CHAPTER 5. ACCIDENT AND SICKNESS INSURANCE.POLICY PROVISIONS
IC 27-8-5
Chapter 5. Accident and Sickness Insurance.Policy Provisions
IC 27-8-5-1
Policy of accident and sickness insurance; filing; review
Sec. 1. (a) The term "policy of accident and sickness insurance",
as used in this chapter, includes any policy or contract covering one
(1) or more of the kinds of insurance described in Class 1(b) or 2(a)
of IC 27-1-5-1. Such policies may be on the individual basis under
this section and sections 2 through 9 of this chapter, on the group
basis under this section and sections 16 through 19 of this chapter,
on the franchise basis under this section and section 11 of this
chapter, or on a blanket basis under section 15 of this chapter and
(except as otherwise expressly provided in this chapter) shall be
exclusively governed by this chapter.
(b) No policy of accident and sickness insurance may be issued or
delivered to any person in this state, nor may any application, rider,
or endorsement be used in connection with an accident and sickness
insurance policy, until a copy of the form of the policy and of the
classification of risks and the premium rates, or, in the case of
assessment companies, the estimated cost pertaining thereto, have
been filed with and reviewed by the commissioner under section 1.5
of this chapter. This section is applicable also to assessment
companies and fraternal benefit associations or societies.
(Formerly: Acts 1953, c.15, s.169.1; Acts 1975, P.L.281, SEC.1.) As
amended by P.L.257-1985, SEC.1; P.L.7-1987, SEC.154;
P.L.173-2007, SEC.21.
IC 27-8-5-1.5
Filing, review, approval, and disapproval process
Sec. 1.5. (a) This section applies to a policy of accident and
sickness insurance issued on an individual, a group, a franchise, or
a blanket basis, including a policy issued by an assessment company
or a fraternal benefit society.
(b) As used in this section, "commissioner" refers to the insurance
commissioner appointed under IC 27-1-1-2.
(c) As used in this section, "grossly inadequate filing" means a
policy form filing:
(1) that fails to provide key information, including state specific
information, regarding a product, policy, or rate; or
(2) that demonstrates an insufficient understanding of
applicable legal requirements.
(d) As used in this section, "policy form" means a policy, a
contract, a certificate, a rider, an endorsement, an evidence of
coverage, or any amendment that is required by law to be filed with
the commissioner for approval before use in Indiana.
(e) As used in this section, "type of insurance" refers to a type of
coverage listed on the National Association of Insurance
Commissioners Uniform Life, Accident and Health, Annuity and
Credit Product Coding Matrix, or a successor document, under the
heading "Continuing Care Retirement Communities", "Health",
"Long Term Care", or "Medicare Supplement".
(f) Each person having a role in the filing process described in
subsection (i) shall act in good faith and with due diligence in the
performance of the person's duties.
(g) A policy form may not be issued or delivered in Indiana unless
the policy form has been filed with and approved by the
commissioner.
(h) The commissioner shall do the following:
(1) Create a document containing a list of all product filing
requirements for each type of insurance, with appropriate
citations to the law, administrative rule, or bulletin that
specifies the requirement, including the citation for the type of
insurance to which the requirement applies.
(2) Make the document described in subdivision (1) available
on the department of insurance Internet site.
(3) Update the document described in subdivision (1) at least
annually and not more than thirty (30) days following any
change in a filing requirement.
(i) The filing process is as follows:
(1) A filer shall submit a policy form filing that:
(A) includes a copy of the document described in subsection
(h);
(B) indicates the location within the policy form or
supplement that relates to each requirement contained in the
document described in subsection (h); and
(C) certifies that the policy form meets all requirements of
state law.
(2) The commissioner shall review a policy form filing and, not
more than thirty (30) days after the commissioner receives the
filing under subdivision (1):
(A) approve the filing; or
(B) provide written notice of a determination:
(i) that deficiencies exist in the filing; or
(ii) that the commissioner disapproves the filing.
A written notice provided by the commissioner under clause (B)
must be based only on the requirements set forth in the
document described in subsection (h) and must cite the specific
requirements not met by the filing. A written notice provided by
the commissioner under clause (B)(i) must state the reasons for
the commissioner's determination in sufficient detail to enable
the filer to bring the policy form into compliance with the
requirements not met by the filing.
(3) A filer may resubmit a policy form that:
(A) was determined deficient under subdivision (2) and has
been amended to correct the deficiencies; or
(B) was disapproved under subdivision (2) and has been
revised.
