§ 27-18-3 - Required provisions.
SECTION 27-18-3
§ 27-18-3 Required provisions. – (a) Except as provided in § 27-18-5, each policy delivered or issued fordelivery to any person in this state shall contain the provisions specified inthis section in the words in which the provisions appear in this section;provided, that the insurer may, at its option, substitute, for one or more ofthe provisions, corresponding provisions of different wording approved by thecommissioner which are in each instance not less favorable in any respect tothe insured or the beneficiary. The provisions shall be preceded individuallyby the caption appearing in this subsection or, at the option of the insurer,by the appropriate individual or group captions or subcaptions as thecommissioner may approve:
(1) A provision as follows:
"ENTIRE CONTRACT; CHANGES: This policy, including theendorsements and the attached papers, if any, constitutes the entire contractof insurance. No change in this policy shall be valid until approved by anexecutive officer of the insurer and unless the approval is endorsed on it orattached to it. No agent has authority to change this policy or to waive any ofits provisions."
(2) A provision as follows:
"TIME LIMIT ON CERTAIN DEFENSES: (a) After three (3) yearsfrom the date of issue of this policy no misstatements, except fraudulentmisstatements, made by the applicant in the application for this policy shallbe 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 that three-yearperiod."
(This policy provision shall not be construed as to affectany legal requirement for avoidance of a policy or denial of a claim during theinitial three (3) year period, nor to limit the application of §27-18-4(1), (2), (3), (4) and (5) in the event of a misstatement with respectto age or occupation or other insurance.)
(A policy which the insured has the right to continue inforce subject to its terms by the timely payment of premium: (i) until at leastage fifty (50); or (ii) in the case of a policy issued after age forty-four(44), for at least five (5) years from its date of issue, may contain in lieuof this provision the following provision (from which the clause in parenthesesmay be omitted at the insurer's option) under the caption "INCONTESTABLE":
"After this policy has been in force for a period of three(3) years during the lifetime of the insured (excluding any period during whichthe insured is disabled), it shall become incontestable as to the statementscontained in the application.")
"(b) No claim for loss incurred or disability (as defined inthe policy) commencing after three (3) years from the date of issue of thispolicy shall be reduced or denied on the ground that a disease or physicalcondition not excluded from coverage by name or specific description effectiveon the date of loss had existed prior to the effective date of coverage of thispolicy."
(3) A provision as follows:
"GRACE PERIOD: A grace period of ]]]]]]]]" (insert a numbernot less than "seven" (7) for weekly premium policies, "ten" (10) for monthlypremium policies and "thirty-one" (31) for all other policies) "days will begranted 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, atthe end of the above provision:
"subject to the right of the insurer to cancel in accordancewith the cancellation provision of this policy.")
(A policy in which the insurer reserves the right to refuseany renewal shall have, at the beginning of the above provision:
"Unless not less than ten (10) days prior to the premium duedate the insurer has delivered to the insured or has mailed to his or her lastaddress as shown by the records of the insurer written notice of its intentionnot to renew this policy beyond the period for which the premium has beenaccepted,")
(4) A provision as follows:
"REINSTATEMENT: If any renewal premium is not paid within thetime granted the insured for payment, a subsequent acceptance of premium by theinsurer or by any agent duly authorized by the insurer to accept this premium,without requiring in connection with it an application for reinstatement, shallreinstate the policy; provided, that if the insurer or the agent requires anapplication for reinstatement and issues a conditional receipt for the premiumtendered, the policy will be reinstated upon approval of the application by theinsurer or, lacking approval, upon the forty-fifth day following the date ofthe conditional receipt unless the insurer has previously notified the insuredin writing of its disapproval of the application. The reinstated policy shallcover only loss resulting from an accidental injury as may be sustained afterthe date of reinstatement and loss due to a sickness as may begin more than ten(10) days after this date. In all other respects the insured and insurer shallhave the same rights under the reinstated policy as they had under the policyimmediately before the due date of the defaulted premium, subject to anyprovisions endorsed on it or attached to it in connection with thereinstatement. Any premium accepted in connection with a reinstatement shall beapplied to a period for which the premium has not been previously paid, but notto any period more than sixty (60) days prior to the date of reinstatement."
(The last sentence of this provision may be omitted from anypolicy which the insured has the right to continue in force subject to itsterms by the timely payment of premiums: (i) until at least age fifty (50); or(ii) in the case of a policy issued after age forty-four (44), for at leastfive (5) years from its date of issue.)
(5) A provision as follows:
"NOTICE OF CLAIM: Written notice of claim must be given tothe insurer within twenty (20) days after the occurrence or commencement of anyloss covered by the policy, or as soon after this as is reasonably possible.Notice given by or on behalf of the insured or the beneficiary to the insurerat ]]]]]]]]]]]]]]]]]]]]]]]]" (insert the location of any office as the insurermay designate for the purpose), "or to any authorized agent of the insurer,with information sufficient to identify the insured, shall be deemed notice tothe insurer."
(In a policy providing a loss of time benefit which may bepayable for at least two (2) years, an insurer may at its option insert thefollowing between the first and second sentences of this provision:
"Subject to the qualifications set forth below, if theinsured suffers loss of time on account of disability for which indemnity maybe payable for at least two (2) years, the insured shall, at least once inevery six (6) months after having given notice of claim, give to the insurernotice of continuance of the disability, except in the event of legalincapacity. The period of six (6) months following any filing of proof by theinsured or any payment by the insurer on account of the claim or any denial ofliability in whole or in part by the insurer shall be excluded in applying thisprovision. Delay in the giving of notice shall not impair the insured's rightto any indemnity which would have accrued during the period of six (6) monthspreceding the date on which the 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 any forms as are usually furnished by it forfiling proofs of loss. If the forms are not furnished within fifteen (15) daysafter the giving of notice, the claimant shall be deemed to have complied withthe requirements of this policy as to proof of loss upon submitting, within thetime fixed in the policy for filing proofs of loss, written proof covering theoccurrence, 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 tothe insurer at its office in the case of a claim for loss for which this policyprovides any periodic payment contingent upon continuing loss within ninety(90) days after the termination of the period for which the insurer is liableand in the case of a claim for any other loss within ninety (90) days after thedate of the loss. Failure to furnish proof within the time required shall notinvalidate nor reduce any claim if it was not reasonably possible to give proofwithin this time, provided the proof is furnished as soon as reasonablypossible and in no event, except in the absence of legal capacity, later thanone year from the time proof is required."
