10350. Except as provided in Section 10323, each disability policy
delivered or issued for delivery to any person in this State shall
contain the provisions specified in Sections 10350.1 to 10350.12,
inclusive, in the words in which the same appear in such sections;
provided, however, that the insurer may, at its option, substitute
for one or more of such provisions corresponding provisions of
different wording approved by the commissioner which are in each
instance not less favorable in any respect to the insured or the
beneficiary. Such provisions shall be preceded individually by the
caption appearing in each section or, at the option of the insurer,
by such appropriate individual or group captions or subcaptions as
the commissioner may approve.
10350.1. A disability policy shall contain a provision which shall
be in the form set forth herein.
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 agent has authority to change
this policy or to waive any of its provisions.
10350.2. A disability policy shall contain a provision that shall
be in one of the two forms set forth in this section. Policies other
than noncancellable policies shall use Form A. Noncancellable
policies shall use either Form A or Form B. In Form B, the clause in
parentheses in paragraph (a) may be omitted at the insurer's option.
Paragraph (a) in Form A shall not be so construed as to affect any
legal requirement for avoidance of a policy or denial of a claim
during the initial two-year period, nor to limit the application of
Sections 10369.2 to 10369.6, inclusive, in the event of misstatement
with respect to age or occupation or other insurance.
Form A.
Time Limit on Certain Defenses: (a) After two years from the date
of issue of this policy, no misstatements, except fraudulent
misstatements, made by the applicant in the application for the
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 the two-year period.
(b) No claim for loss incurred or disability (as defined in the
policy) commencing after two 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.
Form B.
Incontestable: (a) After this policy has been in force for a
period of two 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 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.
10350.3. A disability policy shall contain a provision which shall
be in one of the two forms set forth herein. Form A shall be used in
a policy in which the insurer does not reserve the right to refuse
any renewal. Form B shall be used in a policy in which an insurer
reserves the right to refuse any renewal. The clause in parentheses
may only be added if the policy contains a cancellation provision. In
the blank in each such form shall be inserted a number; not less
than "7" for weekly premium policies, "10" for monthly premium
policies, and "31" for all other policies.
Form A.
Grace Period: A grace period of __ 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 (subject to the
right of the insurer to cancel in accordance with the cancellation
provision hereof).
Form B.
Grace Period: Unless not less than five days prior to the premium
due date the insurer has delivered to the insured or has mailed to
his 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, a grace period of __ 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 (subject to the right of the insurer to cancel in accordance
with the cancellation provision hereof).
10350.4. A disability policy shall contain a provision which shall
be in the form set forth herein. The last sentence of such provision
may be omitted from a noncancellable policy.
Reinstatement: If any renewal premium be not paid within the time
granted the insured for payment, a subsequent acceptance of premium
by the insurer or by any agent duly authorized by the insurer to
accept such premium, without requiring in connection therewith an
application for reinstatement, shall reinstate the policy; provided,
however, 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 10 days after such date. In all other respects the
insured and insurer shall have the same rights thereunder 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 60 days prior to the date of reinstatement.
10350.5. A disability policy shall contain a provision which shall
be in one of the two forms set forth herein. Form A may be used in
any policy. Form B may be used by an insurer, at its option, in a
policy providing a loss of time benefit which may be payable for at
least two years. In the blank space of such provision shall be
inserted the location of such office or offices as the insurer may
designate for the purpose of giving notice of claim.
Form A.
Notice of Claim: Written notice of claim must be given to the
insurer within 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 ____, or to any authorized agent of the
insurer, with information sufficient to identify the insured, shall
be deemed notice to the insurer.
Form B.
Notice of Claim: Written notice of claim must be given to the
insurer within 20 days after the occurrence or commencement of any
loss covered by the policy, or as soon thereafter as is reasonably
possible. 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 years, he shall, at least
once in every six 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 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 insured's right to
any indemnity which would otherwise have accrued during the period of
six months preceding the date on which such notice is actually
given. Notice given by or on behalf of the insured or the beneficiary
to the insurer at ____, or to any authorized agent of the insurer,
with information sufficient to identify the insured, shall be deemed
notice to the insurer.
10350.6. A disability policy shall contain a provision which shall
be in the form set forth herein.
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 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.
10350.7. A disability policy shall contain a provision which shall
be in the form set forth herein.
