Missouri Revised Statutes
Chapter 376
Life, Health and Accident Insurance
←376.776
Section 376.777.1
376.778→
August 28, 2015
Specifically required provisions--exemptions, when--director's powers--inapplicability of certain provisions to individual health insurance coverage.
376.777. 1. Required provisions. Except as provided in subsection 3
of this section each such policy delivered or issued for delivery to any
person in this state shall contain the provisions specified in this
subsection in the words in which the same appear in this section; 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 director of the department of insurance, financial institutions and
professional registration 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 this subsection or, at
the option of the insurer, by such appropriate individual or group captions
or subcaptions as the director of the department of insurance, financial
institutions and professional registration may approve.
(1) A provision as follows:
"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".
(When under the provisions of subdivision (2) of subsection 1 of
section 376.775 the effective and termination dates are stated in the
premium receipt, the insurer shall insert in the first sentence of the
foregoing policy provision immediately following the comma after the word
"any", the following words: "and the insurer's official premium receipt
when executed").
(2) A provision as follows:
"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 such 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 such two-year period".
(The foregoing policy provision shall not be so construed as to affect
any legal requirements for avoidance of a policy or denial of a claim
during such initial two-year period, nor to limit the application of
subdivisions (1), (2), (3), (4) and (5) of subsection 2 of this section in
the event of misstatement with respect to age or occupation or other
insurance.)
(A policy which the insured has the right to continue in force subject
to its terms by the timely payment of premium (1) until at least age fifty
or, (2) in the case of a policy issued after age forty-four, for at least
five years from its date of issue, may contain in lieu of the foregoing the
following provision (from which the clause in parentheses may be omitted at
the insurer's option) under the caption "UNCONTESTABLE":
"After this policy has been in force for a period of three years during the
lifetime of the insured (excluding any period during which the insured is
disabled), it shall become uncontestable 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."
(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) 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."
(A policy which contains a cancellation provision may add, at the end
of the above provision, subject to the right of the insurer to cancel in
accordance with the cancellation provision hereof. A policy in which the
insurer reserves the right to refuse any renewal shall have, at the
beginning of the above provision, "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").
(4) A provision as follows:
"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 ten 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 sixty days prior to the date of reinstatement".
(The last sentence of the above provision may be omitted from any
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 fifty or,
(2) in the case of a policy issued after age forty-four, for at least five
years from its date of issue.)
(5) A provision as follows:
"NOTICE OF CLAIM:
Written notice of claim must be given to the insurer within twenty
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 insured at ..........
(insert the location of such office as the insurer may designate for the
purpose), or to any authorized agent of the insurer, with information
sufficient to identify the insured, shall be deemed notice to the insurer".
(In a policy providing a loss-of-time benefit which may be payable for
at least two years, an insurer may at its option insert the following
between the first and second sentences of the above provision:
"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").
(6) A provision as follows:
"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 fifteen 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".
(7) A provision as follows:
"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 ninety days after
the termination of the period for which the insurer is liable and in case
of claim for any other loss within ninety 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".
(8) A provision as follows:
"TIME OF PAYMENT OF CLAIMS:
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 .......... (insert period for
payment which must not be less frequently than monthly) and any balance
remaining unpaid upon the termination of liability will be paid immediately
upon receipt of due written proof".
(9) A provision as follows:
"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".
(The following provisions, or either of them, may be included with the
foregoing provision at the option of the insurer:
"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 $...... (insert an amount which shall not exceed
one thousand dollars), 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 such loss, be paid
directly to the hospital or person rendering such services; but it is not
required that the service be rendered by a particular hospital or person").
(10) A provision as follows:
"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".
(11) A provision as follows:
"LEGAL ACTIONS:
No action at law or in equity shall be brought to recover on this
policy prior to the expiration of sixty 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".
(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 the
consent of the beneficiary or beneficiaries shall not be requisite to
surrender or assignment of this policy or to change of beneficiary or
beneficiaries, or to any other changes in this policy".
(The first clause of this provision, relating to the irrevocable
designation of beneficiary, may be omitted at the insurer's option).
2. Other provisions. Except as provided in subsection 3 of this
section, 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 director of the department of insurance, financial
institutions and professional registration 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 subsection or, at the option of the insurer, by
such appropriate individual or group captions or subcaptions as the
director of the department of insurance, financial institutions and
professional registration may approve.
(1) A provision as follows:
"CHANGE OF OCCUPATION:
If the insured be injured or contract sickness after having changed
his 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 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) A provision as follows:
"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) A provision as follows:
"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
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 beneficiary or his estate, as the case may be, and the insurer
will return all premiums paid for all other such policies".