A policy form resubmitted under this subdivision must meet the
requirements set forth as described in subdivision (1) and must
be resubmitted not more than thirty (30) days after the filer
receives the commissioner's written notice of deficiency or
disapproval. If a policy form is not resubmitted within thirty
(30) days after receipt of the written notice, the commissioner's
determination regarding the policy form is final.
(4) The commissioner shall review a policy form filing
resubmitted under subdivision (3) and, not more than thirty (30)
days after the commissioner receives the resubmission:
(A) approve the resubmitted policy form; or
(B) provide written notice that the commissioner
disapproves the resubmitted policy form.
A written notice of disapproval provided by the commissioner
under clause (B) must be based only on the requirements set
forth in the document described in subsection (h), must cite the
specific requirements not met by the filing, and must state the
reasons for the commissioner's determination in detail. The
commissioner's approval or disapproval of a resubmitted policy
form under this subdivision is final, except that the
commissioner may allow the filer to resubmit a further revised
policy form if the filer, in the filer's resubmission under
subdivision (3), introduced new provisions or materially
modified a substantive provision of the policy form. If the
commissioner allows a filer to resubmit a further revised policy
form under this subdivision, the filer must resubmit the further
revised policy form not more than thirty (30) days after the filer
receives notice under clause (B), and the commissioner shall
issue a final determination on the further revised policy form
not more than thirty (30) days after the commissioner receives
the further revised policy form.
(5) If the commissioner disapproves a policy form filing under
this subsection, the commissioner shall notify the filer, in
writing, of the filer's right to a hearing as described in
subsection (m). A disapproved policy form filing may not be
used for a policy of accident and sickness insurance unless the
disapproval is overturned in a hearing conducted under this
subsection.
(6) If the commissioner does not take any action on a policy
form that is filed or resubmitted under this subsection in
accordance with any applicable period specified in subdivision
(2), (3), or (4), the policy form filing is considered to be
approved.
(j) Except as provided in this subsection, the commissioner may
not disapprove a policy form resubmitted under subsection (i)(3) or
(i)(4) for a reason other than a reason specified in the original notice
of determination under subsection (i)(2)(B). The commissioner may
disapprove a resubmitted policy form for a reason other than a reason
specified in the original notice of determination under subsection
(i)(2) if:
(1) the filer has introduced a new provision in the resubmission;
(2) the filer has materially modified a substantive provision of
the policy form in the resubmission;
(3) there has been a change in requirements applying to the
policy form; or
(4) there has been reviewer error and the written disapproval
fails to state a specific requirement with which the policy form
does not comply.
(k) The commissioner may return a grossly inadequate filing to
the filer without triggering a deadline set forth in this section.
(l) The commissioner may disapprove a policy form if:
(1) the benefits provided under the policy form are not
reasonable in relation to the premium charged; or
(2) the policy form contains provisions that are unjust, unfair,
inequitable, misleading, or deceptive, or that encourage
misrepresentation of the policy.
(m) Upon disapproval of a filing under this section, the
commissioner shall provide written notice to the filer or insurer of
the right to a hearing within twenty (20) days of a request for a
hearing.
(n) Unless a policy form approved under this chapter contains a
material error or omission, the commissioner may not:
(1) retroactively disapprove the policy form; or
(2) examine the filer of the policy form during a routine or
targeted market conduct examination for compliance with a
policy form filing requirement that was not in existence at the
time the policy form was filed.
As added by P.L.173-2007, SEC.22. Amended by P.L.111-2008,
SEC.3.
IC 27-8-5-2
Requirements for issuance and delivery of policy
Sec. 2. (a) No individual policy of accident and sickness insurance
shall be delivered or issued for delivery to any person in this state
unless it complies with each of the following:
(1) The entire money and other considerations for the policy are
expressed in the policy.
(2) The time at which the insurance takes effect and terminates
is expressed in the policy.
(3) The policy purports to insure only one (1) person, except
that a policy must insure, originally or by subsequent
amendment, upon the application of any member of a family
who shall be deemed the policyholder and who is at least
eighteen (18) years of age, any two (2) or more eligible
members of that family, including husband, wife, dependent
children, or any children who are less than twenty-four (24)
years of age, and any other person dependent upon the
policyholder.