(8) A provision as follows:
"TIME OF PAYMENT OF CLAIMS: Indemnities payable under thispolicy for any loss other than loss for which this policy provides any periodicpayment will be paid immediately upon receipt of due written proof of thisloss. Subject to due written proof of loss, all accrued indemnities for lossfor which this policy provides periodic payment will be paid]]]]]]]]]]]]]]]]]]]]]]]]" (insert period for payments which must not be lessfrequently than monthly) "and any balance remaining unpaid upon the terminationof 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 bepayable in accordance with the beneficiary designation and the provisionsrespecting the payment which may be prescribed in this policy and effective atthe time of payment. If no designation or provision is effective, indemnityshall be payable to the estate of the insured. Any other accrued indemnitiesunpaid at the insured's death may, at the option of the insurer, be paid eitherto the beneficiary or to the estate. All other indemnities will be payable tothe insured."
(The following provisions, or either of them, may be includedwith this provision at the option of the insurer:
"If any indemnity of this policy shall be payable to theestate of the insured, or to an insured or beneficiary who is a minor or notcompetent to give a valid release, the insurer may pay the indemnity, up to anamount not exceeding $]]]]]]]]]]]]" (insert an amount which shall not exceedone thousand dollars ($1,000)), "to any relative by blood or connection bymarriage of the insured or beneficiary who is deemed by the insurer to beequitably entitled to the payment. Any payment made by the insurer in goodfaith pursuant to this provision shall fully discharge the insurer to theextent of the payment." "Subject to any written direction of the insured in theapplication or otherwise, all or a portion of any indemnities provided by thispolicy on account of hospital, nursing, medical, or surgical services may, atthe insurer's option and unless the insured requests otherwise in writing notlater than the time of filing proofs of the loss, be paid directly to thehospital or person rendering the services; but it is not required that theservice be rendered by a particular hospital or person.")
(10) A provision as follows:
"PHYSICAL EXAMINATIONS AND AUTOPSY: The insurer at its ownexpense shall have the right and opportunity to examine the person of theinsured when and as often as it may reasonably require during the pendency of aclaim under this policy and to make an autopsy in case of death where it is notforbidden by law."
(11) A provision as follows:
"LEGAL ACTIONS: No action at law or in equity shall bebrought to recover on this policy prior to the expiration of sixty (60) daysafter written proof of loss has been furnished in accordance with therequirements of this policy. No action shall be brought after the expiration ofthree (3) years after the time written proof of loss is required to befurnished."
(12) A provision as follows:
"CHANGE OF BENEFICIARY: Unless the insured makes anirrevocable designation of beneficiary, the right to change of beneficiary isreserved to the insured and the consent of the beneficiary or beneficiariesshall not be requisite to surrender or assignment of this policy or to anychange of beneficiary or beneficiaries, or to any other changes in this policy."
(The first clause of this provision, relating to theirrevocable designation of beneficiary, may be omitted at the insurer's option.)
(13) A provision as follows:
" "Medical services' means those professional servicesand supplies rendered by or under the direction of persons duly licensed underthe laws of this state to practice medicine, surgery, or podiatry as may bespecified by any medical service plan. Medical service shall not be construedto include hospital services."
(c) Each policy issued and/or renewed shall contain a minimumhome health care benefit as follows:
(i) "Home health care" is defined as a medically necessaryprogram to reduce the length of a hospital stay or to delay or eliminate anotherwise medically necessary hospital admission;
(ii) The home health care program shall be formulated andsupervised by the subscriber's physician;
(iii) Minimum home health care coverage shall not exceed six(6) home or office physician's visits per month, and shall not exceed three (3)nursing visits per week, home health aide visits up to twenty (20) hours perweek, and the following services as needed: physical or occupational therapy asa rehabilitative service, respiratory service, speech therapy, medical socialwork, nutrition counseling, prescription drugs and medication, medical andsurgical supplies, such as dressings, bandages, and casts, minor equipment suchas commodes and walkers, laboratory testing, x-rays and E.E.G. and E.K.G.evaluations; and
(iv) Communicable diseases and/or nervous, emotional andmental illness are excluded from home health care coverage;
(2) The commissioner shall approve the wording in each policythat in each instance shall not be less favorable in any respect to the insuredor the beneficiary, as the benefits are outlined in subdivision (1) of thissubsection. Any accident and sickness insurance policy whose benefits arelimited to income protection or the furnishing of disability income or alimited benefit health coverage are excluded from this subsection.Notwithstanding the provisions of § 27-18-19(3), the minimum home healthcare benefit shall be included in blanket and/or group policies of accident andsickness insurance;
(3) A "limited benefit policy," for the purposes of thissection, is any accident and sickness policy that covers one or more specifiedrisks including, but not limited to, accidental death or injury or specifieddisease. A policy that broadly covers accident and sickness, but which containsexclusions and limitations with respect to certain risks or services, is not alimited benefit policy;
(4) With respect to blanket and/or group policies, theprovisions of this subsection shall apply only to services provided toresidents of Rhode Island or employees of Rhode Island employers.