(4) A provision as follows:
"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 director of the
department of insurance, financial institutions and professional
registration, 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 director of the department of insurance, financial
institutions and professional registration. 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 employees 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) A provision as follows:
"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 director of the
department of insurance, financial institutions and professional
registration 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 director of the department of insurance, financial
institutions and professional registration. 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) A provision as follows:
"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 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 two hundred dollars 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 fifty or, (2) in the case
of a policy issued after age forty-four, for at least five years from this
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
director of the department of insurance, financial institutions and
professional registration, 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 director
of the department of insurance, financial institutions and professional
registration 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) A provision as follows:
"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) A provision as follows:
"CANCELLATION:
The insurer may cancel this policy at any time by written notice
delivered to the insured, or mailed to his 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) A provision as follows:
"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) A provision as follows:
"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) A provision as follows:
"INTOXICANTS AND NARCOTICS:
The insurer shall not be liable for any loss sustained or contracted
in consequence of the insured's being intoxicated or under the influence of
any narcotic unless administered on the advice of a physician".
3. Inapplicable or inconsistent provisions. If any provision of this
section is in whole or in part inapplicable to or inconsistent with the
coverage provided by a particular form of policy the insurer, with the
approval of the director of the department of insurance, financial
institutions and professional registration, shall omit from such policy an
inapplicable provision or part of a provision, and shall modify any
inconsistent provision or part of the provision, in such manner as to make
the provision as contained in the policy consistent with the coverage
provided by the policy.
4. Order of certain policy provisions. The provisions which are the
subject of subsections 1 and 2 of this section, or any corresponding
provisions which are used in lieu thereof in accordance with such
subsections, shall be printed in the consecutive order of the provisions in
such subsections or, at the option of the insurer, any such provision may
appear as a unit in any part of the policy, with other provisions to which
it may be logically related, provided the resulting policy shall not be in
whole or in part unintelligible, uncertain, ambiguous, abstruse, or likely
to mislead a person to whom the policy is offered, delivered or issued.
5. Third party ownership. The word "insured" as used in sections
376.770 to 376.800, shall not be construed as preventing a person other
than the insured with a proper insurable interest from making application
for and owning a policy covering the insured or from being entitled under
such a policy to any indemnities, benefits and rights provided therein.
6. Requirements of other jurisdictions.
(1) Any policy of a foreign or alien insurer, when delivered or
issued for delivery to any person in this state, may contain any provision
which is not less favorable to the insured or the beneficiary than the
provisions of sections 376.770 to 376.800 and which is prescribed or
required by the law of the state under which the insurer is organized.
(2) Any policy of a domestic insurer may, when issued for delivery in
any other state or country, contain any provision permitted or required by
the laws of such other state or country.
7. Approval of policies.
(1) No policy subject to sections 376.770 to 376.800 shall be
delivered or issued for delivery to any person in this state unless such
policy, including any rider, endorsement or other provisions, supplementary
thereto, shall have been approved by the director of the department of
insurance, financial institutions and professional registration.
(2) The director of the department of insurance, financial
institutions and professional registration shall have authority to make
such reasonable rules and regulations concerning the filing and submission
of policies as are necessary, proper or advisable. Such rules and
regulations shall provide, among other things, that if a policy form is
disapproved, all specific reasons for nonconformance shall be stated in
writing within forty-five days from the date of filing; that a hearing
shall be granted upon such disapproval, if so requested; and that the
failure of the director of the department of insurance, financial
institutions and professional registration, to take action approving or
disapproving a submitted policy form within forty-five days from the date
of filing, shall be deemed an approval thereof. If at any time after a
policy form is approved or deemed approved, the director determines that
any provision of the filing is contrary to state law, the director shall
notify the health carrier of the specific provisions that are contrary to
state law and any specific statute or regulation to which the provision is
contrary, and request that the health carrier file within thirty days of
the notification an amendment form that modifies the provision to conform
to state law. Upon approval of the amendment form by the director, the
health carrier shall issue a copy of the amendment to each individual and
entity to which the filing has been issued. Such amendment shall have the
force and effect as if the amendment was in the original filing or policy.
(3) The director of the department of insurance, financial
institutions and professional registration shall approve only those
policies which are in compliance with the insurance laws of this state and
which contain such words, phraseology, conditions and provisions which are
specific, certain and unambiguous and reasonably adequate to meet needed
requirements for the protection of those insured. The disapproval of any
policy form shall be based upon the requirements of the laws of this state
or of any regulation lawfully promulgated thereunder.
(4) The director of the department of insurance, financial
institutions and professional registration may, by order or bulletin,
exempt from the approval requirements of this section for so long as he
deems proper any insurance policy, document, or form or type thereof, as
specified in such order or bulletin, to which, in his opinion, this section
may not practicably be applied, or the approval of which is, in his
opinion, not desirable or necessary for the protection of the public.
