The uniform individual health provisions as they appear in NAIC Model 180 are covered in the national Individual Accident and Health Provisions guide. Louisiana's version is in R.S. 22:975, with policy-form rules in 22:973 and the grace period in 22:977. Several Louisiana numbers differ from the model:

• a three-year time limit on certain defenses
• a 30-day grace period for all individual policies
• one year to sue after proof is required
• a $100 relation-of-earnings floor

Required provisions (R.S. 22:975(A))

Reinstatement. A reinstated policy covers sickness only if it begins more than 10 days after reinstatement. Accidents are covered right away.

Grace period and lapse notice (R.S. 22:977)

• Every individual, group, family, blanket and association health and accident policy has a 30-day grace period. Louisiana doesn't use the model's 7/10/31-day split.
• If an individual policyholder hasn't paid 15 days before the grace period ends, the insurer mails a lapse notice explaining how to reinstate without penalty.

Optional provisions (R.S. 22:975(B))

• Change of occupation (to a more hazardous one). Benefits drop to what the premium would buy at the riskier rates.
• Misstatement of age. Benefits are figured at the correct age. If the policy wouldn't have been issued at the correct age, the insurer's liability is limited to a return of premium.
• Relation of earnings to insurance. Total monthly benefits can't be reduced below the lesser of $100 or the sum of the monthly benefits.
• Cancellation. Where cancellation is allowed, the insurer gives written notice and refunds the pro rata unearned premium. Claims that arose before cancellation are not affected.
• Illegal occupation. A loss to which committing or attempting a felony, or an illegal occupation, contributed is excluded.
• Intoxicants and narcotics. A loss while under the influence of narcotics is excluded unless the narcotic was taken on a physician's advice.

Policy form rules (R.S. 22:973)

• Text must be in at least 10-point type.
• Free look. A notice gives the insured 10 days from receipt to examine the policy. If the policy was sold through deceptive advertising or statements, it may be surrendered in that period for a return of premium.
• If the insurer may cancel or nonrenew at its option, that must be stated on the first page.

Other Louisiana rules

• An insurer may not unilaterally cancel after a covered claim for a terminal, incapacitating or debilitating condition while the insured remains eligible (22:1012).
• Claims are paid within 30 days of notice and proof. An unjustified delay costs double the benefits due plus attorney fees (22:1821).
• Disability income definitions (22:990).
  • A policy may not define total disability solely as the inability to perform "any occupation whatsoever."
  • A general definition may be no stricter than being unable to work in any occupation the insured is qualified for that pays substantially the same earnings.
  • An own-occupation definition is expressly allowed.
  • The insured may be required to be under the care of a physician who isn't the insured or a family member.

Common exam traps

• The grace period is 30 days for every health policy, with a lapse notice 15 days before it ends.
• The time limit on certain defenses is three years.
• A suit is barred one year after proof of loss is required.
• The relation-of-earnings floor is $100. The facility of payment limit is $1,000.
• Claims are paid in 30 days, or the insurer owes double the benefits.
• An insurer can't cancel after a terminal illness claim.