of claim for any
other loss within ninety days after the date of such loss. Failure to furnish such proof
within the time required shall not invalidate nor reduce any claim if it was not reasonably
possible to give proof within such time, provided such proof is furnished as soon as
reasonably possible and in no event, except in the absence of legal capacity, later than
one year from the time proof is otherwise required."
(8) A provision as follows: "TIME OF PAYMENT OF CLAIMS: Indemnities payable under this policy for any loss other than loss for which this policy provides any
periodic payment will be paid immediately upon receipt of due written proof of such
loss. Subject to due written proof of loss, all accrued indemnities for loss for which this
policy provides periodic payment shall be paid .... (insert period for payment which
must not be less frequently than monthly) and any balance remaining unpaid upon the
termination of liability will be paid immediately upon receipt of due written proof."
(9) A provision as follows: "PAYMENT OF CLAIMS: Indemnity for loss of life
will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of
payment. If no such designation or provision is then effective, such indemnity shall be
payable to the estate of the insured. Any other accrued indemnities unpaid at the insured's
death may, at the option of the insurer, be paid either to such beneficiary or to such
estate. All other indemnities will be payable to the insured." The following provisions,
or either of them, may be included with the foregoing provision at the option of the
insurer: "If any indemnity of this policy shall be payable to the estate of the insured, or
to an insured or beneficiary who is a minor or otherwise not competent to give a valid
release, the insurer may pay such indemnity, up to an amount not exceeding $.... (insert
an amount which shall not exceed one thousand dollars), to any relative by blood or
connection by marriage of the insured or beneficiary who is deemed by the insurer to
be equitably entitled thereto. Any payment made by the insurer in good faith pursuant
to this provision shall fully discharge the insurer to the extent of such payment. Subject
to any written direction of the insured in the application or otherwise, all or a portion
of any indemnities provided by this policy on account of hospital, nursing, medical or
surgical services may, at the insurer's option and unless the insured requests otherwise
in writing not later than the time of filing proofs of such loss, be paid directly to the
hospital or person rendering such services; but it is not required that the service be
rendered by a particular hospital or person."
(10) A provision as follows: "PHYSICAL EXAMINATIONS AND AUTOPSY:
The insurer at its own expense shall have the right and opportunity to examine the person
of the insured when and as often as it may reasonably require during the pendency of
a claim hereunder and to make an autopsy in case of death where it is not forbidden
by law."
(11) A provision as follows: "LEGAL ACTIONS: No action at law or in equity
shall be brought to recover on this policy prior to the expiration of sixty days after written
proof of loss has been furnished in accordance with the requirements of this policy. No
such action shall be brought after the expiration of three years after the time written
proof of loss is required to be furnished."
(12) A provision as follows: "CHANGE OF BENEFICIARY: Unless the insured
makes an irrevocable designation of beneficiary, the right to change of beneficiary is
reserved to the insured and the consent of the beneficiary or beneficiaries shall not be
requisite to surrender or assignment of this policy or to any change of beneficiary or
beneficiaries, or to any other changes in this policy." The first clause of this provision,
relating to the irrevocable designation of beneficiary, may be omitted at the insurer's
option.
(b) Except as provided in subsection (c) of this section, no such policy delivered or
issued for delivery to any person in this state shall contain provisions respecting the
matters set forth below unless such provisions are in the words in which the same appear
in this section; provided 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 subsection or, at the option of the insurer, by such appropriate individual
or group captions or subcaptions as the commissioner may approve.
(1) A provision as follows: "CHANGE OF OCCUPATION: If the insured be injured or contract sickness after having changed his occupation to one classified by the
insurer as more hazardous than that stated in his policy or while doing for compensation
anything pertaining to an occupation so classified, the insurer will 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 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, will reduce the premium rate accordingly, and will 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; but if 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 such state prior to the occurrence of the loss or prior to the date of proof of
change in occupation."
(2) A provision as follows: "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."
(3) A provision in accordance with subparagraph (i) or (ii) of this subdivision as
follows: (i) "OTHER INSURANCE IN THIS INSURER: If an accident or sickness or
accident and sickness policy or policies previously issued by the insurer to the insured
be in force concurrently herewith, making the aggregate indemnity for .... (insert type
of coverage or coverages) in excess of $.... (insert maximum limit of indemnity or for
such excess shall be returned to the insured or his estate"; or, (ii) "OTHER INSURANCE
IN THIS INSURER: Insurance effective at any one time on the insured under a like
policy or policies in this insurer is limited to the one such policy elected by the insured,
his beneficiary or his estate, as the case may be, and the insurer will return all premiums
paid for all other such policies."
