A. Except as provided in § 38.2-3505, each individual accident and sickness insurance policy delivered or issued for delivery in this Commonwealth shall contain the provisions specified in this section using the same words which appear in this section. Provisions 1 through 12 shall apply to all such policies. In addition, provision 13 shall apply to all such policies that are delivered, issued for delivery, renewed, or extended in this Commonwealth on or after January 1, 2001. An insurer may substitute corresponding provisions of different wording approved by the Commission that are in each instance not less favorable in any respect to the insured or the beneficiary. These provisions shall be preceded individually by the caption “REQUIRED PROVISIONS” or by such appropriate individual or group captions or subcaptions as the Commission may approve.
1. Provision 1: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 Company and unless such approval is endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions.
2. Provision 2:TIME LIMIT ON CERTAIN DEFENSES: (a) Misstatements in the application: After two years from the date of this policy, only fraudulent misstatements in the application may be used to void the policy or deny any claim for loss incurred or disability (as defined in the policy) that starts after the two-year period.Provision 2 shall not be construed to affect any legal requirement for avoidance of a policy or denial of a claim during such initial two-year period, 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 or other insurance.Instead of Provision 2, a policy which the insured has the right to continue in force subject to its terms by the timely payment of premium (i) until at least age 50 or, (ii) for a policy issued after age 44, for at least five years from its date of issue, may contain the following provision, from which the clause in parentheses may be omitted at the insurer’s option:INCONTESTABLE:
(a. Misstatements in the application: After this policy has been in force for two years during the Insured’s lifetime (excluding any period during which the Insured is disabled), the Company cannot contest the statements in the application.PREEXISTING CONDITIONS:
(b. No claim for loss incurred or disability (as defined in the policy) that starts after one year from the date of issue of this policy will be reduced or denied because a sickness or physical condition, not excluded by name or specific description before the date of loss, had existed before the effective date of coverage.
3. Provision 3:GRACE PERIOD: This policy has a ………..… day grace period. This means that if a renewal premium is not paid on or before the date it is due, it may be paid during the following ………days. During the grace period the policy shall continue 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 shall be inserted between the words “a” and “day,” and between “following” and “days.” However, if provisions of federal law require a policy to have a grace period in excess of one month, the period of time that the policy shall continue in force during the grace period shall not be required to exceed one month from the beginning of the grace period.A policy that contains a cancellation provision may add, at the end of Provision 3: “subject to the right of the Company to cancel in accordance with the cancellation provision.”A policy in which the insurer reserves the right to refuse any renewal shall have, in Provision 3, the following sentence:The grace period will not apply if, at least ..… days before the premium due date, the Company has delivered or has mailed to the Insured’s last address shown in the Company’s records written notice of the Company’s intent not to renew this policy.In the above sentence a number not less than “7″ for weekly premium policies, “10″ for monthly premium policies and “31″ for all other policies shall be inserted between the words “least” and “days.”
4. Provision 4:REINSTATEMENT: If the renewal premium is not paid before the grace period ends, the policy will lapse. Later acceptance of the premium by the Company or by an agent authorized to accept payment, without requiring an application for reinstatement, will reinstate the policy. If the Company or its agent requires an application for reinstatement, the Insured will be given a conditional receipt for the premium. If the application is approved the policy will be reinstated as of the approval date. Lacking such approval, the policy will be reinstated on the forty-fifth day after the date of the conditional receipt unless the Company has previously written the Insured of its disapproval. The reinstated policy will cover only loss that results from an injury sustained after the date of reinstatement and sickness that starts more than 10 days after such date. In all other respects the rights of the Insured and the Company will remain the same, subject to any provisions noted or attached to the reinstated policy. Any premiums the Company accepts for a reinstatement will be applied to a period for which premiums have not been paid. No premiums will be applied to any period more than 60 days prior to the date of reinstatement.The last sentence of Provision 4 may be omitted from any policy that the Insured has the right to continue in force subject to its terms by the timely payment of premiums (i) until at least age 50, or (ii) for a policy issued after 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 a covered loss starts or as soon as reasonably possible. The notice can be given 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 be payable for at least two years, at least once in every six months after the Insured has given notice of claim, the Insured must give the Company notice that the disability has continued. The Insured need not do this if legally incapacitated. The first six months after any filing of proof by the Insured or any payment or denial of a claim by the Company will not be counted in applying this provision. If the Insured delays in giving this notice, the Insured’s right to any benefits for the six months before the date the Insured gives notice will not be impaired.
6. Provision 6:CLAIM FORMS: When the Company receives the notice of claim, it will send the Claimant forms for filing proof of loss. If these forms are not given to the Claimant within 15 days after the giving of such notice, the Claimant shall meet the proof of loss requirements by giving the Company a written statement of the nature and extent of the loss within the time limit stated in the Proofs of Loss Section.
7. Provision 7:PROOFS OF LOSS: If the policy provides for periodic payment for a continuing loss, written proof of loss must be given the Company within 90 days after the 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 not reasonably possible to give written proof in the time required, the Company shall not reduce or deny the claim for this reason if the proof is filed as soon as reasonably possible. In any event, except in the absence of legal capacity, the proof required must be given no later than one year from the time specified.
8. Provision 8:TIME OF PAYMENT OF CLAIMS: After receiving written proof of loss, the Company will pay ………..… (Insert period for payment which must not be less frequently than monthly) all benefits then due for ………..… (Insert type of loss). Benefits for any other loss covered by this policy will be paid as soon as the Company receives proper written proof.
9. Provision 9:PAYMENT OF CLAIMS: Benefits will be paid to the Insured. Loss of life benefits are payable in accordance with the beneficiary designation in effect at the time of payment. If none is then in effect, the benefits will be paid to the Insured’s estate. Any other benefits unpaid at death may be paid, at the Company’s option, either to the Insured’s beneficiary or the Insured’s estate.Optional paragraph: If benefits are payable to the Insured’s estate or a beneficiary who cannot execute a valid release, the Company can pay benefits up to $….… (insert an amount which shall not exceed $ 2,000), to someone related to the Insured or beneficiary by blood or by marriage whom the Company considers to be entitled to the benefits. The Company will be discharged to the extent of any payment made in good faith.Optional paragraph: The Company may pay all or a portion of any indemnities provided for health care services to the health care services provider, unless the Insured directs otherwise in writing by the time proofs of loss are filed. The Company cannot require that the services be rendered by a particular health care services provider.
10. Provision 10:PHYSICAL EXAMINATIONS AND AUTOPSY: The Company at its own expense has the right to have the Insured examined as often as reasonably necessary while a claim 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 policy within 60 days after written proof of loss has been given as required by this policy. No legal action may be brought after three years from the time written proof of loss is required to be given.
12. Provision 12:CHANGE OF BENEFICIARY: The Insured can change the beneficiary at any time by giving the Company written notice. The beneficiary’s consent is not required for this or any other change in the policy, unless the designation of the beneficiary is irrevocable.
13. Provision 13:CANCELLATION BY INSURED: The Insured may cancel this policy at any time by written notice delivered or mailed to the Company effective upon receipt or on such later date as may be specified in the notice. In the event of cancellation, the Company shall return promptly the unearned portion of any premium paid. The earned premium shall be computed pro rata. Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation.
B. The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34.
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; 2013, c. 751.