38.2-3503 - Required accident and sickness policy provisions.
§ 38.2-3503. Required accident and sickness policy provisions.
Except as provided in § 38.2-3505, each individual accident and sicknessinsurance policy delivered or issued for delivery in this Commonwealth shallcontain the provisions specified in this section using the same words whichappear in this section. Provisions 1 through 12 shall apply to all suchpolicies. In addition, provision 13 shall apply to all such policies that aredelivered, issued for delivery, renewed, or extended in this Commonwealth onor after January 1, 2001. An insurer may substitute corresponding provisionsof different wording approved by the Commission that are in each instance notless favorable in any respect to the insured or the beneficiary. Theseprovisions shall be preceded individually by the caption "REQUIREDPROVISIONS" or by such appropriate individual or group captions orsubcaptions as the Commission may approve.
1. Provision 1:
ENTIRE CONTRACT; CHANGES: This policy, including the endorsements and theattached papers, if any, constitutes the entire contract of insurance. Nochange in this policy shall be valid until approved by an executive officerof the Company and unless such approval is endorsed hereon or attachedhereto. No agent has authority to change this policy or to waive any of itsprovisions.
2. Provision 2:
TIME LIMIT ON CERTAIN DEFENSES: (a) Misstatements in the application: Aftertwo years from the date of this policy, only fraudulent misstatements in theapplication may be used to void the policy or deny any claim for lossincurred or disability (as defined in the policy) that starts after thetwo-year period.
Provision 2 shall not be construed to affect any legal requirement foravoidance of a policy or denial of a claim during such initial two-yearperiod, nor to limit the application of subdivisions 1, 2, 3, 4 and 5 of §38.2-3504 in the event of misstatement with respect to age, occupation orother insurance.
Instead of Provision 2, a policy which the insured has the right to continuein force subject to its terms by the timely payment of premium (i) until atleast age 50 or, (ii) for a policy issued after age 44, for at least fiveyears from its date of issue, may contain the following provision, from whichthe clause in parentheses may be omitted at the insurer's option:
INCONTESTABLE:
(a) Misstatements in the application: After this policy has been in force fortwo years during the Insured's lifetime (excluding any period during whichthe Insured is disabled), the Company cannot contest the statements in theapplication.
PREEXISTING CONDITIONS:
(b) No claim for loss incurred or disability (as defined in the policy) thatstarts after one year from the date of issue of this policy will be reducedor denied because a sickness or physical condition, not excluded by name orspecific description before the date of loss, had existed before theeffective date of coverage.
3. Provision 3:
GRACE PERIOD: This policy has a ............... day grace period. This means that if arenewal premium is not paid on or before the date it is due, it may be paidduring the following .......... days. During the grace period the policy shallcontinue in force.
In Provision 3 a number not less than "7" for weekly premium policies,"10" for monthly premium policies and "31" for all other policies shallbe inserted between the words "a" and "day," and between "following"and "days."
A policy that contains a cancellation provision may add, at the end ofProvision 3: "subject to the right of the Company to cancel in accordancewith the cancellation provision."
A policy in which the insurer reserves the right to refuse any renewal shallhave, in Provision 3, the following sentence:
The grace period will not apply if, at least ...... days before the premium duedate, the Company has delivered or has mailed to the Insured's last addressshown in the Company's records written notice of the Company's intent not torenew this policy.
In the above sentence a number not less than "7" for weekly premiumpolicies, "10" for monthly premium policies and "31" for all otherpolicies shall be inserted between the words "least" and "days."
4. Provision 4:
REINSTATEMENT: If the renewal premium is not paid before the grace periodends, the policy will lapse. Later acceptance of the premium by the Companyor by an agent authorized to accept payment, without requiring an applicationfor reinstatement, will reinstate the policy. If the Company or its agentrequires an application for reinstatement, the Insured will be given aconditional receipt for the premium. If the application is approved thepolicy will be reinstated as of the approval date. Lacking such approval, thepolicy will be reinstated on the forty-fifth day after the date of theconditional receipt unless the Company has previously written the Insured ofits disapproval. The reinstated policy will cover only loss that results froman injury sustained after the date of reinstatement and sickness that startsmore than 10 days after such date. In all other respects the rights of theInsured and the Company will remain the same, subject to any provisions notedor attached to the reinstated policy. Any premiums the Company accepts for areinstatement will be applied to a period for which premiums have not beenpaid. No premiums will be applied to any period more than 60 days prior tothe date of reinstatement.
