§ 27-18-4 - Optional provisions.
SECTION 27-18-4
§ 27-18-4 Optional provisions. – Except as provided in § 27-18-5, no policy delivered or issued fordelivery to any person in this state shall contain provisions respecting thematters set forth in this section unless the provisions are in the words inwhich they appear in this section; provided, that the insurer may, at itsoption, use in lieu of any provision a corresponding provision of differentwording approved by the commissioner which is not less favorable in any respectto the insured or the beneficiary. The provision contained in the policy shallbe preceded individually by the appropriate caption appearing in this sectionor, at the option of the insurer, by any appropriate individual or groupcaptions or subcaptions as the commissioner may approve:
(1) A provision as follows:
"CHANGE OF OCCUPATION: If the insured is injured or contractssickness after having changed his or her occupation to one classified by theinsurer as more hazardous than that stated in this policy or while doing forcompensation anything pertaining to an occupation classified as more hazardous,the insurer will pay only that portion of the indemnities provided in thispolicy as the premium paid would have purchased at the rates and within thelimits fixed by the insurer for the more hazardous occupation. If the insuredchanges his or her occupation to one classified by the insurer as lesshazardous than that stated in this policy, the insurer, upon receipt of proofof the change of occupation, will reduce the premium rate accordingly, and willreturn the excess pro rata unearned premium from the date of change ofoccupation or from the policy anniversary date immediately preceding receipt ofthe proof, whichever is the more recent. In applying this provision, theclassification of occupational risk and the premium rates shall be such as havebeen last filed by the insurer, prior to the occurrence of the loss for whichthe insurer is liable or prior to the date of proof of change in occupation,with the state official having supervision of insurance in the state where theinsured resided at the time this policy was issued; but, if the filing was notrequired, then the classification of occupational risk and the premium ratesshall be those last made effective by the insurer in the state prior to theoccurrence 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 beenmisstated, all amounts payable under this policy shall be such as the premiumpaid would have purchased at the correct age."
(3) A provision as follows:
"OTHER INSURANCE IN THIS INSURER: If an accident or sicknessor accident and sickness policy or policies previously issued by the insurer tothe insured is in force concurrently with it, making the aggregate indemnityfor . . . . . . . . . . ." (insert type of coverage or coverages) "in excess of $. . . . . . . ." (insert maximum limit ofindemnity or indemnities) "the excess insurance shall be void and all premiumspaid for the excess shall be returned to the insured or to his or her estate,"or, in lieu of this:
"Insurance effective at any one time on the insured under alike policy or policies in this insurer is limited to the one such policyelected by the insured, his or her beneficiary or his or her estate and theinsurer will return all premiums paid for all other like policies."
(4) A provision as follows:
"INSURANCE WITH OTHER INSURERS: If there is other validcoverage, not with this insurer, providing benefits for the same loss on aprovision of service basis or on an expense incurred basis and of which thisinsurer has not been given written notice prior to the occurrence orcommencement of loss, the only liability under any expense incurred coverage ofthis policy shall be for the proportion of the loss as the amount which wouldhave been payable under this policy plus the total of the like amounts underall the other valid coverage for the same loss of which this insurer had noticebears to the total like amounts under all valid coverage for the loss, and forthe return of the portion of the premiums paid as shall exceed the pro rataportion for the determined amount. For the purpose of applying this provisionwhen other coverage is on a provision of service basis, the "like amount' ofthe other coverage shall be taken as the amount which the services renderedwould have cost in the absence of the coverage."
(If this policy provision is included in a policy which alsocontains the next following policy provision, there shall be added to thecaption of this provision the phrase " – EXPENSE INCURRED BENEFITS." Theinsurer may, at its option, include in this provision a definition of "othervalid coverage", approved as to form by the commissioner, which definitionshall be limited in subject matter to coverage provided by organizationssubject to regulation by insurance law or by insurance authorities of this orany other state of the United States or any province of Canada, and by hospitalor medical service organizations, and to any other coverage the inclusion ofwhich may be approved by the commissioner. In the absence of the definition,the term shall not include group insurance, automobile medical paymentsinsurance, or coverage provided by hospital or medical service organizations orby union welfare plans or employer or employee benefit organizations. For thepurpose of applying this policy provision with respect to any insured, anyamount of benefit provided for the insured pursuant to any compulsory benefitstatute, including any workers' compensation or employer's liability statute,whether provided by a governmental agency or otherwise, shall in all cases bedeemed to be "other valid coverage" of which the insurer has had notice. Inapplying this policy provision, no third party liability coverage shall beincluded as "other valid coverage".)
(5) A provision as follows:
"INSURANCE WITH OTHER INSURERS: If there is other validcoverage, not with this insurer, providing benefits for the same loss on otherthan an expense incurred basis and of which this insurer has not been givenwritten notice prior to the occurrence or commencement of loss, the onlyliability for those benefits under this policy shall be for the proportion ofthe indemnities otherwise provided under this policy for the loss as the likeindemnities of which the insurer had notice (including the indemnities underthis policy) bear to the total amount of all like indemnities for the loss, andfor the return of the portion of the premium paid as shall exceed the pro rataportion for the determined indemnities."