(5) Notwithstanding any other provision of law to the contrary, a
health carrier, as defined in section 376.1350, may offer a health benefit
plan that is a managed care plan that requires all health care services to
be delivered by a participating provider in the health carrier's network,
except for emergency services, as defined in section 376.1350, and the
services described in subsection 4 of section 376.811. Such a provision
shall be disclosed in the policy form.
(L. 1959 H.B. 252 § 4, A.L. 1984 S.B. 592, A.L. 2013 S.B. 262)
1991
1991
376.777. 1. Required provisions. Except as provided in subsection 3 of
this section each such policy delivered or issued for delivery to any person
in this state shall contain the provisions specified in this subsection in the
words in which the same appear in this section; 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 director of the
department of insurance, financial institutions and professional registration
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 this subsection or, at the option of the insurer, by such
appropriate individual or group captions or subcaptions as the director of the
department of insurance, financial institutions and professional registration
may approve.
(1) A provision as follows:
"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".
(When under the provisions of subdivision (2) of subsection 1 of section
376.775 the effective and termination dates are stated in the premium receipt,
the insurer shall insert in the first sentence of the foregoing policy
provision immediately following the comma after the word "any", the following
words: "and the insurer's official premium receipt when executed").
(2) A provision as follows:
"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 such 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 such two-year period".
(The foregoing policy provision shall not be so construed as to affect
any legal requirements for avoidance of a policy or denial of a claim during
such initial two-year period, nor to limit the application of subdivisions
(1), (2), (3), (4) and (5) of subsection 2 of this section in the event of
misstatement with respect to age or occupation or other insurance.)
(A policy which the insured has the right to continue in force subject to
its terms by the timely payment of premium (1) until at least age fifty or,
(2) in the case of a policy issued after age forty-four, for at least five
years from its date of issue, may contain in lieu of the foregoing the
following provision (from which the clause in parentheses may be omitted at
the insurer's option) under the caption "UNCONTESTABLE":
"After this policy has been in force for a period of three years during the
lifetime of the insured (excluding any period during which the insured is
disabled), it shall become uncontestable 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."
(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) 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."
(A policy which contains a cancellation provision may add, at the end of
the above provision, subject to the right of the insurer to cancel in
accordance with the cancellation provision hereof. A policy in which the
insurer reserves the right to refuse any renewal shall have, at the beginning
of the above provision, "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").
(4) A provision as follows:
"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 ten 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 sixty days prior to the date of reinstatement".
(The last sentence of the above provision may be omitted from any 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 fifty or, (2) in the
case of a policy issued after age forty-four, for at least five years from its
date of issue.)
(5) A provision as follows:
"NOTICE OF CLAIM:
Written notice of claim must be given to the insurer within twenty 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 insured at .......... (insert the
location of such office as the insurer may designate for the purpose), or to
any authorized agent of the insurer, with information sufficient to identify
the insured, shall be deemed notice to the insurer".
(In a policy providing a loss-of-time benefit which may be payable for at
least two years, an insurer may at its option insert the following between the
first and second sentences of the above provision:
"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").
(6) A provision as follows:
"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 fifteen 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".
(7) A provision as follows:
"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 ninety days after the termination of
the period for which the insurer is liable and in case of claim for any other
loss within ninety 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".
(8) A provision as follows:
"TIME OF PAYMENT OF CLAIMS:
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 .......... (insert period for payment which must not be
less frequently than monthly) and any balance remaining unpaid upon the
termination of liability will be paid immediately upon receipt of due written
proof".
(9) A provision as follows:
"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".
(The following provisions, or either of them, may be included with the
foregoing provision at the option of the insurer:
"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 $...... (insert an amount which shall not exceed one
thousand dollars), 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 such loss, be paid directly to the
hospital or person rendering such services; but it is not required that the
service be rendered by a particular hospital or person").
(10) A provision as follows:
"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".
(11) A provision as follows:
"LEGAL ACTIONS:
No action at law or in equity shall be brought to recover on this policy
prior to the expiration of sixty 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".
(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 the consent of
the beneficiary or beneficiaries shall not be requisite to surrender or
assignment of this policy or to change of beneficiary or beneficiaries, or to
any other changes in this policy".
(The first clause of this provision, relating to the irrevocable
designation of beneficiary, may be omitted at the insurer's option).
2. Other provisions. Except as provided in subsection 3 of this
section, 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
director of the department of insurance, financial institutions and
professional registration 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
subsection or, at the option of the insurer, by such appropriate individual or
group captions or subcaptions as the director of the department of insurance,
financial institutions and professional registration may approve.
