Section 60. Coverage limitations and exclusions

A. The following policy limitations and exclusions are prohibited under this section:

1. Any life or accident and sickness insurance policy, any health services plan or health maintenance organization subscription contract or any rider used in connection with such policies or subscription contracts that excludes coverage for the treatment of HIV infection or Acquired Immunodeficiency Syndrome (AIDS) or complications or death resulting from such disease.

2. Any life or accident and sickness insurance policy, any health services plan or health maintenance organization subscription contract or any rider used in connection with such policies or subscription contracts that places a dollar limit on face amount of benefits payable for the treatment of HIV infection or Acquired Immunodeficiency Syndrome (AIDS) or complications or death resulting from such disease (other than the overall policy maximum or face amount).

3. A "preexisting condition" limitation related to HIV infection or Acquired Immunodeficiency Syndrome (AIDS) that is:

a. Defined to be more restrictive than the following:

(1) The existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within a five year period preceding the effective date of the coverage of the insured person; or

(2) A condition for which medical advice or treatment, not including preventative educational counseling, was recommended by a physician or received from a physician within a five year period preceding the effective date of the coverage of the insured.

b. Based on the sole existence of a positive HIV-related test result, following the protocol as described in 14VAC5-180-50 C, without the manifestation of symptoms or actual diagnosis of AIDS. Claims may not be denied as a preexisting condition solely on the existence of a positive HIV-related test result without the manifestation of symptoms or actual diagnosis of AIDS. Nothing in this subdivision shall be considered as prohibiting an insurance company from contesting a policy on the basis of material misrepresentation during the contestable period of the policy.

B. In only the following circumstances may insurers utilize a preexisting condition limitation for HIV infection or Acquired Immunodeficiency Syndrome (AIDS) which is more restrictive than that provided in subdivision A 3 above.

1. With regard to open enrollment contracts issued by health services plans pursuant to § 38.2-4216.1 of the Code of Virginia, a preexisting condition waiting period no more restrictive than that for any other illness is permitted. However, after the preexisting condition waiting period has expired, the health services plan shall provide coverage for HIV infection or acquired immunodeficiency syndrome (AIDS) as it does for any other illness not related to AIDS.

2. With regard to group life or accident and sickness insurance policies, group health services plans or health maintenance organization subscription contracts, where the insurer does not retain the right to exclude or limit coverage on any person when evidence of individual insurability is not satisfactory, a preexisting condition waiting period for HIV infection or acquired immunodeficiency syndrome (AIDS) is permitted to the same extent as such period is permitted for all other preexisting conditions. Nothing in this subsection shall prohibit an insurer from excluding or limiting coverage on any person when evidence of individual insurability is not satisfactory, if the person applies for coverage after the period they are first eligible to enroll under the group policy or subscription contract. After the preexisting condition waiting period has expired, the insurer shall provide the same coverage for HIV infection or acquired immunodeficiency syndrome (AIDS) as it does for any other death or illness not related to AIDS.

Historical Notes

Derived from Regulation 34, Case No. INS890325, § 7, eff. May 1, 1990; Section 7.A.3.b. amended, eff. February 23, 1990.

Statutory Authority

§§ 38.2-223, 38.2-316, 38.2-508, 38.2-610, 38.2-3100.1 and 38.2-3401 of the Code of Virginia.