Section 60. Prohibited policy provisions

A. Except as provided in the definition of sickness in 14VAC5-140-40, no policy shall contain provisions establishing a probationary or waiting period during which no coverage is provided under the policy subject to the further exception that a policy may specify a probationary or waiting period not to exceed six months for specified diseases or conditions and losses resulting therefrom for hernia, disorder of reproduction organs, varicose veins, adenoids, appendix and tonsils. However, the permissible six months exception shall not be applicable where such specified diseases or conditions are treated on an emergency basis. Accident policies shall not contain probationary or waiting periods.

B. No policy or rider for additional coverage may be issued as a dividend unless an equivalent cash payment is offered to the policyholder as an alternative to such dividend policy or rider. No such dividend policy or rider shall be issued for an initial term of less than six months.

The initial renewal subsequent to the issuance of any policy or rider as a dividend shall clearly disclose that the policyholder is renewing the coverage that was provided as a dividend for the previous term and that such renewal is optional with the policyholder.

C. No policy shall exclude coverage for a loss due to a preexisting condition for a period greater than 12 months following policy issue where the application for such insurance does not seek disclosure of prior illness, disease or physical conditions or prior medical care and treatment and such preexisting condition is not specifically excluded by the terms of the policy.

D. A disability income protection policy may contain a "return of premium" or "cash value benefit" so long as:

1. Such return of premium or cash value benefit is not reduced by an amount greater than the aggregate of any claims paid under the policy; and

2. The insurer demonstrates that the reserve basis for the policy is adequate.

No other policy shall provide a return of premium or cash value benefit, except return of unearned premium upon termination or suspension of coverage, retroactive waiver of premium paid during disability, payment of dividends on participating policies, or experience rating refunds.

E. Policies providing hospital confinement indemnity coverage shall not contain provisions excluding coverage because of confinement in a hospital operated by the federal government.

F. No policy shall limit or exclude coverage by type of illness, accident, treatment or medical condition, except as follows:

1. Preexisting conditions or diseases, except for congenital anomalies of a covered dependent child;

2. Mental or emotional disorders, alcoholism and drug addiction, subject to § 38.2-3412.1 of the Code of Virginia;

3. Pregnancy, except for complications of pregnancy, other than for policies defined in 14VAC5-140-70 F and G;

4. Illness, treatment or medical condition arising out of:

a. War or act of war (whether declared or undeclared); participation in a felony, riot or insurrections; service in the armed forces or auxiliary units;

b. Suicide (sane or insane), attempted suicide or intentionally self-inflicted injury;

c. Aviation;

d. With respect to short-term nonrenewable policies, interscholastic sports;

5. Cosmetic surgery, except that "cosmetic surgery" shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child which has resulted in a functional defect;

6. Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, or symptomatic complaints of the feet;

7. Care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion, or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of, or in the vertebral column;

8. Treatment provided in a government hospital; benefits provided under Medicare or other governmental program (except Medicaid), any state or federal workers' compensation, employer's liability or occupational disease law, or any motor vehicle no-fault law; services rendered by employees of hospitals, laboratories or other institutions; services performed by a member of the covered person's immediate family and services for which no charge is normally made in the absence of insurance;

9. Dental care or treatment;

10. Eyeglasses, hearing aids and examination for the prescription or fitting thereof;

11. Rest cures, custodial care, transportation and routine physical examinations;

12. Territorial limitations;

13. Services or care not medically necessary;

14. Limited benefit health insurance coverage as approved by the commission and in accordance with 14VAC5-140-70 H (i).

G. Other provisions of this chapter shall not impair or limit the use of waivers to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases, physical condition or extra hazardous activity. Where waivers are required as a condition of issuance, renewal or reinstatement, signed acceptance by the insured is required unless on initial issuance the full text of the waiver is contained either on the first page or specification page of the policy or unless notice of the waiver appears on the first page or specification page of the policy.

H. Policy provisions precluded in this section shall not be construed as a limitation on the authority of the commission to disapprove other policy provisions in accordance with § 38.2-3518 of the Code of Virginia that, in the opinion of the commission, are unjust, unfair, or unfairly discriminatory to the policyholder, beneficiary, or any person insured under the policy.

I. Except as provided in provisions pertaining to "preexisting conditions" in 14VAC5-140-40, no policy shall exclude coverage for an illness or sickness that manifests itself prior to the effective date of the policy.

Historical Notes

Derived from Regulation 19, Case No. INS880413, § 7, eff. January 1, 1989; amended, Volume 18, Issue 21, eff. July 1, 2002.

Statutory Authority

§§ 12.1-13, 38.2-223, and 38.2-3516 of the Code of Virginia.