§ 27-8-5-19 — Contents; group accident and sickness insurance

(a) As used in this chapter, "late enrollee" has
the meaning set forth in 26 U.S.C. 9801(b)(3).
(b) A policy of group accident and sickness insurance may not be
issued to a group that has a legal situs in Indiana unless it contains in
substance:
(1) the provisions described in subsection (c); or
(2) provisions that, in the opinion of the commissioner, are:
(A) more favorable to the persons insured; or
(B) at least as favorable to the persons insured and more
favorable to the policyholder;
than the provisions set forth in subsection (c).
(c) The provisions referred to in subsection (b)(1) are as follows:
(1) A provision that the policyholder is entitled to a grace period
of thirty-one (31) days for the payment of any premium due
except the first, during which grace period the policy will
continue in force, unless the policyholder has given the insurer
written notice of discontinuance in advance of the date of
discontinuance and in accordance with the terms of the policy.
The policy may provide that the policyholder is liable to the
insurer for the payment of a pro rata premium for the time the
policy was in force during the grace period. A provision under
this subdivision may provide that the insurer is not obligated to
pay claims incurred during the grace period until the premium
due is received.
(2) A provision that the validity of the policy may not be
contested, except for nonpayment of premiums, after the policy
has been in force for two (2) years after its date of issue, and that
no statement made by a person covered under the policy relating
to the person's insurability may be used in contesting the validity
of the insurance with respect to which the statement was made,
unless:
(A) the insurance has not been in force for a period of two (2)
years or longer during the person's lifetime; or
(B) the statement is contained in a written instrument signed by
the insured person.
However, a provision under this subdivision may not preclude the
assertion at any time of defenses based upon a person's
ineligibility for coverage under the policy or based upon other
provisions in the policy.
(3) A provision that a copy of the application, if there is one, of
the policyholder must be attached to the policy when issued, that
all statements made by the policyholder or by the persons insured
are to be deemed representations and not warranties, and that no
statement made by any person insured may be used in any contest
unless a copy of the instrument containing the statement is or has
been furnished to the insured person or, in the event of death or
incapacity of the insured person, to the insured person's
beneficiary or personal representative.
(4) A provision setting forth the conditions, if any, under which
the insurer reserves the right to require a person eligible for
insurance to furnish evidence of individual insurability
satisfactory to the insurer as a condition to part or all of the
person's coverage.
(5) A provision specifying any additional exclusions or limitations
applicable under the policy with respect to a disease or physical
condition of a person that existed before the effective date of the
person's coverage under the policy and that is not otherwise
excluded from the person's coverage by name or specific
description effective on the date of the person's loss. An exclusion
or limitation that must be specified in a provision under this
subdivision:
(A) may apply only to a disease or physical condition for which
medical advice, diagnosis, care, or treatment was received by
the person or recommended to the person during the six (6)
months before the effective date of the person's coverage; and
(B) may not apply to a loss incurred or disability beginning
after the earlier of:
(i) the end of a continuous period of twelve (12) months
beginning on or after the effective date of the person's
coverage; or
(ii) the end of a continuous period of eighteen (18) months
beginning on the effective date of the person's coverage if the
person is a late enrollee.
This subdivision applies only to group policies of accident and
sickness insurance other than those described in section 2.5(a)(1)
through 2.5(a)(8) and 2.5(b)(2) of this chapter.
(6) A provision specifying any additional exclusions or limitations
applicable under the policy with respect to a disease or physical
condition of a person that existed before the effective date of the
person's coverage under the policy. An exclusion or limitation that
must be specified in a provision under this subdivision:
(A) may apply only to a disease or physical condition for which
medical advice or treatment was received by the person during
a period of three hundred sixty-five (365) days before the
effective date of the person's coverage; and
(B) may not apply to a loss incurred or disability beginning
after the earlier of the following:
(i) The end of a continuous period of three hundred sixty-five
(365) days, beginning on or after the effective date of the
person's coverage, during which the person did not receive
medical advice or treatment in connection with the disease or
physical condition.
(ii) The end of the two (2) year period beginning on the
effective date of the person's coverage.
This subdivision applies only to group policies of accident and
sickness insurance described in section 2.5(a)(1) through
2.5(a)(8) of this chapter.
(7) If premiums or benefits under the policy vary according to a
person's age, a provision specifying an equitable adjustment of:
(A) premiums;
(B) benefits; or
(C) both premiums and benefits;
to be made if the age of a covered person has been misstated. A
provision under this subdivision must contain a clear statement of
the method of adjustment to be used.
(8) A provision that the insurer will issue to the policyholder, for
delivery to each person insured, a certificate, in electronic or
paper form, setting forth a statement that:
(A) explains the insurance protection to which the person
insured is entitled;
(B) indicates to whom the insurance benefits are payable; and
(C) explains any family member's or dependent's coverage
under the policy.
The provision must specify that the certificate will be provided in
paper form upon the request of the insured.
(9) A provision stating that written notice of a claim must be
given to the insurer within twenty (20) days after the occurrence
or commencement of any loss covered by the policy, but that a
failure to give notice within the twenty (20) day period does not
invalidate or reduce any claim if it can be shown that it was not
reasonably possible to give notice within that period and that
notice was given as soon as was reasonably possible.
(10) A provision stating that:
(A) the insurer will furnish to the person making a claim, or to
the policyholder for delivery to the person making a claim,
forms usually furnished by the insurer for filing proof of loss;
and
(B) if the forms are not furnished within fifteen (15) days after