(If this policy provision is included in a policy which alsocontains the next preceding policy provision, there shall be added to thecaption of this provision the phrase " – OTHER BENEFITS." The insurer may,at its option, include in this provision a definition of "other validcoverage", approved as to form by the commissioner, which definition shall belimited in subject matter to coverage provided by organizations subject toregulation by insurance law or by insurance authorities of this or any otherstate of the United States or any province of Canada, and to any other coveragethe inclusion of which may be approved by the commissioner. In the absence ofthe definition, this term shall not include group insurance, or benefitsprovided by union welfare plans or by employer or employee benefitorganizations. For the purpose of applying this policy provision with respectto any insured, any amount of benefit provided for the insured pursuant to anycompulsory benefit statute, including any workers' compensation or employer'sliability statute, whether provided by a governmental agency or otherwise,shall in all cases be deemed to be "other valid coverage" of which the insurerhas had notice. In applying this policy provision, no third party liabilitycoverage shall be included as "other valid coverage".)
(6) A provision as follows:
"RELATION OF EARNINGS TO INSURANCE: If the total monthlyamount of loss of time benefits promised for the same loss under all valid lossof time coverage upon the insured, whether payable on a weekly or monthlybasis, shall exceed the monthly earnings of the insured at the time disabilitycommenced or his or her average monthly earnings for the period of two (2)years immediately preceding a disability for which claim is made, whichever isthe greater, the insurer will be liable only for the proportionate amount ofthe benefits under this policy as the amount of the monthly earnings or theaverage monthly earnings of the insured bears to the total amount of monthlybenefits for the same loss under all the coverage upon the insured at the timethe disability commences, and for the return of the part of the premiums paidduring the two (2) years that exceeds the pro rata amount of the premiums forthe benefits actually paid under this policy; but this shall not operate toreduce the total monthly amount of benefits payable under all the coverage uponthe insured below the sum of two hundred dollars ($200) or the sum of themonthly benefits specified in the coverage, whichever is the lesser, nor shallit operate to reduce benefits other than those payable for loss of time." (Thispolicy provision may be inserted only in a policy which the insured has theright to continue in force subject to its terms by the timely payment ofpremiums: (i) until at least age fifty (50); or (ii) in the case of a policyissued after age forty-four (44), for at least five (5) years from its date ofissue. The insurer may, at its option, include in this provision a definitionof "valid loss of time coverage", approved as to form by the commissioner,which definition shall be limited in subject matter to coverage provided bygovernmental agencies or by organizations subject to regulation by insurancelaw or by insurance authorities of this or any other state of the United Statesor any province of Canada, or to any other coverage the inclusion of which maybe approved by the commissioner or any combination of this coverage. In theabsence of a definition, the term shall not include any coverage provided forthe insured pursuant to any compulsory benefit statute, including any workers'compensation or employer's liability statute, or benefits provided by unionwelfare plans or by employer or employee benefit organizations.)
(7) A provision as follows:
"UNPAID PREMIUM: Upon the payment of a claim under thispolicy, any premium then due and unpaid or covered by any note or written ordermay be deducted from this payment."
(8) A provision as follows:
"CANCELLATION: The insurer may cancel this policy at any timeby written notice delivered to the insured, or mailed to his or her lastaddress as shown by the records of the insurer, stating when, not less than ten(10) days after this, the cancellation shall be effective; and, after thepolicy has been continued beyond its original term, the insured may cancel thispolicy at any time by written notice delivered or mailed to the insurer,effective upon receipt or on a later date as may be specified in the notice. Inthe event of cancellation, the insurer will return promptly the unearnedportion of any premium paid. If the insured cancels, the earned premium shallbe computed by the use of the short-rate table last filed with the stateofficial having supervision of insurance in the state where the insured residedwhen the policy was issued. If the insurer cancels, the earned premium shall becomputed pro rata. Cancellation shall be without prejudice to any claimoriginating prior to the effective date of cancellation."
(9) A provision as follows:
"CONFORMITY WITH STATE STATUTE: Any provision of this policywhich, on its effective date, is in conflict with the statutes of the state inwhich the insured resides on that date, is hereby amended to conform to theminimum requirements of those statutes."
(10) A provision as follows:
"ILLEGAL OCCUPATION: The insurer shall not be liable for anyloss to which a contributing cause was the insured's commission of or attemptto commit a felony or to which a contributing cause was the insured's beingengaged in an illegal occupation."
(11) A provision as follows included in any policy that isnot a medical expense policy:
"INTOXICANTS AND NARCOTICS: The insurer shall not be liablefor any loss sustained or contracted in consequence of the insured's beingintoxicated or under the influence of any narcotic unless administered on theadvice of a physician."
No such provision may be included in a medical expensepolicy, which, for purposes of this subsection, shall mean an accident andsickness insurance policy that provides hospital, medical or surgical expensecoverage.