(4) The style, arrangement, and overall appearance of the policy
give no undue prominence to any portion of the text, and unless
every printed portion of the text of the policy and of any
endorsements or attached papers is plainly printed in lightface
type of a style in general use, the size of which shall be uniform
and not less than ten point with a lower-case unspaced alphabet
length not less than one hundred and twenty point (the "text"
shall include all printed matter except the name and address of
the insurer, name or title of the policy, the brief description if
any, and captions and subcaptions).
(5) The exceptions and reductions of indemnity are set forth in
the policy and, except those which are set forth in section 3 of
this chapter, are printed, at the insurer's option, either included
with the benefit provision to which they apply, or under an
appropriate caption such as "EXCEPTIONS", or
"EXCEPTIONS AND REDUCTIONS", provided that if an
exception or reduction specifically applies only to a particular
benefit of the policy, a statement of such exception or reduction
shall be included with the benefit provision to which it applies.
(6) Each such form of the policy, including riders and
endorsements, shall be identified by a form number in the lower
left-hand corner of the first page of the policy.
(7) The policy contains no provision purporting to make any
portion of the charter, rules, constitution, or bylaws of the
insurer a part of the policy unless such portion is set forth in full
in the policy, except in the case of the incorporation of or
reference to a statement of rates or classification of risks, or
short-rate table filed with the commissioner.
(8) If an individual accident and sickness insurance policy or
hospital service plan contract or medical service plan contract
provides that hospital or medical expense coverage of a
dependent child terminates upon attainment of the limiting age
for dependent children specified in such policy or contract, the
policy or contract must also provide that attainment of such
limiting age does not operate to terminate the hospital and
medical coverage of such child while the child is and continues
to be both:
(A) incapable of self-sustaining employment by reason of
mental retardation or mental or physical disability; and
(B) chiefly dependent upon the policyholder for support and
maintenance.
Proof of such incapacity and dependency must be furnished to
the insurer by the policyholder within thirty-one (31) days of
the child's attainment of the limiting age. The insurer may
require at reasonable intervals during the two (2) years
following the child's attainment of the limiting age subsequent
proof of the child's disability and dependency. After such two
(2) year period, the insurer may require subsequent proof not
more than once each year. The foregoing provision shall not
require an insurer to insure a dependent who is a child who has
mental retardation or a mental or physical disability where such
dependent does not satisfy the conditions of the policy
provisions as may be stated in the policy or contract required
for coverage thereunder to take effect. In any such case the
terms of the policy or contract shall apply with regard to the
coverage or exclusion from coverage of such dependent. This
subsection applies only to policies or contracts delivered or
issued for delivery in this state more than one hundred twenty
(120) days after August 18, 1969.
(b) If any policy is issued by an insurer domiciled in this state for
delivery to a person residing in another state, and if the official
having responsibility for the administration of the insurance laws of
such other state shall have advised the commissioner that any such
policy is not subject to approval or disapproval by such official, the
commissioner may by ruling require that such policy meet the
standards set forth in subsection (a) and in section 3 of this chapter.
(c) An insurer may issue a policy described in this section in
electronic or paper form. However, the insurer shall:
(1) inform the insured that the insured may request the policy in
paper form; and
(2) issue the policy in paper form upon the request of the
insured.
(Formerly: Acts 1953, c.15, s.169.2; Acts 1969, c.266, s.1; Acts
1973, P.L.275, SEC.3.) As amended by Acts 1977, P.L.2, SEC.79;
P.L.23-1993, SEC.153; P.L.207-1999, SEC.3 and P.L.233-1999,
SEC.9; P.L.125-2005, SEC.2; P.L.99-2007, SEC.192; P.L.218-2007,
SEC.45.
IC 27-8-5-2.5
Coverage under individual, and certain association group, policies
of accident and sickness insurance; waivers
Sec. 2.5. (a) As used in this section, the term "policy of accident
and sickness insurance" does not include the following:
(1) Accident only, credit, dental, vision, Medicare supplement,
long term care, or disability income insurance.
(2) Coverage issued as a supplement to liability insurance.
(3) Automobile medical payment insurance.
(4) A specified disease policy.
(5) A short term insurance plan that:
(A) may not be renewed; and
(B) has a duration of not more than six (6) months.
(6) A policy that provides indemnity benefits not based on any
expense incurred requirement, including a plan that provides
coverage for:
(A) hospital confinement, critical illness, or intensive care;
or
(B) gaps for deductibles or copayments.
