CHAPTER 5. ACCIDENT AND SICKNESS INSURANCE.POLICY PROVISIONS
IC 27-8-5
Chapter 5. Accident and Sickness Insurance.Policy Provisions
IC 27-8-5-1
Policy of accident and sickness insurance; filing; review
Sec. 1. (a) The term "policy of accident and sickness insurance",as used in this chapter, includes any policy or contract covering one(1) or more of the kinds of insurance described in Class 1(b) or 2(a)of IC 27-1-5-1. Such policies may be on the individual basis underthis section and sections 2 through 9 of this chapter, on the groupbasis under this section and sections 16 through 19 of this chapter,on the franchise basis under this section and section 11 of thischapter, or on a blanket basis under section 15 of this chapter and(except as otherwise expressly provided in this chapter) shall beexclusively governed by this chapter.
(b) No policy of accident and sickness insurance may be issued ordelivered to any person in this state, nor may any application, rider,or endorsement be used in connection with an accident and sicknessinsurance policy, until a copy of the form of the policy and of theclassification of risks and the premium rates, or, in the case ofassessment companies, the estimated cost pertaining thereto, havebeen filed with and reviewed by the commissioner under section 1.5of this chapter. This section is applicable also to assessmentcompanies and fraternal benefit associations or societies.
(Formerly: Acts 1953, c.15, s.169.1; Acts 1975, P.L.281, SEC.1.) Asamended by P.L.257-1985, SEC.1; P.L.7-1987, SEC.154;P.L.173-2007, SEC.21.
IC 27-8-5-1.5
Filing, review, approval, and disapproval process
Sec. 1.5. (a) This section applies to a policy of accident andsickness insurance issued on an individual, a group, a franchise, ora blanket basis, including a policy issued by an assessment companyor a fraternal benefit society.
(b) As used in this section, "commissioner" refers to the insurancecommissioner appointed under IC 27-1-1-2.
(c) As used in this section, "grossly inadequate filing" means apolicy form filing:
(1) that fails to provide key information, including state specificinformation, regarding a product, policy, or rate; or
(2) that demonstrates an insufficient understanding ofapplicable legal requirements.
(d) As used in this section, "policy form" means a policy, acontract, a certificate, a rider, an endorsement, an evidence ofcoverage, or any amendment that is required by law to be filed withthe commissioner for approval before use in Indiana.
(e) As used in this section, "type of insurance" refers to a type ofcoverage listed on the National Association of InsuranceCommissioners Uniform Life, Accident and Health, Annuity andCredit Product Coding Matrix, or a successor document, under the
heading "Continuing Care Retirement Communities", "Health","Long Term Care", or "Medicare Supplement".
(f) Each person having a role in the filing process described insubsection (i) shall act in good faith and with due diligence in theperformance of the person's duties.
(g) A policy form may not be issued or delivered in Indiana unlessthe policy form has been filed with and approved by thecommissioner.
(h) The commissioner shall do the following:
(1) Create a document containing a list of all product filingrequirements for each type of insurance, with appropriatecitations to the law, administrative rule, or bulletin thatspecifies the requirement, including the citation for the type ofinsurance to which the requirement applies.
(2) Make the document described in subdivision (1) availableon the department of insurance Internet site.
(3) Update the document described in subdivision (1) at leastannually and not more than thirty (30) days following anychange in a filing requirement.
(i) The filing process is as follows:
(1) A filer shall submit a policy form filing that:
(A) includes a copy of the document described in subsection(h);
(B) indicates the location within the policy form orsupplement that relates to each requirement contained in thedocument described in subsection (h); and
(C) certifies that the policy form meets all requirements ofstate law.
(2) The commissioner shall review a policy form filing and, notmore than thirty (30) days after the commissioner receives thefiling under subdivision (1):
(A) approve the filing; or
(B) provide written notice of a determination:
(i) that deficiencies exist in the filing; or
(ii) that the commissioner disapproves the filing.
A written notice provided by the commissioner under clause (B)must be based only on the requirements set forth in thedocument described in subsection (h) and must cite the specificrequirements not met by the filing. A written notice provided bythe commissioner under clause (B)(i) must state the reasons forthe commissioner's determination in sufficient detail to enablethe filer to bring the policy form into compliance with therequirements not met by the filing.
(3) A filer may resubmit a policy form that:
(A) was determined deficient under subdivision (2) and hasbeen amended to correct the deficiencies; or
(B) was disapproved under subdivision (2) and has beenrevised.
A policy form resubmitted under this subdivision must meet therequirements set forth as described in subdivision (1) and must
be resubmitted not more than thirty (30) days after the filerreceives the commissioner's written notice of deficiency ordisapproval. If a policy form is not resubmitted within thirty(30) days after receipt of the written notice, the commissioner'sdetermination regarding the policy form is final.
(4) The commissioner shall review a policy form filingresubmitted under subdivision (3) and, not more than thirty (30)days after the commissioner receives the resubmission:
(A) approve the resubmitted policy form; or
(B) provide written notice that the commissionerdisapproves the resubmitted policy form.
A written notice of disapproval provided by the commissionerunder clause (B) must be based only on the requirements setforth in the document described in subsection (h), must cite thespecific requirements not met by the filing, and must state thereasons for the commissioner's determination in detail. Thecommissioner's approval or disapproval of a resubmitted policyform under this subdivision is final, except that thecommissioner may allow the filer to resubmit a further revisedpolicy form if the filer, in the filer's resubmission undersubdivision (3), introduced new provisions or materiallymodified a substantive provision of the policy form. If thecommissioner allows a filer to resubmit a further revised policyform under this subdivision, the filer must resubmit the furtherrevised policy form not more than thirty (30) days after the filerreceives notice under clause (B), and the commissioner shallissue a final determination on the further revised policy formnot more than thirty (30) days after the commissioner receivesthe further revised policy form.