(4) A provision as follows: "INSURANCE WITH OTHER INSURERS: If there
be other valid coverage, not with this insurer, providing benefits for the same loss on a
provision of service basis or on an expense incurred basis and of which this insurer has
not been given written notice prior to the occurrence or commencement of loss, the only
liability under any expense incurred coverage of this policy shall be for such proportion
of the loss as the amount which would otherwise have been payable hereunder plus the
total of the like amounts under all such other valid coverages for the same loss of which
this insurer had notice bears to the total like amounts under all valid coverages for such
loss, and for the return of such portion of the premiums paid as shall exceed the pro-rata portion for the amount so determined. For the purpose of applying this provision
when other coverage is on a provision of service basis, the "like amount" of such other
coverage shall be taken as the amount which the services rendered would have cost in
the absence of such coverage." If the foregoing policy provision is included in a policy
which also contains the policy provisions specified in subdivision (5) of this subsection,
there shall be added to the caption of the foregoing provision the phrase "- EXPENSE
INCURRED BENEFITS". The insurer may, at its option, include in this provision a
definition of "other valid coverage", approved as to form by the commissioner, which
definition shall be limited in subject matter to coverage provided 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, and by hospital or medical service
organizations, and to any other coverage the inclusion of which may be approved by
the commissioner. In the absence of such definition, such terms shall not include group
insurance, automobile medical payments insurance, or coverage provided by hospital
or medical service organizations or by union welfare plans or employer or employee
benefit organizations. For the purpose of applying the foregoing policy provision with
respect to any insured, any amount of benefit provided for such insured pursuant to any
compulsory benefit statute, including any workers' compensation or employer's liability
statute, whether provided by a governmental agency or otherwise, shall in all cases be
deemed to be "other valid coverage" of which the insurer has had notice. In applying
the foregoing policy provision no third party liability coverage shall be included as
"other valid coverage".
(5) A provision as follows: "INSURANCE WITH OTHER INSURERS: If there
be other valid coverage, not with this insurer, providing benefits for the same loss on
other than an expense incurred basis and of which this insurer has not been given written
notice prior to the occurrence or commencement of loss, the only liability for such
benefits under this policy shall be for such proportion of the indemnities otherwise
provided hereunder for such loss as the like indemnities of which the insurer had notice
(including the indemnities under this policy) bear to the total amount of all like indemnities for such loss, and for the return of such portion of the premium paid as shall exceed
the pro-rata portion for the indemnities thus determined." If the foregoing policy provision is included in a policy which also contains the policy provision specified in subdivision (4) of this subsection, there shall be added to the caption of the foregoing provision
the phrase "- OTHER BENEFITS". The insurer may, at its option, include in this provision a definition of "other valid coverage", approved as to form by the commissioner,
which definition shall be limited in subject matter to coverage provided 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, and to any other coverage the
inclusion of which may be approved by the commissioner. In the absence of such definition, such term shall not include group insurance, or benefits provided by union welfare
plans or by employer or employee benefit organizations. For the purpose of applying
the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute including any workers'
compensation or employer's liability statute, whether provided by a governmental
agency or otherwise shall in all cases be deemed to be "other valid coverage" of which
the insurer has had notice. In applying the foregoing policy provision no third party
liability coverage shall be included as "other valid coverage".
(6) A provision as follows: "RELATION OF EARNINGS TO INSURANCE: 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 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
such monthly earnings or such 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 such part of the
premiums paid during such two years as shall exceed 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 such coverage upon the insured
below the sum of two hundred dollars or the sum of the monthly benefits specified in
such coverages, whichever is the lesser, nor shall it operate to reduce benefits other than
those payable for loss of time." The foregoing policy provision 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 (1) until at least age fifty or (2), in the case of a policy
issued after age forty-four, 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 such definition such term shall not include any coverage provided for such
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.
(7) A provision as follows: "UNPAID PREMIUM: Upon the payment of a claim
under this policy, any premium then due and unpaid or covered by any note or written
order may be deducted therefrom."
