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The Vermont Statutes Online



Title

08

:
Banking and Insurance






Chapter

107

:
HEALTH INSURANCE






Subchapter

001
:
GENERALLY










 

§

4066. Optional standard policy provisions

Except as

provided in section 4067 of this title, no such policy delivered or issued for

delivery to any person in this state shall contain provisions respecting the

matters set forth below unless such provisions are in the words in which the

same appear in this section; provided, however, that the insurer may, at its

option, use in lieu of any such provision a corresponding provision of

different wording approved by the commissioner which is not less favorable in

any respect to the insured or the beneficiary. Any such provision contained in

the policy shall be preceded individually by the appropriate caption appearing

in this section or, at the option of the insurer, by such appropriate

individual or group captions or subcaptions as the commissioner may approve:

(1) CHANGE OF

OCCUPATION: If the insured be injured or contract sickness after having changed

his or her occupation to one classified by the insurer as more hazardous than

that stated in this policy or while doing for compensation anything pertaining

to an occupation so classified, the insurer will pay only such portion of the

indemnities provided in this policy as the premium paid would have purchased at

the rates and within the limits fixed by the insurer for such more hazardous

occupation. If the insured changes his or her occupation to one classified by

the insurer as less hazardous than that stated in this policy, the insurer,

upon receipt of proof of such change of occupation, will reduce the premium

rate accordingly, and will return the excess pro rata unearned premium from the

date of change of occupation or from the policy anniversary date immediately

preceding receipt of such proof, whichever is the more recent. In applying this

provision, the classification of occupational risk and the premium rates shall

be such as have been last filed by the insurer prior to the occurrence of the

loss for which the insurer is liable or prior to date of proof of change in

occupation with the state official having supervision of insurance in the state

where the insured resided at the time this policy was issued; but if such

filing was not required, then the classification of occupational risk and the

premium rates shall be those last made effective by the insurer in such state

prior to the occurrence of the loss or prior to the date of proof of change in

occupation.

(2) MISSTATEMENT

OF AGE: If the age of the insured has been misstated, all amounts payable under

this policy shall be such as the premium paid would have purchased at the

correct age.

(3) OTHER

INSURANCE IN THIS INSURER: If an accident or sickness or accident and sickness

policy or policies previously issued by the insurer to the insured be in force

concurrently herewith, making the aggregate indemnity for ..... (insert type of

coverage or coverages) in excess of $ ..................... (insert maximum

limit of indemnity or indemnities) the excess insurance shall be void and all

premiums paid for such excess shall be returned to the insured or to his or her

estate.

or, in lieu thereof:

Insurance

effective at any one time on the insured under a like policy or policies in

this insurer is limited to the one such policy elected by the insured, his or

her beneficiary or his or her estate, as the case may be, and the insurer will

return all premiums paid for all other such policies.

(4) INSURANCE

WITH OTHER INSURERS: If there be other valid coverage, not with this insurer,

providing benefits for the same loss on a provision of service basis or on an

expense incurred basis and of which this insurer has not been given written

notice prior to the occurrence or commencement of loss, the only liability

under any expense incurred coverage of this policy shall be for such proportion

of the loss as the amount which would otherwise have been payable hereunder

plus the total of the like amounts under all such other valid coverages for the

same loss of which this insurer had notice bears to the total like amounts

under all valid coverages for such loss, and for the return of such portion of

the premiums paid as shall exceed the pro rata portion for the amount so

determined. For the purpose of applying this provision when other coverage is

on a provision of service basis, the "like amount" of such other

coverage shall be taken as the amount which the services rendered would have

cost in the absence of such coverage.

(If the foregoing policy provision is

included in a policy which also contains the next following policy provision

there shall be added to the caption of the foregoing provision the phrase

"-EXPENSE INCURRED BENEFITS." The insurer may, at its option, include

in this provision a definition of "other valid coverage," approved as

to form by the commissioner, which definition shall be limited in subject

matter to coverage provided by organizations subject to regulation by insurance

law or by insurance authorities of this or any other state of the United States

or any province of Canada, and by hospital or medical service organizations,

and to any other coverage the inclusion of which may be approved by the

commissioner. In the absence of such definition such term shall not include

group insurance, automobile medical payments insurance, or coverage provided by

hospital or medical service organizations or by union welfare plans or employer

or employee benefit organizations. For the purpose of applying the foregoing

policy provision with respect to any insured, any amount of benefit provided

for such insured pursuant to any compulsory benefit statute (including any

workers' compensation or employer's liability statute) whether provided by a

governmental agency or otherwise shall in all cases be deemed to be "other

valid coverage" of which the insurer has had notice. In applying the

foregoing policy provision no third party liability coverage shall be included

as "other valid coverage.")