(5) If the commissioner disapproves a policy form filing underthis subsection, the commissioner shall notify the filer, inwriting, of the filer's right to a hearing as described insubsection (m). A disapproved policy form filing may not beused for a policy of accident and sickness insurance unless thedisapproval is overturned in a hearing conducted under thissubsection.
(6) If the commissioner does not take any action on a policyform that is filed or resubmitted under this subsection inaccordance with any applicable period specified in subdivision(2), (3), or (4), the policy form filing is considered to beapproved.
(j) Except as provided in this subsection, the commissioner maynot disapprove a policy form resubmitted under subsection (i)(3) or(i)(4) for a reason other than a reason specified in the original noticeof determination under subsection (i)(2)(B). The commissioner maydisapprove a resubmitted policy form for a reason other than a reasonspecified in the original notice of determination under subsection(i)(2) if:
(1) the filer has introduced a new provision in the resubmission;
(2) the filer has materially modified a substantive provision of
the policy form in the resubmission;
(3) there has been a change in requirements applying to thepolicy form; or
(4) there has been reviewer error and the written disapprovalfails to state a specific requirement with which the policy formdoes not comply.
(k) The commissioner may return a grossly inadequate filing tothe filer without triggering a deadline set forth in this section.
(l) The commissioner may disapprove a policy form if:
(1) the benefits provided under the policy form are notreasonable in relation to the premium charged; or
(2) the policy form contains provisions that are unjust, unfair,inequitable, misleading, or deceptive, or that encouragemisrepresentation of the policy.
(m) Upon disapproval of a filing under this section, thecommissioner shall provide written notice to the filer or insurer ofthe right to a hearing within twenty (20) days of a request for ahearing.
(n) Unless a policy form approved under this chapter contains amaterial error or omission, the commissioner may not:
(1) retroactively disapprove the policy form; or
(2) examine the filer of the policy form during a routine ortargeted market conduct examination for compliance with apolicy form filing requirement that was not in existence at thetime the policy form was filed.
As added by P.L.173-2007, SEC.22. Amended by P.L.111-2008,SEC.3.
IC 27-8-5-2
Requirements for issuance and delivery of policy
Sec. 2. (a) No individual policy of accident and sickness insuranceshall be delivered or issued for delivery to any person in this stateunless it complies with each of the following:
(1) The entire money and other considerations for the policy areexpressed in the policy.
(2) The time at which the insurance takes effect and terminatesis expressed in the policy.
(3) The policy purports to insure only one (1) person, exceptthat a policy must insure, originally or by subsequentamendment, upon the application of any member of a familywho shall be deemed the policyholder and who is at leasteighteen (18) years of age, any two (2) or more eligiblemembers of that family, including husband, wife, dependentchildren, or any children who are less than twenty-four (24)years of age, and any other person dependent upon thepolicyholder.
(4) The style, arrangement, and overall appearance of the policygive no undue prominence to any portion of the text, and unlessevery printed portion of the text of the policy and of anyendorsements or attached papers is plainly printed in lightface
type of a style in general use, the size of which shall be uniformand not less than ten point with a lower-case unspaced alphabetlength not less than one hundred and twenty point (the "text"shall include all printed matter except the name and address ofthe insurer, name or title of the policy, the brief description ifany, and captions and subcaptions).
(5) The exceptions and reductions of indemnity are set forth inthe policy and, except those which are set forth in section 3 ofthis chapter, are printed, at the insurer's option, either includedwith the benefit provision to which they apply, or under anappropriate caption such as "EXCEPTIONS", or"EXCEPTIONS AND REDUCTIONS", provided that if anexception or reduction specifically applies only to a particularbenefit of the policy, a statement of such exception or reductionshall be included with the benefit provision to which it applies.
(6) Each such form of the policy, including riders andendorsements, shall be identified by a form number in the lowerleft-hand corner of the first page of the policy.
(7) The policy contains no provision purporting to make anyportion of the charter, rules, constitution, or bylaws of theinsurer a part of the policy unless such portion is set forth in fullin the policy, except in the case of the incorporation of orreference to a statement of rates or classification of risks, orshort-rate table filed with the commissioner.
(8) If an individual accident and sickness insurance policy orhospital service plan contract or medical service plan contractprovides that hospital or medical expense coverage of adependent child terminates upon attainment of the limiting agefor dependent children specified in such policy or contract, thepolicy or contract must also provide that attainment of suchlimiting age does not operate to terminate the hospital andmedical coverage of such child while the child is and continuesto be both:
(A) incapable of self-sustaining employment by reason ofmental retardation or mental or physical disability; and
(B) chiefly dependent upon the policyholder for support andmaintenance.
Proof of such incapacity and dependency must be furnished tothe insurer by the policyholder within thirty-one (31) days ofthe child's attainment of the limiting age. The insurer mayrequire at reasonable intervals during the two (2) yearsfollowing the child's attainment of the limiting age subsequentproof of the child's disability and dependency. After such two(2) year period, the insurer may require subsequent proof notmore than once each year. The foregoing provision shall notrequire an insurer to insure a dependent who is a child who hasmental retardation or a mental or physical disability where suchdependent does not satisfy the conditions of the policyprovisions as may be stated in the policy or contract requiredfor coverage thereunder to take effect. In any such case the
terms of the policy or contract shall apply with regard to thecoverage or exclusion from coverage of such dependent. Thissubsection applies only to policies or contracts delivered orissued for delivery in this state more than one hundred twenty(120) days after August 18, 1969.