(7) Worker's compensation or similar insurance.
(8) A student health plan.
(9) A supplemental plan that always pays in addition to other
coverage.
(10) An employer sponsored health benefit plan that is:
(A) provided to individuals who are eligible for Medicare;
and
(B) not marketed as, or held out to be, a Medicare
supplement policy.
(b) The benefits provided by:
(1) an individual policy of accident and sickness insurance; or
(2) a certificate of coverage that is issued under a nonemployer
based association group policy of accident and sickness
insurance to an individual who is a resident of Indiana;
may not be excluded, limited, or denied for more than twelve (12)
months after the effective date of the coverage because of a
preexisting condition of the individual.
(c) An individual policy of accident and sickness insurance or a
certificate of coverage described in subsection (b) may not define a
preexisting condition, a rider, or an endorsement more restrictively
than as:
(1) a condition that would have caused an ordinarily prudent
person to seek medical advice, diagnosis, care, or treatment
during the twelve (12) months immediately preceding the
effective date of the plan;
(2) a condition for which medical advice, diagnosis, care, or
treatment was recommended or received during the twelve (12)
months immediately preceding the effective date of the plan; or
(3) a pregnancy existing on the effective date of the plan.
(d) An insurer shall reduce the period allowed for a preexisting
condition exclusion described in subsection (b) by the amount of
time the individual has continuously served under a preexisting
condition clause for a policy of accident and sickness insurance
issued under IC 27-8-15 if the individual applies for a policy under
this chapter not more than thirty (30) days after coverage under a
policy of accident and sickness insurance issued under IC 27-8-15
expires.
As added by P.L.93-1995, SEC.6. Amended by P.L.190-1996, SEC.1;
P.L.211-2003, SEC.2; P.L.127-2006, SEC.1; P.L.173-2007, SEC.23;
P.L.3-2008, SEC.212.
IC 27-8-5-2.6
Repealed
(Repealed by P.L.1-2001, SEC.51.)
IC 27-8-5-2.7
Individual policy of accident and sickness insurance; waiver of
coverage
Sec. 2.7. (a) Notwithstanding section 2.5 of this chapter and any
other law, and except as provided in subsection (b), an individual
policy of accident and sickness insurance that is issued after June 30,
2005, may contain a waiver of coverage for a specified condition and
any complications that arise from the specified condition if:
(1) the waiver period does not exceed ten (10) years; and
(2) all the following conditions are met:
(A) The insurer provides to the applicant before issuance of
the policy written notice explaining the waiver of coverage
for the specified condition and complications arising from
the specified condition.
(B) The:
(i) offer of coverage; and
(ii) policy;
include the waiver in a separate section stating in bold print
that the applicant is receiving coverage with an exception for
the waived condition.
(C) The:
(i) offer of coverage; and
(ii) policy;
do not include more than two (2) waivers per individual.
(D) The waiver period is concurrent with and not in addition
to any applicable preexisting condition limitation or
exclusionary period.
(E) The insurer agrees to:
(i) review the underwriting basis for the waiver upon
request one (1) time per year; and
(ii) remove the waiver if the insurer determines that
evidence of insurability is satisfactory.
(F) The insurer discloses to the applicant that the applicant
may decline the offer of coverage and apply for a policy
issued by the Indiana comprehensive health insurance
association under IC 27-8-10.
(G) An insurance benefit card issued by the insurer to the
applicant includes a telephone number for verification of
coverage waived.
The insurer shall require an applicant to initial the written notice
provided under subdivision (2)(A) and the waiver included in the
offer of coverage and in the policy under subdivision (2)(B) to
acknowledge acceptance of the waiver of coverage. An offer of
coverage under a policy that includes a waiver under this subsection
does not preclude eligibility for an Indiana comprehensive health
insurance association policy under IC 27-8-10-5.1.
(b) An individual policy of accident and sickness insurance may
not include a waiver of coverage for a:
(1) mental health condition; or
(2) developmental disability.
(c) An insurer may not, on the basis of a waiver contained in a
policy as provided in subsection (a), deny coverage for any condition
or complication that is not specified as required in the:
(1) written notice under subsection (a)(2)(A); and
(2) offer of coverage and policy under subsection (a)(2)(B).
(d) An insurer that removes a waiver under subsection (a)(2)(E)
shall not consider the condition or any complication to which the
waiver previously applied in making policy renewal and
underwriting determinations.