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 90 days after the termination of the period for which the
insurer is liable and in case of claim for any other loss within 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
year from the time proof is otherwise required.
10350.8. A disability policy shall contain a provision which shall
be in the form set forth herein. In the blank of such provision will
be inserted the period for payment which must not be less frequently
than monthly.
Time of Payment of Claim: Indemnities payable under this policy
for any loss other than loss for which this policy provides any
periodic payment will be paid immediately upon receipt of due written
proof of such loss. Subject to due written proof of loss, all
accrued indemnities for loss for which this policy provides periodic
payment will be paid ____ and any balance remaining unpaid upon the
termination of liability will be paid immediately upon receipt of due
written proof.
10350.9. A disability policy shall contain a provision which shall
include the following first paragraph and which may, at the option of
the insurer, include either or both of the following second and
third paragraphs. If the provision contains the second paragraph,
there shall be inserted in the blank an amount which shall not exceed
one thousand dollars ($1,000).
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.
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 $____, 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 that
loss, be paid directly to the person or persons having paid for the
hospitalization or medical or surgical aid, or to the hospital or
person rendering those services; but it is not required that the
service be rendered by a particular hospital or person.
10350.10. A disability policy shall contain a provision which shall
be in the form set forth herein.
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.
10350.11. A disability policy shall contain a provision which shall
be in the form set forth herein.
Legal Actions: No action at law or in equity shall be brought to
recover on this policy prior to the expiration of 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 years after the time written proof of loss is
required to be furnished.
10350.12. A disability policy shall contain a provision which shall
be in the form set forth herein. At the insurer's option, the clause
of such provision which precedes the first comma may be omitted.
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.
10351. Each policy of disability insurance issued or renewed on or
after the effective date of this section, shall provide, where
feasible, that benefits for confinement in an extended care facility,
as defined in subsection (j) of Section 1395x of Title 42 of the
United States Code, may be provided under such terms and conditions
as may be agreed upon between the insured, or group policyholder, and
the insurer.
Nothing in this section shall preclude a disability insurance
policy from providing benefits for confinement in institutions other
than extended care facilities as defined in this section.
10352. (a) Every policy of disability insurance issued, amended, or
renewed on and after January 1, 1987, that offers coverage for
medical transportation services, shall contain a provision providing
for direct reimbursement to any provider of covered medical
transportation services if the provider has not received payment for
those services from any other source.
(b) Subdivision (a) shall not apply to any transaction between a
provider of medical transportation services and the insurer under a
disability insurance policy if the parties have entered into a
contract providing for direct payment.
(c) For purposes of this subdivision, "direct reimbursement" means
the following:
The insured shall file a claim for the medical transportation
service with the insurer; the insurer shall pay the medical
transportation provider directly; and the medical transportation
provider shall not demand payment from the insured until having
received payment from the insurer, at which time the medical
transportation provider may demand payment from the insured for any
unpaid portion of the provider's fee.
10353. (a) Every policy of disability insurance issued, amended, or
renewed on or after January 1, 1992, that offers coverage for
perinatal services shall contain a provision providing for direct
reimbursement to certified nurse-midwives and nurse practitioners for
perinatal services. The certified nurse-midwife or nurse
practitioner may collect payment for any unpaid portion of his or her
fee, as provided for under the plan for other providers.
(b) For purposes of this section, "direct reimbursement" means
that after the enrollee files a claim for the perinatal service
provided by the certified nurse-midwife or nurse practitioner, the
plan pays the certified nurse-midwife or nurse practitioner directly.
10354. (a) (1) Every policy of disability insurance issued,
amended, or renewed on or after January 1, 1994, that offers coverage
for perinatal services shall contain a provision for direct
reimbursement to licensed midwives for perinatal services rendered
under terms and conditions as may be agreed upon between the
policyholder and the insurer.
(2) The licensed midwife may collect payment for any unpaid
portion of his or her fee, as provided under the policy for other
providers.
(3) Reasonable consideration shall be given to licensed midwives
by disability insurers contracting for services at alternative rates.
For the purposes of this section, "reasonable consideration" shall
have the meaning provided in Section 10180.
(b) For purposes of this section, "direct reimbursement" means
that after the policyholder files a claim for the perinatal service
provided under those terms and conditions as may be agreed upon
between the policyholder and the insurer, the insurer pays the
licensed midwife directly.