(b) If any policy is issued by an insurer domiciled in this state fordelivery to a person residing in another state, and if the officialhaving responsibility for the administration of the insurance laws ofsuch other state shall have advised the commissioner that any suchpolicy is not subject to approval or disapproval by such official, thecommissioner may by ruling require that such policy meet thestandards set forth in subsection (a) and in section 3 of this chapter.
(c) An insurer may issue a policy described in this section inelectronic or paper form. However, the insurer shall:
(1) inform the insured that the insured may request the policy inpaper form; and
(2) issue the policy in paper form upon the request of theinsured.
(Formerly: Acts 1953, c.15, s.169.2; Acts 1969, c.266, s.1; Acts1973, P.L.275, SEC.3.) As amended by Acts 1977, P.L.2, SEC.79;P.L.23-1993, SEC.153; P.L.207-1999, SEC.3 and P.L.233-1999,SEC.9; P.L.125-2005, SEC.2; P.L.99-2007, SEC.192; P.L.218-2007,SEC.45.
IC 27-8-5-2.5
Coverage under individual, and certain association group, policiesof accident and sickness insurance; waivers
Sec. 2.5. (a) As used in this section, the term "policy of accidentand sickness insurance" does not include the following:
(1) Accident only, credit, dental, vision, Medicare supplement,long term care, or disability income insurance.
(2) Coverage issued as a supplement to liability insurance.
(3) Automobile medical payment insurance.
(4) A specified disease policy.
(5) A short term insurance plan that:
(A) may not be renewed; and
(B) has a duration of not more than six (6) months.
(6) A policy that provides indemnity benefits not based on anyexpense incurred requirement, including a plan that providescoverage for:
(A) hospital confinement, critical illness, or intensive care;or
(B) gaps for deductibles or copayments.
(7) Worker's compensation or similar insurance.
(8) A student health plan.
(9) A supplemental plan that always pays in addition to othercoverage.
(10) An employer sponsored health benefit plan that is:
(A) provided to individuals who are eligible for Medicare;and (B) not marketed as, or held out to be, a Medicaresupplement policy.
(b) The benefits provided by:
(1) an individual policy of accident and sickness insurance; or
(2) a certificate of coverage that is issued under a nonemployerbased association group policy of accident and sicknessinsurance to an individual who is a resident of Indiana;
may not be excluded, limited, or denied for more than twelve (12)months after the effective date of the coverage because of apreexisting condition of the individual.
(c) An individual policy of accident and sickness insurance or acertificate of coverage described in subsection (b) may not define apreexisting condition, a rider, or an endorsement more restrictivelythan as:
(1) a condition that would have caused an ordinarily prudentperson to seek medical advice, diagnosis, care, or treatmentduring the twelve (12) months immediately preceding theeffective date of the plan;
(2) a condition for which medical advice, diagnosis, care, ortreatment was recommended or received during the twelve (12)months immediately preceding the effective date of the plan; or
(3) a pregnancy existing on the effective date of the plan.
(d) An insurer shall reduce the period allowed for a preexistingcondition exclusion described in subsection (b) by the amount oftime the individual has continuously served under a preexistingcondition clause for a policy of accident and sickness insuranceissued under IC 27-8-15 if the individual applies for a policy underthis chapter not more than thirty (30) days after coverage under apolicy of accident and sickness insurance issued under IC 27-8-15expires.
As added by P.L.93-1995, SEC.6. Amended by P.L.190-1996, SEC.1;P.L.211-2003, SEC.2; P.L.127-2006, SEC.1; P.L.173-2007, SEC.23;P.L.3-2008, SEC.212.
IC 27-8-5-2.6
Repealed
(Repealed by P.L.1-2001, SEC.51.)
IC 27-8-5-2.7
Individual policy of accident and sickness insurance; waiver ofcoverage
Sec. 2.7. (a) Notwithstanding section 2.5 of this chapter and anyother law, and except as provided in subsection (b), an individualpolicy of accident and sickness insurance that is issued after June 30,2005, may contain a waiver of coverage for a specified condition andany complications that arise from the specified condition if:
(1) the waiver period does not exceed ten (10) years; and
(2) all the following conditions are met:
(A) The insurer provides to the applicant before issuance ofthe policy written notice explaining the waiver of coverage
for the specified condition and complications arising fromthe specified condition.
(B) The:
(i) offer of coverage; and
(ii) policy;
include the waiver in a separate section stating in bold printthat the applicant is receiving coverage with an exception forthe waived condition.
(C) The:
(i) offer of coverage; and
(ii) policy;
do not include more than two (2) waivers per individual.
(D) The waiver period is concurrent with and not in additionto any applicable preexisting condition limitation orexclusionary period.
(E) The insurer agrees to:
(i) review the underwriting basis for the waiver uponrequest one (1) time per year; and
(ii) remove the waiver if the insurer determines thatevidence of insurability is satisfactory.
(F) The insurer discloses to the applicant that the applicantmay decline the offer of coverage and apply for a policyissued by the Indiana comprehensive health insuranceassociation under IC 27-8-10.
(G) An insurance benefit card issued by the insurer to theapplicant includes a telephone number for verification ofcoverage waived.
The insurer shall require an applicant to initial the written noticeprovided under subdivision (2)(A) and the waiver included in theoffer of coverage and in the policy under subdivision (2)(B) toacknowledge acceptance of the waiver of coverage. An offer ofcoverage under a policy that includes a waiver under this subsectiondoes not preclude eligibility for an Indiana comprehensive healthinsurance association policy under IC 27-8-10-5.1.
(b) An individual policy of accident and sickness insurance maynot include a waiver of coverage for a:
(1) mental health condition; or
(2) developmental disability.