(5) INSURANCE

WITH OTHER INSURERS: If there be other valid coverage, not with this insurer,

providing benefits for the same loss on other than an expense incurred basis

and of which this insurer has not been given written notice prior to the

occurrence or commencement of loss, the only liability for such benefits under

this policy shall be for such proportion of the indemnities otherwise provided

hereunder for such loss as the like indemnities of which the insurer had notice

(including the indemnities under this policy) bear to the total amount of all

like indemnities for such loss, and for the return of such portion of the

premium paid as shall exceed the pro rata portion for the indemnities thus

determined.

(If the foregoing policy provision is

included in a policy which also contains the next preceding policy provision

there shall be added to the caption of the foregoing provision the phrase

"-OTHER BENEFITS." The insurer may, at its option, include in this

provision a definition of "other valid coverage," approved as to form

by the commissioner, which definition shall be limited in subject matter to

coverage provided by organizations subject to regulation by insurance law or by

insurance authorities of this or any other state of the United States or any

province of Canada, and to any other coverage the inclusion of which may be

approved by the commissioner. In the absence of such definition such term shall

not include group insurance, or benefits provided by union welfare plans or by

employer or employee benefit organizations. For the purpose of applying the

foregoing policy provision with respect to any insured, any amount of benefit

provided for such insured pursuant to any compulsory benefit statute (including

any workers' compensation or employer's liability statute)  whether provided by a governmental agency or

otherwise shall in all cases be deemed to be "other valid coverage"

of which the insurer has had notice. In applying the foregoing policy provision

no third party liability coverage shall be included as "other valid

coverage.")

(6) RELATION OF

EARNINGS TO INSURANCE: If the total monthly amount of loss of time benefits

promised for the same loss under all valid loss of time coverage upon the

insured, whether payable on a weekly or monthly basis, shall exceed the monthly

earnings of the insured at the time disability commenced or his or her average

monthly earnings for the period of two years immediately preceding a disability

for which claim is made, whichever is the greater, the insurer will be liable

only for such proportionate amount of such benefits under this policy as the

amount of such monthly earnings or such average monthly earnings of the insured

bears to the total amount of monthly benefits for the same loss under all such

coverage upon the insured at the time such disability commences and for the

return of such part of the premiums paid during such two years as shall exceed

the pro rata amount of the premiums for the benefits actually paid hereunder;

but this shall not operate to reduce the total monthly amount of benefits

payable under all such coverage upon the insured below the sum of $200.00 or

the sum of the monthly benefits specified in such coverages, whichever is the

lesser, nor shall it operate to reduce benefits other than those payable for

loss of time.

(The foregoing policy provision may be

inserted only in a policy which the insured has the right to continue in force

subject to its terms by the timely payment of premiums (1) until at least age

50; or (2) in the case of a policy issued after age 44, for at least five years

from its date of issue. The insurer may, at its option, include in this

provision a definition of "valid loss of time coverage," approved as

to form by the commissioner, which definition shall be limited in subject

matter to coverage provided by governmental agencies or by organizations

subject to regulation by insurance law or by insurance authorities of this or

any other state of the United States or any province of Canada, or to any other

coverage the inclusion of which may be approved by the commissioner or any

combination of such coverages. In the absence of such definition such term

shall not include any coverage provided for such insured pursuant to any

compulsory benefit statute (including any workers' compensation or employer's

liability statute), or benefits provided by union welfare plans or by employer

or employee benefit organizations.)

(7) UNPAID

PREMIUM: Upon the payment of a claim under this policy, any premium then due

and unpaid or covered by any note or written order may be deducted therefrom.

(8)

CANCELLATION: The insurer may cancel this policy at any time by written notice

delivered to the insured, or mailed to his or her last address as shown by the

records of the insurer, stating when, not less than five days thereafter, such

cancellation shall be effective; and after the policy has been continued beyond

its original term the insured may cancel this policy at any time by written notice

delivered or mailed to the insurer, effective upon receipt or on such later

date as may be specified in such notice. In the event of cancellation, the

insurer will return promptly the unearned portion of any premium paid. If the

insured cancels, the earned premium shall be computed by the use of the

short-rate table last filed with the state official having supervision of

insurance in the state where the insured resided when the policy was issued. If

the insurer cancels, the earned premium shall be computed pro rata.

Cancellation shall be without prejudice to any claim originating prior to the

effective date of cancellation.

(9) CONFORMITY

WITH STATE STATUTES: Any provision of this policy which, on its effective date,

is in conflict with the statutes of the state in which the insured resides on

such date is hereby amended to conform to the minimum requirements of such

statutes.

(10) ILLEGAL

OCCUPATION: The insurer 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 to which a contributing cause was the insured's being engaged in an

illegal occupation.

(11) Repealed.]  (Amended 1981, No. 165 (Adj. Sess.), § 1;

2001, No. 121 (Adj. Sess.), § 6, eff. June 5, 2002.)