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The Vermont Statutes Online



Title

08

:
Banking and Insurance






Chapter

107

:
HEALTH INSURANCE






Subchapter

001
:
GENERALLY










 

§

4080. Required policy provisions

No such policy

shall contain any provision relative to notice of claim, proofs of loss, time

of payment of claims, or time within which legal action must be brought upon

the policy which, in the opinion of the commissioner, is less favorable to the

persons insured than would be permitted by the provisions set forth in section

4065 of this title. In addition each such policy shall contain in substance the

following provisions:

(1) A provision

that the policy, the application of the policyholder, if such application or

copy thereof is attached to such policy, and the individual applications, if

any, submitted in connection with such policy by the employees or members,

shall constitute the entire contract between the parties, and that all

statements, in the absence of fraud, made by any applicant or applicants shall

be deemed representations and not warranties, and that no such statement shall

avoid the insurance or reduce benefits thereunder unless contained in a written

application of which a copy is attached to the policy.

(2) A provision

that the insurer will furnish to the policyholder, for delivery to each

employee or member of the insured group, an individual certificate setting

forth in summary form a statement of the essential features of the insurance

coverage of such employee or member and to whom benefits thereunder are

payable. If dependents are included in the coverage, only one certificate need

be issued for each family unit.

(3) A provision

that to the group originally insured may be added from time to time eligible

new employees or members or dependents, as the case may be, in accordance with

the terms of the policy.

(4) In the case

of an approved employer-sponsored plan under section 1974 of Title 33, a provision

that defines as a qualifying event a finding by the agency of human services

that an eligible employee, member, or dependent qualifies for premium

assistance or is required to participate in the group in accordance with the

provisions of section 1974 of Title 33 (employer-sponsored insurance; premium

assistance), and that entitles the employee, member, or dependent to a special

enrollment period of 30 days from the date of notice of the agency finding.

(5) A provision

that the insurer shall not exclude part-time employees and shall offer the same

group health benefits to part-time employees as it offers to the employee

groups of which the part-time employees would be members if they were full-time

employees. The insurer shall offer to include the part-time employees as part

of the employer's employee group, at the full rate to be paid by the employer

and the employee, at a rate prorated between the employer and the employee or

at the employee's expense. "Part-time employee" means any employee

who works a minimum of at least 17 1/2 hours per week. (Amended 1989, No. 34, §

1; 2007, No. 70, § 20.)