(c) An insurer may not, on the basis of a waiver contained in apolicy as provided in subsection (a), deny coverage for any conditionor complication that is not specified as required in the:
(1) written notice under subsection (a)(2)(A); and
(2) offer of coverage and policy under subsection (a)(2)(B).
(d) An insurer that removes a waiver under subsection (a)(2)(E)shall not consider the condition or any complication to which thewaiver previously applied in making policy renewal andunderwriting determinations.
(e) Upon the expiration of the waiver period allowed under thissection, the insurer shall:
(1) remove the waiver; (2) not consider the condition or any complication to which thewaiver previously applied in making policy underwritingdeterminations; and
(3) renew the policy in accordance with 45 CFR 148.122.
As added by P.L.211-2005, SEC.1.
IC 27-8-5-3
Required provisions; statutory option provisions; inapplicable orinconsistent provisions; order of provisions; third partyownership; requirements of other jurisdictions; filing procedure
Sec. 3. (a) Except as provided in subsection (c), each policydelivered or issued for delivery to any person in this state shallcontain the provisions specified in this subsection in the words inwhich the same appear in this section. However, the insurer may, atits option, substitute for one (1) or more of the provisionscorresponding provisions of different wording approved by thecommissioner that are in each instance no less favorable in anyrespect to the insured or the beneficiary. The provisions shall bepreceded individually by the caption appearing in this subsection or,at the option of the insurer, by appropriate individual or groupcaptions or subcaptions as the commissioner may approve.
(1) A provision as follows: ENTIRE CONTRACT; CHANGES:This policy, including the endorsements and the attached papers, ifany, constitutes the entire contract of insurance. No change in thispolicy shall be valid until approved by an executive officer of theinsurer and unless such approval be endorsed hereon or attachedhereto. No insurance producer has authority to change this policy orto waive any of its provisions.
(2) A provision as follows: TIME LIMIT ON CERTAINDEFENSES: (A) After two (2) years from the date of issue of thispolicy no misstatements, except fraudulent misstatements, made bythe applicant in the application for such policy shall be used to voidthe policy or to deny a claim for loss incurred or disability (asdefined in the policy) commencing after the expiration of such two(2) year period.
The foregoing policy provision shall not be so construed as toaffect any legal requirement for avoidance of a policy of denial of aclaim during such initial two (2) year period, nor to limit theapplication of subsection (b), (1), (2), (3), (4), and (5) in the event ofmisstatement with respect to age or occupation or other insurance.
A policy which the insured has the right to continue in forcesubject to its terms by the timely payment of premium:
(1) until at least age fifty (50); or
(2) in the case of a policy issued after forty-four (44) years ofage, for at least five (5) years from its date of issue;
may contain in lieu of the foregoing the following provision (fromwhich the clause in parentheses may be omitted at the insurer'soption) under the caption "INCONTESTABLE": After this policyhas been in force for a period of two (2) years during the lifetime ofthe insured (excluding any period during which the insured is
disabled), it shall become incontestable as to the statementscontained in the application.
(B) No claim for loss incurred or disability (as defined in thepolicy) commencing after two (2) years from the date of issue of thispolicy shall be reduced or denied on the ground that a disease orphysical condition, not excluded from coverage by name or specificdescription effective on the date of loss, had existed prior to theeffective date of coverage of this policy.
(3) A provision as follows: GRACE PERIOD: A grace period of(insert a number not less than "7" for weekly premium policies, "10"for monthly premium policies and "31" for all other policies) dayswill be granted for the payment of each premium falling due after thefirst premium, during which grace period the policy shall continue inforce.
A policy in which the insurer reserves the right to refuse renewalshall have, at the beginning of the above provision: "Unless not lessthan thirty (30) days prior to the premium due date the insurer hasdelivered to the insured or has mailed to the insured's last address asshown by the records of the insurer written notice of its intention notto renew this policy beyond the period for which the premium hasbeen accepted.".
Each policy in which the insurer reserves the right to refuserenewal on an individual basis shall provide, in substance, in aprovision of the policy, in an endorsement on the policy, or in a riderattached to the policy, that subject to the right to terminate the policyupon non-payment of premium when due, such right to refuserenewal shall not be exercised before the renewal date occurring on,or after and nearest, each anniversary, or in the case of lapse andreinstatement at the renewal date occurring on, or after and nearest,each anniversary of the last reinstatement, and that any refusal orrenewal shall be without prejudice to any claim originating while thepolicy is in force. The preceding sentence shall not apply to accidentinsurance only policies.
(4) A provision as follows: REINSTATEMENT: If any renewalpremium is not paid within the time granted the insured for payment,a subsequent acceptance of premium by the insurer or by any agentauthorized by the insurer to accept such premium, without requiringin connection therewith an application for reinstatement, shallreinstate the policy. Provided, that if the insurer or such agentrequires an application for reinstatement and issues a conditionalreceipt for the premium tendered, the policy will be reinstated uponapproval of such application by the insurer or, lacking such approval,upon the forty-fifth day following the date of such conditional receiptunless the insurer has previously notified the insured in writing of itsdisapproval of such application. The reinstated policy shall coveronly loss resulting from such accidental injury as may be sustainedafter the date of reinstatement and loss due to such sickness as maybegin more than ten (10) days after such date. In all other respectsthe insured and insurer shall have the same rights as they had underthe policy immediately before the due date of the defaulted premium,
subject to any provisions endorsed hereon or attached hereto inconnection with the reinstatement. Any premium accepted inconnection with a reinstatement shall be applied to a period forwhich premium has not been previously paid, but not to any periodmore than sixty (60) days prior to the date of reinstatement.