The last sentence of Provision 4 may be omitted from any policy that theInsured has the right to continue in force subject to its terms by the timelypayment of premiums (i) until at least age 50, or (ii) for a policy issuedafter age 44, for at least five years from its effective date.
5. Provision 5:
NOTICE OF CLAIM: Written notice of claim must be given within 20 days after acovered loss starts or as soon as reasonably possible. The notice can begiven to the Company at ................... (insert the location of such office as the insurer may designate for the purpose), or to the Company's agent. Notice should include the name of the Insured, and Claimant if other than the Insured, and the policy number.
Optional paragraph: If the Insured has a disability for which benefits may bepayable for at least two years, at least once in every six months after theInsured has given notice of claim, the Insured must give the Company noticethat the disability has continued. The Insured need not do this if legallyincapacitated. The first six months after any filing of proof by the Insuredor any payment or denial of a claim by the Company will not be counted inapplying this provision. If the Insured delays in giving this notice, theInsured's right to any benefits for the six months before the date theInsured gives notice will not be impaired.
6. Provision 6:
CLAIM FORMS: When the Company receives the notice of claim, it will send theClaimant forms for filing proof of loss. If these forms are not given to theClaimant within 15 days after the giving of such notice, the Claimant shallmeet the proof of loss requirements by giving the Company a written statementof the nature and extent of the loss within the time limit stated in theProofs of Loss Section.
7. Provision 7:
PROOFS OF LOSS: If the policy provides for periodic payment for a continuingloss, written proof of loss must be given the Company within 90 days afterthe end of each period for which the Company is liable. For any other loss,written proof must be given within 90 days after such loss. If it was notreasonably possible to give written proof in the time required, the Companyshall not reduce or deny the claim for this reason if the proof is filed assoon as reasonably possible. In any event, except in the absence of legalcapacity, the proof required must be given no later than one year from thetime specified.
8. Provision 8:
TIME OF PAYMENT OF CLAIMS: After receiving written proof of loss, the Companywill pay ............... (Insert period for payment which must not be less frequentlythan monthly) all benefits then due for ..... (Insert type of loss). Benefitsfor any other loss covered by this policy will be paid as soon as the Companyreceives proper written proof.
9. Provision 9:
PAYMENT OF CLAIMS: Benefits will be paid to the Insured. Loss of lifebenefits are payable in accordance with the beneficiary designation in effectat the time of payment. If none is then in effect, the benefits will be paidto the Insured's estate. Any other benefits unpaid at death may be paid, atthe Company's option, either to the Insured's beneficiary or the Insured'sestate.
Optional paragraph: If benefits are payable to the Insured's estate or abeneficiary who cannot execute a valid release, the Company can pay benefitsup to $........ (insert an amount which shall not exceed $2,000), to someonerelated to the Insured or beneficiary by blood or by marriage whom theCompany considers to be entitled to the benefits. The Company will bedischarged to the extent of any payment made in good faith.
Optional paragraph: The Company may pay all or a portion of any indemnitiesprovided for health care services to the health care services provider,unless the Insured directs otherwise in writing by the time proofs of lossare filed. The Company cannot require that the services be rendered by aparticular health care services provider.
10. Provision 10:
PHYSICAL EXAMINATIONS AND AUTOPSY: The Company at its own expense has theright to have the Insured examined as often as reasonably necessary while aclaim is pending. It may also have an autopsy made unless prohibited by law.
11. Provision 11:
LEGAL ACTIONS: No legal action may be brought to recover on this policywithin 60 days after written proof of loss has been given as required by thispolicy. No legal action may be brought after three years from the timewritten proof of loss is required to be given.
12. Provision 12:
CHANGE OF BENEFICIARY: The Insured can change the beneficiary at any time bygiving the Company written notice. The beneficiary's consent is not requiredfor this or any other change in the policy, unless the designation of thebeneficiary is irrevocable.
13. Provision 13:
CANCELLATION BY INSURED: The Insured may cancel this policy at any time bywritten notice delivered or mailed to the Company effective upon receipt oron such later date as may be specified in the notice. In the event ofcancellation, the Company shall return promptly the unearned portion of anypremium paid. The earned premium shall be computed pro rata. Cancellationshall be without prejudice to any claim originating prior to the effectivedate of cancellation.
(1952, c. 317, § 38.1-349; 1958, c. 452; 1966, c. 101; 1986, c. 562; 1987, c.520; 1995, c. 522; 2000, c. 540; 2003, c. 377.)