(e) Upon the expiration of the waiver period allowed under this
section, the insurer shall:
(1) remove the waiver;
(2) not consider the condition or any complication to which the
waiver previously applied in making policy underwriting
determinations; and
(3) renew the policy in accordance with 45 CFR 148.122.
As added by P.L.211-2005, SEC.1.
IC 27-8-5-3
Required provisions; statutory option provisions; inapplicable or
inconsistent provisions; order of provisions; third party
ownership; requirements of other jurisdictions; filing procedure
Sec. 3. (a) Except as provided in subsection (c), each 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. However, the insurer may, at
its option, substitute for one (1) or more of the provisions
corresponding provisions of different wording approved by the
commissioner that are in each instance no less favorable in any
respect to the insured or the beneficiary. The provisions shall be
preceded individually by the caption appearing in this subsection or,
at the option of the insurer, by appropriate individual or group
captions or subcaptions as the commissioner may approve.
(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 insurance producer has authority to change this policy or
to waive any of its provisions.
(2) A provision as follows: TIME LIMIT ON CERTAIN
DEFENSES: (A) After two (2) years from the date of issue of this
policy no misstatements, except fraudulent misstatements, made by
the applicant in the application for such policy shall be used to void
the policy or to deny a claim for loss incurred or disability (as
defined in the policy) commencing after the expiration of such two
(2) year period.
The foregoing policy provision shall not be so construed as to
affect any legal requirement for avoidance of a policy of denial of a
claim during such initial two (2) year period, nor to limit the
application of subsection (b), (1), (2), (3), (4), and (5) in the event of
misstatement with respect to age or occupation or other insurance.
A policy which the insured has the right to continue in force
subject to its terms by the timely payment of premium:
(1) until at least age fifty (50); or
(2) in the case of a policy issued after forty-four (44) years of
age, for at least five (5) years from its date of issue;
may contain in lieu of the foregoing the following provision (from
which the clause in parentheses may be omitted at the insurer's
option) under the caption "INCONTESTABLE": After this policy
has been in force for a period of two (2) years during the lifetime of
the insured (excluding any period during which the insured is
disabled), it shall become incontestable as to the statements
contained in the application.
(B) No claim for loss incurred or disability (as defined in the
policy) commencing after two (2) years from the date of issue of this
policy shall be reduced or denied on the ground that a disease or
physical condition, not excluded from coverage by name or specific
description effective on the date of loss, had existed prior to the
effective date of coverage of this policy.
(3) A provision as follows: GRACE PERIOD: A grace period of
(insert a number not less than "7" for weekly premium policies, "10"
for monthly premium policies and "31" 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 in which the insurer reserves the right to refuse renewal
shall have, at the beginning of the above provision: "Unless not less
than thirty (30) days prior to the premium due date the insurer has
delivered to the insured or has mailed to the insured's 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.".
Each policy in which the insurer reserves the right to refuse
renewal on an individual basis shall provide, in substance, in a
provision of the policy, in an endorsement on the policy, or in a rider
attached to the policy, that subject to the right to terminate the policy
upon non-payment of premium when due, such right to refuse
renewal shall not be exercised before the renewal date occurring on,
or after and nearest, each anniversary, or in the case of lapse and
reinstatement at the renewal date occurring on, or after and nearest,
each anniversary of the last reinstatement, and that any refusal or
renewal shall be without prejudice to any claim originating while the
policy is in force. The preceding sentence shall not apply to accident
insurance only policies.
(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
authorized by the insurer to accept such premium, without requiring
in connection therewith an application for reinstatement, shall
reinstate the policy. Provided, that if the insurer or such agent
requires an application for reinstatement and issues a conditional
receipt for the premium tendered, the policy will 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 (10) days after such date. In all other respects
the insured and insurer shall have the same rights 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 (60) 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 fifty (50) years of age; or
(2) in the case of a policy issued after forty-four (44) years of
age, for at least five (5) 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 (20) 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 (2) years, an insurer may 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 (2) years, the insured shall, at least once in
every six (6) 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 (6) 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 insurer's right to any indemnity
which would otherwise have accrued during the period of six (6)
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, will 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 (15) 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 must 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 (90) days after the
termination of the period for which the insurer is liable and in case
of claim for any other loss within ninety (90) 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 (1) 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:
(1) immediately upon receipt of due written proof of such loss;
or
(2) in accordance with IC 27-8-5.7;
whichever is more favorable to the policyholder. Subject to due
written proof of loss, all accrued indemnities for loss for which this
policy provides periodic payment will 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. This provision
must reflect compliance with IC 27-8-5.7.
