Free Individual Accident and Health Provisions Study Guide
West Virginia Life, Accident & Health exam — Individual Accident and Health Provisions.
The national Individual Accident and Health Provisions guide covers the uniform provisions from NAIC Model 180 and what each one does. West Virginia puts them in W. Va. Code 33-15-4 (required) and 33-15-5 (optional). West Virginia keeps an optional intoxicants and narcotics provision. This guide covers the West Virginia wording and time periods, the free look, renewability and prompt payment.
Free look (33-6-11b)
Individual accident and sickness policies print on the first page a right to return the policy within 10 days of receipt for a premium refund.
Renewability and format (33-15-2)
- An individual accident and sickness policy must be guaranteed renewable at the insured's option, with limited exceptions (33-15-2(d)).
- Printed text is at least 10-point type, and the first page states the renewal conditions.
- A policy may cover family members, including children under a stated age that can't exceed 19.
Required provisions (33-15-4)
| Provision | West Virginia rule |
|---|---|
| Entire contract; changes (a) | A change is valid only if an officer approves it. An agent can't change the policy. |
| Time limit on certain defenses (b) | After two years from issue, only fraudulent misstatements may void the policy or deny a claim. A policy the insured may keep until at least age 50 (or 5 years if issued after 44) may use incontestable wording instead. |
| Grace period (c) | 7 days weekly, 10 days monthly, 31 days otherwise. |
| Reinstatement (d) | Without approval or written disapproval, the policy is reinstated on the 45th day after the conditional receipt. It covers accidents after reinstatement and sickness beginning more than 10 days after. |
| Notice of claim (e) | Written notice within 20 days, or as soon as reasonably possible. For income benefits payable 2 years or more, the insurer may require notice of continuing disability every 6 months. |
| Claim forms (f) | If forms aren't sent within 15 days, written proof of the loss is enough. |
| Proof of loss (g) | Within 90 days. Late proof is accepted if given as soon as reasonably possible and within one year, unless the claimant lacked legal capacity. |
| Time of payment (h) | Paid promptly on proof. Periodic benefits are paid at least monthly. |
| Payment of claims (i) | An optional facility-of-payment clause lets the insurer pay up to $1,000 to a relative by blood or marriage. Medical benefits may be paid directly to the provider unless the insured objects in writing. |
| Physical exam and autopsy (j) | At the insurer's expense during a claim. Autopsy only where the law allows. |
| Legal actions (k) | No suit until 60 days after proof of loss and none after three years from when proof was required. |
| Change of beneficiary (l) | The insured keeps the right to change the beneficiary unless the designation is irrevocable. The beneficiary's consent isn't needed. |
Optional provisions (33-15-5)
- Change of occupation: benefits are adjusted for a more or less hazardous job.
- Misstatement of age: benefits are adjusted to what the premium would have bought at the correct age.
- Other insurance: a policy paying hospital, nursing, medical, surgical or ambulance benefits can't be reduced or avoided because of other such insurance (33-15-5(c)).
- Relation of earnings to insurance: disability benefits above earnings may be prorated, but total monthly benefits can't drop below $200 or the sum of the stated benefits, whichever is less.
- Unpaid premium: an unpaid premium may be deducted from a claim.
- Conformity with state statutes: any provision that conflicts with the law of the insured's state is amended to meet it.
- Illegal occupation: no benefits for a loss caused by committing a felony or working in an illegal occupation.
- Intoxicants and narcotics: no benefits for a loss while intoxicated or under a narcotic, unless taken on a doctor's advice. West Virginia keeps this optional provision.
Children
- Newborns are covered from birth, including congenital defects. If extra premium is required, notice and payment may be required within 31 days (33-6-32).
- Adopted children are covered from placement. A child can't be refused because they were born out of wedlock or don't live with the parent (33-15-16).
Prompt payment (33-11-4(9)(o))
- The insurer responds within 15 calendar days of proof of loss and updates every 30 days.
- A claim unpaid after 90 days, without a legitimate dispute or fraud, earns interest at prime + 1%.
Common exam traps
- The free look is 10 days.
- Individual A&S policies must be guaranteed renewable.
- Grace periods are 7/10/31 days.
- The time limit on certain defenses is two years.
- The intoxicants provision is still available in West Virginia.
- The newborn notice window is 31 days.
- Medical coverage can't be reduced because of other insurance.
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Practice questions are study aids generated for exam preparation and are not actual exam questions. Content is provided for educational purposes and is not legal advice. Verify current statutes, rules, and exam specifications with the Insurance Department and the exam administrator before relying on it.