the insurer received notice of a claim, the person making the
claim will be deemed to have complied with the requirements
of the policy as to proof of loss upon submitting, within the
time fixed in the policy for filing proof of loss, written proof
covering the occurrence, character, and extent of the loss for
which the claim is made.
(11) A provision stating that:
(A) in the case of a claim for loss of time for disability, written
proof of the loss must be furnished to the insurer within ninety
(90) days after the commencement of the period for which the
insurer is liable, and that subsequent written proofs of the
continuance of the disability must be furnished to the insurer at
reasonable intervals as may be required by the insurer;
(B) in the case of a claim for any other loss, written proof of the
loss must be furnished to the insurer within ninety (90) days
after the date of the loss; and
(C) the failure to furnish proof within the time required under
clause (A) or (B) does not invalidate or reduce any claim if it
was not reasonably possible to furnish proof within that time,
and if proof is furnished as soon as reasonably possible but
(except in case of the absence of legal capacity of the claimant)
no later than one (1) year from the time proof is otherwise
required under the policy.
(12) A provision that:
(A) all benefits payable under the policy (other than benefits for
loss of time) will be paid:
(i) not more than forty-five (45) days after the insurer's (as
defined in IC 27-8-5.7-3) receipt of written proof of loss if the
claim is filed by the policyholder; or
(ii) in accordance with IC 27-8-5.7 if the claim is filed by the
provider (as defined in IC 27-8-5.7-4); and
(B) subject to due proof of loss, all accrued benefits under the
policy for loss of time will be paid not less frequently than
monthly during the continuance of the period for which the
insurer is liable, and any balance remaining unpaid at the
termination of the period for which the insurer is liable will be
paid as soon as possible after receipt of the proof of loss.
(13) A provision that benefits for loss of life of the person insured
are payable to the beneficiary designated by the person insured.
However, if the policy contains conditions pertaining to family
status, the beneficiary may be the family member specified by the
policy terms. In either case, payment of benefits for loss of life is
subject to the provisions of the policy if no designated or
specified beneficiary is living at the death of the person insured.
All other benefits of the policy are payable to the person insured.
The policy may also provide that if any benefit is payable to the
estate of a person or to a person who is a minor or otherwise not
competent to give a valid release, the insurer may pay the benefit,
up to an amount of five thousand dollars ($5,000), to any relative
by blood or connection by marriage of the person who is deemed
by the insurer to be equitably entitled to the benefit.
(14) A provision that the insurer, at the insurer's expense, has the
right and must be allowed the opportunity to:
(A) examine the person of the individual for whom a claim is
made under the policy when and as often as the insurer
reasonably requires during the pendency of the claim; and
(B) conduct an autopsy in case of death if it is not prohibited by
law.
(15) A provision that no action at law or in equity may be brought
to recover on the policy less than sixty (60) days after proof of
loss is filed in accordance with the requirements of the policy and
that no action may be brought at all more than three (3) years after
the expiration of the time within which proof of loss is required
by the policy.
(16) In the case of a policy insuring debtors, a provision that the
insurer will furnish to the policyholder, for delivery to each debtor
insured under the policy, a certificate of insurance describing the
coverage and specifying that the benefits payable will first be
applied to reduce or extinguish the indebtedness.
(17) If the policy provides that hospital or medical expense
coverage of a dependent child of a group member terminates upon
the child's attainment of the limiting age for dependent children
set forth in the policy, a provision that the child's attainment of the
limiting age does not terminate the hospital and medical coverage
of the child while the child is:
(A) incapable of self-sustaining employment because of a
mental, intellectual, or physical disability; and
(B) chiefly dependent upon the group member for support and
maintenance.
A provision under this subdivision may require that proof of the
child's incapacity and dependency be furnished to the insurer by
the group member within one hundred twenty (120) days of the
child's attainment of the limiting age and, subsequently, at
reasonable intervals during the two (2) years following the child's
attainment of the limiting age. The policy may not require proof
more than once per year in the time more than two (2) years after
the child's attainment of the limiting age. This subdivision does
not require an insurer to provide coverage to a child who has a
mental, intellectual, or physical disability who does not satisfy the
requirements of the group policy as to evidence of insurability or
other requirements for coverage under the policy to take effect. In
any case, the terms of the policy apply with regard to the coverage
or exclusion from coverage of the child.
(18) A provision that complies with the group portability and
guaranteed renewability provisions of the federal Health
Insurance Portability and Accountability Act of 1996
(P.L.104-191).
(d) Subsection (c)(5), (c)(8), and (c)(13) do not apply to policies
insuring the lives of debtors. The standard provisions required under
section 3(a) of this chapter for individual accident and sickness
insurance policies do not apply to group accident and sickness
insurance policies.
(e) If any policy provision required under subsection (c) is in whole
or in part inapplicable to or inconsistent with the coverage provided by
an insurer under a particular form of policy, the insurer, with the
approval of the commissioner, shall delete the provision from the
policy or modify the provision in such a manner as to make it
consistent with the coverage provided by the policy.
(f) An insurer that issues a policy described in this section shall
include in the insurer's enrollment materials information concerning the
manner in which an individual insured under the policy may:
(1) obtain a certificate described in subsection (c)(8); and
(2) request the certificate in paper form.

Legislative History

As added by P.L.257-1985, SEC.5. Amended by P.L.165-1986, SEC.1; P.L.23-1993, SEC.154; P.L.185-1996, SEC.14; P.L.91-1998, SEC.11; P.L.207-1999, SEC.4; P.L.233-1999, SEC.10; P.L.14-2000, SEC.58; P.L.162-2001, SEC.4; P.L.125-2005, SEC.3; P.L.127-2006, SEC.3; P.L.99-2007, SEC.193; P.L.173-2007, SEC.25; P.L.117-2015, SEC.38.