10350. Except as provided in Section 10323, each disability policy
delivered or issued for delivery to any person in this State shall
contain the provisions specified in Sections 10350.1 to 10350.12,
inclusive, in the words in which the same appear in such sections;
provided, however, that the insurer may, at its option, substitute
for one or more of such provisions corresponding provisions of
different wording approved by the commissioner which are in each
instance not less favorable in any respect to the insured or the
beneficiary. Such provisions shall be preceded individually by the
caption appearing in each section or, at the option of the insurer,
by such appropriate individual or group captions or subcaptions as
the commissioner may approve.
10350.1. A disability policy shall contain a provision which shall
be in the form set forth herein.
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 agent has authority to change
this policy or to waive any of its provisions.
10350.2. A disability policy shall contain a provision that shall
be in one of the two forms set forth in this section. Policies other
than noncancellable policies shall use Form A. Noncancellable
policies shall use either Form A or Form B. In Form B, the clause in
parentheses in paragraph (a) may be omitted at the insurer's option.
Paragraph (a) in Form A shall not be so construed as to affect any
legal requirement for avoidance of a policy or denial of a claim
during the initial two-year period, nor to limit the application of
Sections 10369.2 to 10369.6, inclusive, in the event of misstatement
with respect to age or occupation or other insurance.
Form A.
Time Limit on Certain Defenses: (a) After two years from the date
of issue of this policy, no misstatements, except fraudulent
misstatements, made by the applicant in the application for the
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 the two-year period.
(b) No claim for loss incurred or disability (as defined in the
policy) commencing after two 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.
Form B.
Incontestable: (a) After this policy has been in force for a
period of two 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 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.
10350.3. A disability policy shall contain a provision which shall
be in one of the two forms set forth herein. Form A shall be used in
a policy in which the insurer does not reserve the right to refuse
any renewal. Form B shall be used in a policy in which an insurer
reserves the right to refuse any renewal. The clause in parentheses
may only be added if the policy contains a cancellation provision. In
the blank in each such form shall be inserted a number; not less
than "7" for weekly premium policies, "10" for monthly premium
policies, and "31" for all other policies.
Form A.
Grace Period: A grace period of __ 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 (subject to the
right of the insurer to cancel in accordance with the cancellation
provision hereof).
Form B.
Grace Period: Unless not less than five days prior to the premium
due date the insurer has delivered to the insured or has mailed to
his 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, a grace period of __ 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 (subject to the right of the insurer to cancel in accordance
with the cancellation provision hereof).
10350.4. A disability policy shall contain a provision which shall
be in the form set forth herein. The last sentence of such provision
may be omitted from a noncancellable policy.
Reinstatement: If any renewal premium be not paid within the time
granted the insured for payment, a subsequent acceptance of premium
by the insurer or by any agent duly authorized by the insurer to
accept such premium, without requiring in connection therewith an
application for reinstatement, shall reinstate the policy; provided,
however, 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 10 days after such date. In all other respects the
insured and insurer shall have the same rights thereunder 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 60 days prior to the date of reinstatement.
10350.5. A disability policy shall contain a provision which shall
be in one of the two forms set forth herein. Form A may be used in
any policy. Form B may be used by an insurer, at its option, in a
policy providing a loss of time benefit which may be payable for at
least two years. In the blank space of such provision shall be
inserted the location of such office or offices as the insurer may
designate for the purpose of giving notice of claim.
Form A.
Notice of Claim: Written notice of claim must be given to the
insurer within 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 ____, or to any authorized agent of the
insurer, with information sufficient to identify the insured, shall
be deemed notice to the insurer.
Form B.
Notice of Claim: Written notice of claim must be given to the
insurer within 20 days after the occurrence or commencement of any
loss covered by the policy, or as soon thereafter as is reasonably
possible. 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 years, he shall, at least
once in every six 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 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 insured's right to
any indemnity which would otherwise have accrued during the period of
six months preceding the date on which such notice is actually
given. Notice given by or on behalf of the insured or the beneficiary
to the insurer at ____, or to any authorized agent of the insurer,
with information sufficient to identify the insured, shall be deemed
notice to the insurer.
10350.6. A disability policy shall contain a provision which shall
be in the form set forth herein.
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 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.
10350.7. A disability policy shall contain a provision which shall
be in the form set forth herein.