(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 $1,000), 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.
For the purposes of this section a "minor" is a person under the
age of eighteen (18) years. A person eighteen (18) years of age or
over is competent, insofar as the person's age is concerned, to sign a
valid release.
(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 (60) 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 (3) 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.
(13) A provision as follows: GUARANTEED RENEWABILITY:
In compliance with the federal Health Insurance Portability and
Accountability Act of 1996 (P.L.104-191), renewability is
guaranteed.
(b) Except as provided in subsection (c), no policy delivered or
issued for delivery to any person in Indiana shall contain provisions
respecting the matters set forth below unless the provisions are in the
words in which the provisions appear in this section. However, the
insurer may use, instead of any 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
substitute 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 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 the
insured's 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 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 the insured's 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 as follows: 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 are 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 such excess shall be returned
to the insured or to the insured's estate. Or, instead of that provision:
Insurance effective at any one (1) time on the insured under a like
policy or policies, in this insurer is limited to the one (1) such policy
elected by the insured, the insured's beneficiary or the insured's
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
INSURER: If there is 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 of 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 next following policy provision 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 term 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 worker's
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 is 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 next preceding policy provision, 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 to 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 worker's 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 the insured's average monthly earnings for the period
of two (2) 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 (2) years as shall exceed the pro rata amount of
the premiums for the benefits actually paid; 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
($200) 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 fifty (50) years of age; or
(2) in the case of a policy issued after forty-four (44) years of
age, for at least five (5) 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 the term shall not
include any coverage provided for the insured pursuant to any
compulsory benefit statute (including any worker's 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: 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.
(9) A provision as follows: 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.
(10) A provision as follows: INTOXICANTS AND
NARCOTICS: The insurer shall not be liable for any loss sustained
or contracted in consequence of the insured's being intoxicated or
under the influence of any narcotic unless administered on the advice
of a physician.
The policy provision under this subdivision may not be used with
respect to a policy that provides coverage for hospital, medical, or
surgical expenses.
(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 which are the subject of subsections (a) and
(b), or any corresponding provisions which are used in lieu thereof
in accordance with such 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) "Insured", as used in this chapter, 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 is provided in this chapter and which is prescribed or required
by the law of the state under which the insurer is organized.
(f)(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 reasonable rules under IC 4-22-2
concerning the procedure for the filing or submission of policies
subject to this chapter as are necessary, proper, or advisable to the
administration of this chapter. This provision shall not abridge any
other authority granted the commissioner by law.
(Formerly: Acts 1953, c.15, s.169.3; Acts 1971, P.L.392, SEC.1; Acts
1973, P.L.275, SEC.4; Acts 1974, P.L.1, SEC.13.) As amended by
P.L.28-1988, SEC.104; P.L.93-1995, SEC.8; P.L.91-1998, SEC.10;
P.L.162-2001, SEC.2; P.L.178-2003, SEC.60; P.L.98-2007, SEC.1.
IC 27-8-5-4
Effect of other policy provisions or policy conflicting with chapter
Sec. 4. (a) No policy provision which is not subject to section 3
of this chapter shall make a policy, or any portion thereof, less
favorable in any respect to the insured or the beneficiary than the
provisions thereof which are subject to this chapter.
(b) A policy delivered or issued for delivery to any person in this
state in violation of this chapter shall be held valid but shall be
construed as provided in this chapter. When any provision in a policy
subject to this chapter is in conflict with any provision of this
chapter, the rights, duties, and obligations of the insurer, the insured,
and the beneficiary shall be governed by the provisions of this
chapter.
(Formerly: Acts 1953, c.15, s.169.4.) As amended by P.L.252-1985,
SEC.303.
IC 27-8-5-5
Application; attaching copy to policy; furnishing copy to insured;
alterations; effect of false statements
Sec. 5. (a) The insured shall not be bound by any statement made
in an application for a policy unless a copy of such application is
attached to or endorsed on the policy when issued as a part thereof.