(8) A provision as follows: "CANCELLATION: The insurer may cancel this policy
at any time by written notice delivered to the insured and to any dependents who were
listed on the application and any subsequent revisions thereto, or mailed to their last
address as shown by the records of the insurer, stating when, not less than five days
thereafter, such cancellation shall be effective; and after the policy has been continued
beyond its original term the insured may cancel this policy at any time by written notice
delivered or mailed to the insurer, effective upon receipt or on such later date as may
be specified in such notice. In the event of cancellation, the insurer will return promptly
the unearned portion of any premium paid. If the insured cancels, 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. If the insurer cancels, the earned premium shall be computed pro-rata. Cancellation shall be without prejudice to any claim originating prior to the effective date of
cancellation."
(9) A provision as follows: "CONFORMITY WITH STATE STATUTES: Any
provision of this policy which, on its effective date, is in conflict with the statutes of
the state in which the insured resides on such date is hereby amended to conform to the
minimum requirements of such statutes."
(c) If any provision of this section 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 such policy any inapplicable provision or part of
a provision, and shall modify any inconsistent provision or part of the provision in such
manner as to make the provision as contained in the policy consistent with the coverage
provided by the policy.
(d) The provisions specified in subsections (a) and (b) of this section, or any corresponding provisions which are used in lieu thereof in accordance with said subsections,
shall be printed in the consecutive order of the provisions in such subsections or, at the
option of the insurer, any such provision may appear as a unit in any part of the policy,
with other provisions to which it may be logically related, provided the resulting policy
shall not be in whole or in part unintelligible, uncertain, ambiguous, abstruse or likely
to mislead a person to whom the policy is offered, delivered or issued.
(e) The word "insured", as used in sections 38a-481 to 38a-488, inclusive, shall not
be construed as preventing a person other than the insured with a proper insurable interest
from making application for and owning a policy covering the insured or from being
entitled under such a policy to any indemnities, benefits and rights provided therein.
(f) (1) Any policy of a foreign or alien insurer, when delivered or issued for delivery
to any person in this state, may contain any provision which is not less favorable to the
insured or the beneficiary than the provisions of sections 38a-481 to 38a-488, inclusive,
and which is prescribed or required by the law of the state under which the insurer is
organized.
(2) Any policy of a domestic insurer may, when issued for delivery in any other
state or country, contain any provision permitted or required by the laws of such other
state or country.
(g) The commissioner may make such reasonable rules and regulations concerning
the procedure for the filing or submission of policies subject to sections 38a-481 to
38a-488, inclusive, as are necessary, proper or advisable to the administration of said
sections. This provision shall not abridge any other authority granted the commissioner
by law.
(1949 Rev., S. 6179, 6180, 6186; Apps. B, C; 1951, S. 2837d; 1971, P.A. 267; P.A. 79-376, S. 58; P.A. 90-243, S. 74;
P.A. 95-40.)
History: 1971 act replaced previous provisions re "time limit on defenses" which had detailed voidance of policy
because of misstatements on application with provision stating that policy is uncontestable except for premium nonpayment
after it is in force for two years; P.A. 79-376 substituted "workers' compensation" for "workmen's compensation" where
appearing; P.A. 90-243 added reference to "an individual health insurance" policy; Sec. 38-167 transferred to Sec. 38a-483 in 1991; P.A. 95-40 added requirement to Subsec. (b)(8) that written notice be delivered not only to the insured but
also to any dependents listed on the application and any subsequent revisions thereto; (Revisor's note: When P.A. 95-40,
which amended Subsec. (b)(8) concerning "CANCELLATION", was incorporated into the section by the Revisors, the
unamended text of Subsec. (b)(8) was inadvertently moved to and replaced the then existing Subsec. (a)(8) concerning
"TIME OF PAYMENT OF CLAIMS". Since there was no legislation in 1995, or subsequently, making any changes to
Subsec. (a)(8), the Revisors editorially corrected their 1995 codification error by reinstating the correct wording of Subsec.
(a)(8) for the 2001 revision).
Annotation to former section 38-167:
Gardener setting off a single bomb on fourth of July held not to have changed occupation to a more hazardous one. 91
C. 729.
Annotation to present section:
Subsec. (a):
"Entire contract" provision does not prohibit insurer from incorporating by reference its underwriting income rules in
an increase option rider to a disability insurance policy, when application of those rules can neither decrease nor eliminate
a fixed benefit of original policy. 273 C. 12.