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 90 days after the termination of the period for which the
insurer is liable and in case of claim for any other loss within 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
year from the time proof is otherwise required.
10350.8. A disability policy shall contain a provision which shall
be in the form set forth herein. In the blank of such provision will
be inserted the period for payment which must not be less frequently
than monthly.
Time of Payment of Claim: Indemnities payable under this policy
for any loss other than loss for which this policy provides any
periodic payment will be paid immediately upon receipt of due written
proof of such loss. Subject to due written proof of loss, all
accrued indemnities for loss for which this policy provides periodic
payment will be paid ____ and any balance remaining unpaid upon the
termination of liability will be paid immediately upon receipt of due
written proof.
10350.9. A disability policy shall contain a provision which shall
include the following first paragraph and which may, at the option of
the insurer, include either or both of the following second and
third paragraphs. If the provision contains the second paragraph,
there shall be inserted in the blank an amount which shall not exceed
one thousand dollars ($1,000).
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.
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 $____, 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 that
loss, be paid directly to the person or persons having paid for the
hospitalization or medical or surgical aid, or to the hospital or
person rendering those services; but it is not required that the
service be rendered by a particular hospital or person.
10350.10. A disability policy shall contain a provision which shall
be in the form set forth herein.
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.
10350.11. A disability policy shall contain a provision which shall
be in the form set forth herein.
Legal Actions: No action at law or in equity shall be brought to
recover on this policy prior to the expiration of 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 years after the time written proof of loss is
required to be furnished.
10350.12. A disability policy shall contain a provision which shall
be in the form set forth herein. At the insurer's option, the clause
of such provision which precedes the first comma may be omitted.
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.
10351. Each policy of disability insurance issued or renewed on or
after the effective date of this section, shall provide, where
feasible, that benefits for confinement in an extended care facility,
as defined in subsection (j) of Section 1395x of Title 42 of the
United States Code, may be provided under such terms and conditions
as may be agreed upon between the insured, or group policyholder, and
the insurer.
Nothing in this section shall preclude a disability insurance
policy from providing benefits for confinement in institutions other
than extended care facilities as defined in this section.
10352. (a) Every policy of disability insurance issued, amended, or
renewed on and after January 1, 1987, that offers coverage for
medical transportation services, shall contain a provision providing
for direct reimbursement to any provider of covered medical
transportation services if the provider has not received payment for
those services from any other source.
(b) Subdivision (a) shall not apply to any transaction between a
provider of medical transportation services and the insurer under a
disability insurance policy if the parties have entered into a
contract providing for direct payment.
(c) For purposes of this subdivision, "direct reimbursement" means
the following:
The insured shall file a claim for the medical transportation
service with the insurer; the insurer shall pay the medical
transportation provider directly; and the medical transportation
provider shall not demand payment from the insured until having
received payment from the insurer, at which time the medical
transportation provider may demand payment from the insured for any
unpaid portion of the provider's fee.
10353. (a) Every policy of disability insurance issued, amended, or
renewed on or after January 1, 1992, that offers coverage for
perinatal services shall contain a provision providing for direct
reimbursement to certified nurse-midwives and nurse practitioners for
perinatal services. The certified nurse-midwife or nurse
practitioner may collect payment for any unpaid portion of his or her
fee, as provided for under the plan for other providers.
(b) For purposes of this section, "direct reimbursement" means
that after the enrollee files a claim for the perinatal service
provided by the certified nurse-midwife or nurse practitioner, the
plan pays the certified nurse-midwife or nurse practitioner directly.
10354. (a) (1) Every policy of disability insurance issued,
amended, or renewed on or after January 1, 1994, that offers coverage
for perinatal services shall contain a provision for direct
reimbursement to licensed midwives for perinatal services rendered
under terms and conditions as may be agreed upon between the
policyholder and the insurer.
(2) The licensed midwife may collect payment for any unpaid
portion of his or her fee, as provided under the policy for other
providers.
(3) Reasonable consideration shall be given to licensed midwives
by disability insurers contracting for services at alternative rates.
For the purposes of this section, "reasonable consideration" shall
have the meaning provided in Section 10180.
(b) For purposes of this section, "direct reimbursement" means
that after the policyholder files a claim for the perinatal service
provided under those terms and conditions as may be agreed upon
between the policyholder and the insurer, the insurer pays the
licensed midwife directly.