If any such policy delivered or issued for delivery to any person in
this state shall be reinstated or renewed, and the insured or the
beneficiary or assignee of such policy shall make written request to
the insurer for a copy of the application, if any, for such
reinstatement or renewal, the insurer shall within fifteen (15) days
after the receipt of such request at its home office or any branch
office of the insurer, deliver or mail to the person making such
request, a copy of such application. If such copy shall not be so
delivered or mailed, the insurer shall be precluded from introducing
such application as evidence in any action or proceeding based upon
or involving such policy or its reinstatement or renewal.
(b) No alteration of any written application for any such policy
shall be made by any person other than the applicant without his
written consent, except that insertions may be made by the insurer,
for administrative purposes only, in such manner as to indicate
clearly that such insertions are not to be ascribed to the applicant.
(c) The falsity of any statement in the application for any policy
covered by this chapter may not bar the right to recovery thereunder
unless such false statement materially affected either the acceptance
of the risk or the hazard assumed by the insurer.
(Formerly: Acts 1953, c.15, s.169.5.) As amended by P.L.252-1985,
SEC.304.
IC 27-8-5-6
Defenses of insurer; acts not constituting waiver
Sec. 6. The acknowledgment by any insurer of the receipt of
notice given under any policy covered by this chapter, or the
furnishing of forms for filing proofs of loss, or the acceptance of
such proofs, or the investigation of any claim thereunder shall not
operate as a waiver of any of the rights of the insurer in defense of
any claim arising under such policy.
(Formerly: Acts 1953, c.15, s.169.6.) As amended by P.L.252-1985,
SEC.305.
IC 27-8-5-7
Acceptance of premium for period beyond termination date; effect;
misstatement of age
Sec. 7. If any such policy contains a provision establishing, as an
age limit or otherwise, a date after which the coverage provided by
the policy will not be effective, and if such date falls within a period
for which premium is accepted by the insurer or if the insurer accepts
a premium after such date, the coverage provided by the policy will
continue in force subject to any right of cancellation until the end of
the period for which premium has been accepted. In the event the age
of the insured has been misstated and if, according to the correct age
of the insured, the coverage provided by the policy would not have
become effective, or would have ceased prior to the acceptance of
such premium or premiums, then the liability of the insurer shall be
limited to the refund, upon request, of all premiums paid for the
period not covered by the policy.
(Formerly: Acts 1953, c.15, s.169.7.)
IC 27-8-5-8
Exemption of accident and sickness coverage incidental to
designated other forms of insurance
Sec. 8. Except as otherwise expressly indicated in this section,
nothing contained in sections 1 through 7 of this chapter shall apply
to or affect:
(1) any policy of worker's compensation insurance or any policy
of liability insurance with or without supplementary coverage
in the policy;
(2) any policy or contract of reinsurance;
(3) as to sections 2 through 7 of this chapter, any blanket or
group policy of insurance;
(4) life insurance, endowment, or annuity contracts, or contracts
supplemental thereto which contain only such provisions
relating to accident and sickness insurance as:
(A) provide additional benefits in case of death or
dismemberment or loss of sight by accident; or
(B) operate to safeguard such contracts against lapse, or to
give a special surrender value or special benefit or an
annuity in the event that the insured or annuitant shall
become totally and permanently disabled, as defined by the
contract or supplemental contract;
(5) as to sections 2 through 5 of this chapter, any policies of
accident and sickness insurance issued on the industrial plan
with premiums payable on a weekly basis; or
(6) transportation ticket policies sold only at public
transportation stations or at public transportation ticket offices
by public transportation employees, as to such of the required
provisions set out in section 3 of this chapter as are incongruous
with the coverage and conditions of the policies.
(Formerly: Acts 1953, c.15, s.169.8; Acts 1955, c.129, s.1.) As
amended by P.L.252-1985, SEC.306; P.L.28-1988, SEC.105.
IC 27-8-5-9
Exemption of certain individual policies
Sec. 9. An individual accident and sickness insurance policy form
or any form of rider or endorsement appertaining to such a policy
form, which could have been lawfully used or delivered or issued for
delivery to any person in this state immediately before February 20,
1953, may be used or delivered or issued for delivery to any such
person at any time prior to January 1, 1956, without being subject to
the provisions of sections 2, 3, and 4 of this chapter.
(Formerly: Acts 1953, c.15, s.169.9.) As amended by P.L.252-1985,
SEC.307.
IC 27-8-5-10
Repealed
(Repealed by P.L.257-1985, SEC.6.)
IC 27-8-5-11
Franchise plan; accident and sickness insurance; definitions,
limitat