The last sentence of the above provision may be omitted from anypolicy which the insured has the right to continue in force subject toits terms by the timely payment of premiums:
(1) until at least fifty (50) years of age; or
(2) in the case of a policy issued after forty-four (44) years ofage, for at least five (5) years from its date of issue.
(5) A provision as follows: NOTICE OF CLAIM: Written noticeof claim must be given to the insurer within twenty (20) days afterthe occurrence or commencement of any loss covered by the policy,or as soon thereafter as is reasonably possible. Notice given by or onbehalf of the insured or the beneficiary to the insurer at _______(insert the location of such office as the insurer may designate for thepurpose), or to any authorized agent of the insurer, with informationsufficient to identify the insured, shall be deemed notice to theinsurer.
In a policy providing a loss-of-time benefit which may be payablefor at least two (2) years, an insurer may insert the following betweenthe first and second sentences of the above provision:
Subject to the qualifications set forth below, if the insured suffersloss of time on account of disability for which indemnity may bepayable for at least two (2) years, the insured shall, at least once inevery six (6) months after having given notice of claim, give to theinsurer notice of continuance of said disability, except in the eventof legal incapacity. The period of six (6) months following any filingof proof by the insured or any payment by the insurer on account ofsuch claim or any denial of liability in whole or in part by the insurershall be excluded in applying this provision. Delay in the giving ofsuch notice shall not impair the insurer's right to any indemnitywhich would otherwise have accrued during the period of six (6)months preceding the date on which such notice is actually given.
(6) A provision as follows: CLAIM FORMS: The insurer, uponreceipt of a notice of claim, will furnish to the claimant such formsas are usually furnished by it for filing proofs of loss. If such formsare not furnished within fifteen (15) days after the giving of suchnotice, the claimant shall be deemed to have complied with therequirements of this policy as to proof of loss upon submitting,within the time fixed in the policy for filing proofs of loss, writtenproof covering the occurrence, the character, and the extent of theloss for which claim is made.
(7) A provision as follows: PROOFS OF LOSS: Written proof ofloss must be furnished to the insurer at its said office in case of claimfor loss for which this policy provides any periodic paymentcontingent upon continuing loss within ninety (90) days after thetermination of the period for which the insurer is liable and in caseof claim for any other loss within ninety (90) days after the date of
such loss. Failure to furnish such proof within the time required shallnot invalidate nor reduce any claim if it was not reasonably possibleto give proof within such time, provided such proof is furnished assoon as reasonably possible and in no event, except in the absence oflegal capacity, later than one (1) year from the time proof isotherwise required.
(8) A provision as follows: TIME OF PAYMENT OF CLAIMS:Indemnities payable under this policy for any loss other than loss forwhich this policy provides any periodic payment will be paid:
(1) immediately upon receipt of due written proof of such loss;or
(2) in accordance with IC 27-8-5.7;
whichever is more favorable to the policyholder. Subject to duewritten proof of loss, all accrued indemnities for loss for which thispolicy provides periodic payment will be paid _______ (insert periodfor payment which must not be less frequently than monthly) and anybalance remaining unpaid upon the termination of liability will bepaid immediately upon receipt of due written proof. This provisionmust reflect compliance with IC 27-8-5.7.
(9) A provision as follows: PAYMENT OF CLAIMS: Indemnityfor loss of life will be payable in accordance with the beneficiarydesignation and the provisions respecting such payment which maybe prescribed herein and effective at the time of payment. If no suchdesignation or provision is then effective, such indemnity shall bepayable to the estate of the insured. Any other accrued indemnitiesunpaid at the insured's death may, at the option of the insurer, be paideither to such beneficiary or to such estate. All other indemnities willbe payable to the insured.
The following provisions, or either of them, may be included withthe foregoing provision at the option of the insurer:
If any indemnity of this policy shall be payable to the estate of theinsured, or to an insured or beneficiary who is a minor or otherwisenot competent to give a valid release, the insurer may pay suchindemnity, up to an amount not exceeding $ _______ (insert anamount which shall not exceed $1,000), to any relative by blood orconnection by marriage of the insured or beneficiary who is deemedby the insurer to be equitably entitled thereto. Any payment made bythe insurer in good faith pursuant to this provision shall fullydischarge the insurer to the extent of such payment.
Subject to any written direction of the insured in the applicationor otherwise all or a portion of any indemnities provided by thispolicy on account of hospital, nursing, medical, or surgical servicesmay, at the insurer's option and unless the insured requests otherwisein writing not later than the time of filing proofs of such loss, be paiddirectly to the hospital or person rendering such services; but it is notrequired that the service be rendered by a particular hospital orperson.
For the purposes of this section a "minor" is a person under theage of eighteen (18) years. A person eighteen (18) years of age orover is competent, insofar as the person's age is concerned, to sign a
valid release.
(10) A provision as follows: PHYSICAL EXAMINATIONS ANDAUTOPSY: The insurer at its own expense shall have the right andopportunity to examine the person of the insured when and as oftenas it may reasonably require during the pendency of a claimhereunder 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 lawor in equity shall be brought to recover on this policy prior to theexpiration of sixty (60) days after written proof of loss has beenfurnished in accordance with the requirements of this policy. Nosuch action shall be brought after the expiration of three (3) yearsafter the time written proof of loss is required to be furnished.
(12) A provision as follows: CHANGE OF BENEFICIARY:Unless the insured makes an irrevocable designation of beneficiary,the right to change of beneficiary is reserved to the insured and theconsent of the beneficiary or beneficiaries shall not be requisite tosurrender or assignment of this policy or to any change of beneficiaryor beneficiaries, or to any other changes in this policy.
The first clause of this provision, relating to the irrevocabledesignation of beneficiary, may be omitted at the insurer's option.