10350. Except as provided in Section 10323, each disability policy
delivered or issued for delivery to any person in this State shall
contain the provisions specified in Sections 10350.1 to 10350.12,
inclusive, in the words in which the same appear in such sections;
provided, however, that the insurer may, at its option, substitute
for one or more of such provisions corresponding provisions of
different wording approved by the commissioner which are in each
instance not less favorable in any respect to the insured or the
beneficiary. Such provisions shall be preceded individually by the
caption appearing in each section or, at the option of the insurer,
by such appropriate individual or group captions or subcaptions as
the commissioner may approve.
10350.1. A disability policy shall contain a provision which shall
be in the form set forth herein.
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 agent has authority to change
this policy or to waive any of its provisions.
10350.2. A disability policy shall contain a provision that shall
be in one of the two forms set forth in this section. Policies other
than noncancellable policies shall use Form A. Noncancellable
policies shall use either Form A or Form B. In Form B, the clause in
parentheses in paragraph (a) may be omitted at the insurer's option.
Paragraph (a) in Form A shall not be so construed as to affect any
legal requirement for avoidance of a policy or denial of a claim
during the initial two-year period, nor to limit the application of
Sections 10369.2 to 10369.6, inclusive, in the event of misstatement
with respect to age or occupation or other insurance.
Form A.
Time Limit on Certain Defenses: (a) After two years from the date
of issue of this policy, no misstatements, except fraudulent
misstatements, made by the applicant in the application for the
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 the two-year period.
(b) No claim for loss incurred or disability (as defined in the
policy) commencing after two 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.
Form B.
Incontestable: (a) After this policy has been in force for a
period of two 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 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.
10350.3. A disability policy shall contain a provision which shall
be in one of the two forms set forth herein. Form A shall be used in
a policy in which the insurer does not reserve the right to refuse
any renewal. Form B shall be used in a policy in which an insurer
reserves the right to refuse any renewal. The clause in parentheses
may only be added if the policy contains a cancellation provision. In
the blank in each such form shall be inserted a number; not less
than "7" for weekly premium policies, "10" for monthly premium
policies, and "31" for all other policies.
Form A.
Grace Period: A grace period of __ 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 (subject to the
right of the insurer to cancel in accordance with the cancellation
provision hereof).
Form B.
Grace Period: Unless not less than five days prior to the premium
due date the insurer has delivered to the insured or has mailed to
his 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, a grace period of __ 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 (subject to the right of the insurer to cancel in accordance
with the cancellation provision hereof).
10350.4. A disability policy shall contain a provision which shall
be in the form set forth herein. The last sentence of such provision
may be omitted from a noncancellable policy.
Reinstatement: If any renewal premium be not paid within the time
granted the insured for payment, a subsequent acceptance of premium
by the insurer or by any agent duly authorized by the insurer to
accept such premium, without requiring in connection therewith an
application for reinstatement, shall reinstate the policy; provided,
however, 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 10 days after such date. In all other respects the
insured and insurer shall have the same rights thereunder 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 60 days prior to the date of reinstatement.
10350.5. A disability policy shall contain a provision which shall
be in one of the two forms set forth herein. Form A may be used in
any policy. Form B may be used by an insurer, at its option, in a
policy providing a loss of time benefit which may be payable for at
least two years. In the blank space of such provision shall be
inserted the location of such office or offices as the insurer may
designate for the purpose of giving notice of claim.
Form A.
Notice of Claim: Written notice of claim must be given to the
insurer within 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 ____, or to any authorized agent of the
insurer, with information sufficient to identify the insured, shall
be deemed notice to the insurer.
Form B.
Notice of Claim: Written notice of claim must be given to the
insurer within 20 days after the occurrence or commencement of any
loss covered by the policy, or as soon thereafter as is reasonably
possible. 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 years, he shall, at least
once in every six 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 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 insured's right to
any indemnity which would otherwise have accrued during the period of
six months preceding the date on which such notice is actually
given. Notice given by or on behalf of the insured or the beneficiary
to the insurer at ____, or to any authorized agent of the insurer,
with information sufficient to identify the insured, shall be deemed
notice to the insurer.
10350.6. A disability policy shall contain a provision which shall
be in the form set forth herein.
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 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.
10350.7. A disability policy shall contain a provision which shall
be in the form set forth herein.