(1) A provision as follows:
"CHANGE OF OCCUPATION:
If the insured be injured or contract sickness after having changed his
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 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) A provision as follows:
"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) A provision as follows:
"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 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 beneficiary or his estate, as the case may be, and the insurer
will return all premiums paid for all other such policies".
(4) A provision as follows:
"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 director of the department
of insurance, financial institutions and professional registration, 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 director of the
department of insurance, financial institutions and professional registration.
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 employees 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) A provision as follows:
"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 director of the department of insurance,
financial institutions and professional registration 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 director of the
department of insurance, financial institutions and professional registration.
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) A provision as follows:
"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 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 two hundred dollars 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 fifty or, (2) in the case of
a policy issued after age forty-four, for at least five years from this 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
director of the department of insurance, financial institutions and
professional registration, 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 director of the department of
insurance, financial institutions and professional registration 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) A provision as follows:
"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) A provision as follows:
"CANCELLATION:
The insurer may cancel this policy at any time by written notice
delivered to the insured, or mailed to his 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) A provision as follows:
"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) A provision as follows:
"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) A provision as follows:
"INTOXICANTS AND NARCOTICS:
The insurer shall not be liable for any loss sustained or contracted in
consequence of the insured's being intoxicated or under the influence of any
narcotic unless administered on the advice of a physician".
3. Inapplicable or inconsistent provisions. If any provision of this
section is in whole or in part inapplicable to or inconsistent with the
coverage provided by a particular form of policy the insurer, with the
approval of the director of the department of insurance, financial
institutions and professional registration, shall omit from such policy an
inapplicable provision or part of a provision, and shall modify any
inconsistent provision or part of the provision, in such manner as to make the
provision as contained in the policy consistent with the coverage provided by
the policy.
4. Order of certain policy provisions. The provisions which are the
subject of subsections 1 and 2 of this section, or any corresponding
provisions which are used in lieu thereof in accordance with such subsections,
shall be printed in the consecutive order of the provisions in such
subsections or, at the option of the insurer, any such provision may appear as
a unit in any part of the policy, with other provisions to which it may be
logically related, provided the resulting policy shall not be in whole or in
part unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a
person to whom the policy is offered, delivered or issued.
5. Third party ownership. The word "insured" as used in sections
376.770 to 376.800, shall not be construed as preventing a person other than
the insured with a proper insurable interest from making application for and
owning a policy covering the insured or from being entitled under such a
policy to any indemnities, benefits and rights provided therein.
6. Requirements of other jurisdictions.
(1) Any policy of a foreign or alien insurer, when delivered or issued
for delivery to any person in this state, may contain any provision which is
not less favorable to the insured or the beneficiary than the provisions of
sections 376.770 to 376.800 and which is prescribed or required by the law of
the state under which the insurer is organized.
(2) Any policy of a domestic insurer may, when issued for delivery in
any other state or country, contain any provision permitted or required by the
laws of such other state or country.
7. Approval of policies.
(1) No policy subject to sections 376.770 to 376.800 shall be delivered
or issued for delivery to any person in this state unless such policy,
including any rider, endorsement or other provisions, supplementary thereto,
shall have been approved by the director of the department of insurance,
financial institutions and professional registration.
(2) The director of the department of insurance, financial institutions
and professional registration shall have authority to make such reasonable
rules and regulations concerning the filing and submission of policies as are
necessary, proper or advisable. Such rules and regulations shall provide,
among other things, that if a policy form is disapproved, the reasons therefor
shall be stated in writing; that a hearing shall be granted upon such
disapproval, if so requested; and that the failure of the director of the
department of insurance, financial institutions and professional registration
to take action approving or disapproving a submitted policy form within a
stipulated time, not to exceed sixty days from the date of filing, shall be
deemed an approval thereof until such time as the director of the department
of insurance, financial institutions and professional registration shall
notify the submitting company, in writing, of his disapproval thereof.
(3) The director of the department of insurance, financial institutions
and professional registration shall approve only those policies which are in
compliance with the insurance laws of this state and which contain such words,
phraseology, conditions and provisions which are specific, certain and
unambiguous and reasonably adequate to meet needed requirements for the
protection of those insured. The disapproval of any policy form shall be
based upon the requirements of the laws of this state or of any regulation
lawfully promulgated thereunder.
(4) The director of the department of insurance, financial institutions
and professional registration may, by order or bulletin, exempt from the
approval requirements of this section for so long as he deems proper any
insurance policy, document, or form or type thereof, as specified in such
order or bulletin, to which, in his opinion, this section may not practicably
be applied, or the approval of which is, in his opinion, not desirable or
necessary for the protection of the public.
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Missouri General Assembly
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