(13) A provision as follows: GUARANTEED RENEWABILITY:In compliance with the federal Health Insurance Portability andAccountability Act of 1996 (P.L.104-191), renewability isguaranteed.
(b) Except as provided in subsection (c), no policy delivered orissued for delivery to any person in Indiana shall contain provisionsrespecting the matters set forth below unless the provisions are in thewords in which the provisions appear in this section. However, theinsurer may use, instead of any provision, a corresponding provisionof different wording approved by the commissioner which is not lessfavorable in any respect to the insured or the beneficiary. Anysubstitute provision contained in the policy shall be precededindividually by the appropriate caption appearing in this subsectionor, at the option of the insurer, by appropriate individual or groupcaptions or subcaptions as the commissioner may approve.
(1) A provision as follows: CHANGE OF OCCUPATION: If theinsured be injured or contract sickness after having changed theinsured's occupation to one classified by the insurer as morehazardous than that stated in this policy or while doing forcompensation anything pertaining to an occupation so classified, theinsurer will pay only such portion of the indemnities provided in thispolicy as the premium paid would have purchased at the rates andwithin the limits fixed by the insurer for such more hazardousoccupation. If the insured changes the insured's occupation to oneclassified by the insurer as less hazardous than that stated in thispolicy, the insurer, upon receipt of proof of such change ofoccupation, will reduce the premium rate accordingly, and will returnthe excess pro rata unearned premium from the date of change ofoccupation or from the policy anniversary date immediately
preceding receipt of such proof, whichever is the more recent. Inapplying this provision, the classification of occupational risk and thepremium rates shall be such as have been last filed by the insurerprior to the occurrence of the loss for which the insurer is liable orprior to date of proof of change in occupation with the state officialhaving supervision of insurance in the state where the insured residedat the time this policy was issued; but if such filing was not required,then the classification of occupational risk and the premium ratesshall be those last made effective by the insurer in such state prior tothe occurrence of the loss or prior to the date of proof of change inoccupation.
(2) A provision as follows: MISSTATEMENT OF AGE: If theage of the insured has been misstated, all amounts payable under thispolicy shall be such as the premium paid would have purchased atthe correct age.
(3) A provision as follows: OTHER INSURANCE IN THISINSURER: If an accident or sickness or accident and sickness policyor policies previously issued by the insurer to the insured are in forceconcurrently herewith, making the aggregate indemnity for _______(insert type of coverage or coverages) in excess of $ _______ (insertmaximum limit of indemnity or indemnities) the excess insuranceshall be void and all premiums paid for such excess shall be returnedto the insured or to the insured's estate. Or, instead of that provision:Insurance effective at any one (1) time on the insured under a likepolicy or policies, in this insurer is limited to the one (1) such policyelected by the insured, the insured's beneficiary or the insured'sestate, as the case may be, and the insurer will return all premiumspaid for all other such policies.
(4) A provision as follows: INSURANCE WITH OTHERINSURER: If there is other valid coverage, not with this insurer,providing benefits for the same loss on a provision of service basisor on an expense incurred basis and of which this insurer has notbeen given written notice prior to the occurrence or commencementof loss, the only liability under any expense incurred coverage of thispolicy shall be for such proportion of the loss as the amount whichwould otherwise have been payable hereunder plus the total of thelike amounts under all such other valid coverages for the same lossof which this insurer had notice bears to the total like amounts underall valid coverages for such loss, and for the return of such portionof the premiums paid as shall exceed the pro-rata portion of theamount so determined. For the purpose of applying this provisionwhen other coverage is on a provision of service basis, the "likeamount" of such other coverage shall be taken as the amount whichthe services rendered would have cost in the absence of suchcoverage.
If the foregoing policy provision is included in a policy whichalso contains the next following policy provision there shall be addedto the caption of the foregoing provision the phrase "EXPENSEINCURRED BENEFITS". The insurer may, at its option, include inthis provision a definition of "other valid coverage," approved as to
form by the commissioner, which definition shall be limited insubject matter to coverage provided by organizations subject toregulation by insurance law or by insurance authorities of this or anyother state of the United States or any province of Canada, and byhospital or medical service organizations, and to any other coveragethe inclusion of which may be approved by the commissioner. In theabsence of such definition such term shall not include groupinsurance, automobile medical payments insurance, or coverageprovided by hospital or medical service organizations or by unionwelfare plans or employer or employee benefit organizations. For thepurpose of applying the foregoing policy provision with respect toany insured, any amount of benefit provided for such insuredpursuant to any compulsory benefit statute (including any worker'scompensation or employer's liability statute) whether provided by agovernmental agency or otherwise shall in all cases be deemed to be"other valid coverage" of which the insurer has had notice. Inapplying the foregoing policy provision no third party liabilitycoverage shall be included as "other valid coverage".