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 90 days after the termination of the period for which the
insurer is liable and in case of claim for any other loss within 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
year from the time proof is otherwise required.
10350.8. A disability policy shall contain a provision which shall
be in the form set forth herein. In the blank of such provision will
be inserted the period for payment which must not be less frequently
than monthly.
Time of Payment of Claim: Indemnities payable under this policy
for any loss other than loss for which this policy provides any
periodic payment will be paid immediately upon receipt of due written
proof of such loss. Subject to due written proof of loss, all
accrued indemnities for loss for which this policy provides periodic
payment will be paid ____ and any balance remaining unpaid upon the
termination of liability will be paid immediately upon receipt of due
written proof.
10350.9. A disability policy shall contain a provision which shall
include the following first paragraph and which may, at the option of
the insurer, include either or both of the following second and
third paragraphs. If the provision contains the second paragraph,
there shall be inserted in the blank an amount which shall not exceed
one thousand dollars ($1,000).
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.
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 $____, 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 that
loss, be paid directly to the person or persons having paid for the
hospitalization or medical or surgical aid, or to the hospital or
person rendering those services; but it is not required that the
service be rendered by a particular hospital or person.
10350.10. A disability policy shall contain a provision which shall
be in the form set forth herein.
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.
10350.11. A disability policy shall contain a provision which shall
be in the form set forth herein.
Legal Actions: No action at law or in equity shall be brought to
recover on this policy prior to the expiration of 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 years after the time written proof of loss is
required to be furnished.
10350.12. A disability policy shall contain a provision which shall
be in the form set forth herein. At the insurer's option, the clause
of such provision which precedes the first comma may be omitted.
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.
10351. Each policy of disability insurance issued or renewed on or
after the effective date of this section, shall provide, where
feasible, that benefits for confinement in an extended care facility,
as defined in subsection (j) of Section 1395x of Title 42 of the
United States Code, may be provided under such terms and conditions
as may be agreed upon between the insured, or group policyholder, and
the insurer.
Nothing in this section shall preclude a disability insurance
policy from providing benefits for confinement in institutions other
than extended care facilities as defined in this section.
10352. (a) Every policy of disability insurance issued, amended, or
renewed on and after January 1, 1987, that offers coverage for
medical transportation services, shall contain a provision providing
for direct reimbursement to any provider of covered medical
transportation services if the provider has not received payment for
those services from any other source.
(b) Subdivision (a) shall not apply to any transaction between a
provider of medical transportation services and the insurer under a
disability insurance policy if the parties have entered into a
contract providing for direct payment.
(c) For purposes of this subdivision, "direct reimbursement" means
the following:
The insured shall file a claim for the medical transportation
service with the insurer; the insurer shall pay the medical
transportation provider directly; and the medical transportation
provider shall not demand payment from the insured until having
received payment from the insurer, at which time the medical
transportation provider may demand payment from the insured for any
unpaid portion of the provider's fee.
10353. (a) Every policy of disability insurance issued, amended, or
renewed on or after January 1, 1992, that offers coverage for
perinatal services shall contain a provision providing for direct
reimbursement to certified nurse-midwives and nurse practitioners for
perinatal services. The certified nurse-midwife or nurse
practitioner may collect payment for any unpaid portion of his or her
fee, as provided for under the plan for other providers.
(b) For purposes of this section, "direct reimbursement" means
that after the enrollee files a claim for the perinatal service
provided by the certified nurse-midwife or nurse practitioner, the
plan pays the certified nurse-midwife or nurse practitioner directly.
10354. (a) (1) Every policy of disability insurance issued,
amended, or renewed on or after January 1, 1994, that offers coverage
for perinatal services shall contain a provision for direct
reimbursement to licensed midwives for perinatal services rendered
under terms and conditions as may be agreed upon between the
policyholder and the insurer.
(2) The licensed midwife may collect payment for any unpaid
portion of his or her fee, as provided under the policy for other
providers.
(3) Reasonable consideration shall be given to licensed midwives
by disability insurers contracting for services at alternative rates.
For the purposes of this section, "reasonable consideration" shall
have the meaning provided in Section 10180.
(b) For purposes of this section, "direct reimbursement" means
that after the policyholder files a claim for the perinatal service
provided under those terms and conditions as may be agreed upon
between the policyholder and the insurer, the insurer pays the
licensed midwife directly.