(5) A provision as follows: INSURANCE WITH OTHERINSURERS: If there is other valid coverage, not with this insurer,providing benefits for the same loss on other than an expenseincurred basis and of which this insurer has not been given writtennotice prior to the occurrence or commencement of loss, the onlyliability for such benefits under this policy shall be for suchproportion of the indemnities otherwise provided hereunder for suchloss as the like indemnities of which the insurer had notice (includingthe indemnities under this policy) bear to the total amount of all likeindemnities for such loss, and for the return of such portion of thepremium paid as shall exceed the pro-rata portion for the indemnitiesthus determined. If the foregoing policy provision is included in apolicy which also contains the next preceding policy provision, thereshall be added to the caption of the foregoing provision the phrase"-OTHER BENEFITS". The insurer may, at its option, include in thisprovision a definition of "other valid coverage," approved as to formby the commissioner, which definition shall be limited in subjectmatter to coverage provided by organizations subject to regulation byinsurance law or by insurance authorities of this or any other state ofthe United States or any province of Canada, and to any othercoverage to the inclusion of which may be approved by thecommissioner. In the absence of such definition such term shall notinclude group insurance or benefits provided by union welfare plansor by employer or employee benefit organizations. For the purposeof applying the foregoing policy provision with respect to anyinsured, any amount of benefit provided for such insured pursuant toany compulsory benefit statute (including any worker's compensationor employer's liability statute) whether provided by a governmentalagency or otherwise shall in all cases be deemed to be "other validcoverage" of which the insurer has had notice. In applying theforegoing policy provision no third party liability coverage shall beincluded as "other valid coverage". (6) A provision as follows: RELATION OF EARNINGS TOINSURANCE: If the total monthly amount of loss of time benefitspromised for the same loss under all valid loss of time coverage uponthe insured, whether payable on a weekly or monthly basis, shallexceed the monthly earnings of the insured at the time disabilitycommenced or the insured's average monthly earnings for the periodof two (2) years immediately preceding a disability for which claimis made, whichever is the greater, the insurer will be liable only forsuch proportionate amount of such benefits under this policy as theamount of such monthly earnings or such average monthly earningsof the insured bears to the total amount of monthly benefits for thesame loss under all such coverage upon the insured at the time suchdisability commences and for the return of such part of the premiumspaid during such two (2) years as shall exceed the pro rata amount ofthe premiums for the benefits actually paid; but this shall not operateto reduce the total monthly amount of benefits payable under all suchcoverage upon the insured below the sum of two hundred dollars($200) or the sum of the monthly benefits specified in suchcoverages, whichever is the lesser, nor shall it operate to reducebenefits other than those payable for loss of time.
The foregoing policy provision may be inserted only in a policywhich the insured has the right to continue in force subject to itsterms by the timely payment of premiums:
(1) until at least fifty (50) years of age; or
(2) in the case of a policy issued after forty-four (44) years ofage, for at least five (5) years from its date of issue.
The insurer may, at its option, include in this provision a definitionof "valid loss of time coverage", approved as to form by thecommissioner, which definition shall be limited in subject matter tocoverage provided by governmental agencies or by organizationssubject to regulation by insurance law or by insurance authorities ofthis or any other state of the United States or any province ofCanada, or to any other coverage the inclusion of which may beapproved by the commissioner or any combination of suchcoverages. In the absence of such definition the term shall notinclude any coverage provided for the insured pursuant to anycompulsory benefit statute (including any worker's compensation oremployer's liability statute), or benefits provided by union welfareplans or by employer or employee benefit organizations.
(7) A provision as follows: UNPAID PREMIUM: Upon thepayment of a claim under this policy, any premium then due andunpaid or covered by any note or written order may be deductedtherefrom.
(8) A provision as follows: CONFORMITY WITH STATESTATUTES: Any provision of this policy which, on its effectivedate, is in conflict with the statutes of the state in which the insuredresides on such date is hereby amended to conform to the minimumrequirements of such statutes.
(9) A provision as follows: ILLEGAL OCCUPATION: Theinsurer shall not be liable for any loss to which a contributing cause
was the insured's commission of or attempt to commit a felony or towhich a contributing cause was the insured's being engaged in anillegal occupation.
(10) A provision as follows: INTOXICANTS ANDNARCOTICS: The insurer shall not be liable for any loss sustainedor contracted in consequence of the insured's being intoxicated orunder the influence of any narcotic unless administered on the adviceof a physician.
The policy provision under this subdivision may not be used withrespect to a policy that provides coverage for hospital, medical, orsurgical expenses.
(c) If any provision of this section is in whole or in partinapplicable to or inconsistent with the coverage provided by aparticular form of policy the insurer, with the approval of thecommissioner, shall omit from such policy any inapplicableprovision or part of a provision, and shall modify any inconsistentprovision or part of the provision in such manner as to make theprovision as contained in the policy consistent with the coverageprovided by the policy.
(d) The provisions which are the subject of subsections (a) and(b), or any corresponding provisions which are used in lieu thereofin accordance with such subsections, shall be printed in theconsecutive order of the provisions in such subsections or, at theoption of the insurer, any such provision may appear as a unit in anypart of the policy, with other provisions to which it may be logicallyrelated, provided the resulting policy shall not be in whole or in partunintelligible, uncertain, ambiguous, abstruse, or likely to mislead aperson to whom the policy is offered, delivered, or issued.
(e) "Insured", as used in this chapter, shall not be construed aspreventing a person other than the insured with a proper insurableinterest from making application for and owning a policy coveringthe insured or from being entitled under such a policy to anyindemnities, benefits, and rights provided therein.
(f)(1) Any policy of a foreign or alien insurer, when delivered orissued for delivery to any person in this state, may contain anyprovision which is not less favorable to the insured or the beneficiarythan is provided in this chapter and which is prescribed or requiredby the law of the state under which the insurer is organized.
(f)(2) Any policy of a domestic insurer may, when issued fordelivery in any other state or country, contain any provisionpermitted or required by the laws of such other state or country.
(g) The commissioner may make reasonable rules under IC 4-22-2concerning the procedure for the filing or submission of policiessubject to this chapter as are necessary, proper, or advisable to theadministration of this chapter. This provision shall not abridge anyother authority granted the commissioner by law.
(Formerly: Acts 1953, c.15, s.169.3; Acts 1971, P.L.392, SEC.1; Acts1973, P.L.275, SEC.4; Acts 1974, P.L.1, SEC.13.) As amended byP.L.28-1988, SEC.104; P.L.93-1995, SEC.8; P.L.91-1998, SEC.10;P.L.162-2001, SEC.2; P.L.178-2003, SEC.60; P.L.98-2007, SEC.1.
IC 27-8-5-4
Effect of other policy provisions or policy conflicting with chapter
Sec. 4. (a) No policy provision which is not subject to section 3of this chapter shall make a policy, or any portion thereof, lessfavorable in any respect to the insured or the beneficiary than theprovisions thereof which are subject to this chapter.
(b) A policy delivered or issued for delivery to any person in thisstate in violation of this chapter shall be held valid but shall beconstrued as provided in this chapter. When any provision in a policysubject to this chapter is in conflict with any provision of thischapter, the rights, duties, and obligations of the insurer, the insured,and the beneficiary shall be governed by the provisions of thischapter.
(Formerly: Acts 1953, c.15, s.169.4.) As amended by P.L.252-1985,SEC.303.
IC 27-8-5-5
Application; attaching copy to policy; furnishing copy to insured;alterations; effect of false statements
Sec. 5. (a) The insured shall not be bound by any statement madein an application for a policy unless a copy of such application isattached to or endorsed on the policy when issued as a part thereof.If any such policy delivered or issued for delivery to any person inthis state shall be reinstated or renewed, and the insured or thebeneficiary or assignee of such policy shall make written request tothe insurer for a copy of the application, if any, for suchreinstatement or renewal, the insurer shall within fifteen (15) daysafter the receipt of such request at its home office or any branchoffice of the insurer, deliver or mail to the person making suchrequest, a copy of such application. If such copy shall not be sodelivered or mailed, the insurer shall be precluded from introducingsuch application as evidence in any action or proceeding based uponor involving such policy or its reinstatement or renewal.
(b) No alteration of any written application for any such policyshall be made by any person other than the applicant without hiswritten consent, except that insertions may be made by the insurer,for administrative purposes only, in such manner as to indicateclearly that such insertions are not to be ascribed to the applicant.
(c) The falsity of any statement in the application for any policycovered by this chapter may not bar the right to recovery thereunderunless such false statement materially affected either the acceptanceof the risk or the hazard assumed by the insurer.
(Formerly: Acts 1953, c.15, s.169.5.) As amended by P.L.252-1985,SEC.304.
IC 27-8-5-6
Defenses of insurer; acts not constituting waiver
Sec. 6. The acknowledgment by any insurer of the receipt ofnotice given under any policy covered by this chapter, or thefurnishing of forms for filing proofs of loss, or the acceptance of
such proofs, or the investigation of any claim thereunder shall notoperate as a waiver of any of the rights of the insurer in defense ofany claim arising under such policy.
(Formerly: Acts 1953, c.15, s.169.6.) As amended by P.L.252-1985,SEC.305.
IC 27-8-5-7
Acceptance of premium for period beyond termination date; effect;misstatement of age
Sec. 7. If any such policy contains a provision establishing, as anage limit or otherwise, a date after which the coverage provided bythe policy will not be effective, and if such date falls within a periodfor which premium is accepted by the insurer or if the insurer acceptsa premium after such date, the coverage provided by the policy willcontinue in force subject to any right of cancellation until the end ofthe period for which premium has been accepted. In the event the ageof the insured has been misstated and if, according to the correct ageof the insured, the coverage provided by the policy would not havebecome effective, or would have ceased prior to the acceptance ofsuch premium or premiums, then the liability of the insurer shall belimited to the refund, upon request, of all premiums paid for theperiod not covered by the policy.
(Formerly: Acts 1953, c.15, s.169.7.)
IC 27-8-5-8
Exemption of accident and sickness coverage incidental todesignated other forms of insurance
Sec. 8. Except as otherwise expressly indicated in this section,nothing contained in sections 1 through 7 of this chapter shall applyto or affect:
(1) any policy of worker's compensation insurance or any policyof liability insurance with or without supplementary coveragein the policy;
(2) any policy or contract of reinsurance;
(3) as to sections 2 through 7 of this chapter, any blanket orgroup policy of insurance;
(4) life insurance, endowment, or annuity contracts, or contractssupplemental thereto which contain only such provisionsrelating to accident and sickness insurance as:
(A) provide additional benefits in case of death ordismemberment or loss of sight by accident; or
(B) operate to safeguard such contracts against lapse, or togive a special surrender value or special benefit or anannuity in the event that the insured or annuitant shallbecome totally and permanently disabled, as defined by thecontract or supplemental contract;
(5) as to sections 2 through 5 of this chapter, any policies ofaccident and sickness insurance issued on the industrial planwith premiums payable on a weekly basis; or
(6) transportation ticket policies sold only at public
transportation stations or at public transportation ticket officesby public transportation employees, as to such of the requiredprovisions set out in section 3 of this chapter as are incongruouswith the coverage and conditions of the policies.
(Formerly: Acts 1953, c.15, s.169.8; Acts 1955, c.129, s.1.) Asamended by P.L.252-1985, SEC.306; P.L.28-1988, SEC.105.
IC 27-8-5-9
Exemption of certain individual policies
Sec. 9. An individual accident and sickness insurance policy formor any form of rider or endorsement appertaining to such a policyform, which could have been lawfully used or delivered or issued fordelivery to any person in this state immediately before February 20,1953, may be used or delivered or issued for delivery to any suchperson at any time prior to January 1, 1956, without being subject tothe provisions of sections 2, 3, and 4 of this chapter.
(Formerly: Acts 1953, c.15, s.169.9.) As amended by P.L.252-1985,SEC.307.
IC 27-8-5-10
Repealed
(Repealed by P.L.257-1985, SEC.6.)
IC 27-8-5-11
Franchise plan; accident and sickness insurance; definitions,limitat