§ 26.1-36-05 — Group health policy or service contract standard provisions

North Dakota § 26.1-36-05

• Jurisdiction: North Dakota
• Title 26.1: Insurance
• Ch. 26.1-36: Accident and Health Insurance

Text

Neither a group health insurance policy nor a group health service contract may be
delivered in this state unless it contains in substance the following provisions, or provisions that
in the opinion of the commissioner are more favorable to the persons insured and more
favorable to the policyholder or contractholder; provided, however, that subsections 5, 7, and 12
do not apply to credit accident and health insurance policies, that the standard provisions
required for individual health insurance policies do not apply to group health insurance policies,
and that if any provision of this section is in whole or in part inapplicable to or inconsistent with
the coverage provided by a particular form of policy or contract, the insurer shall omit from the
policy or contract any inapplicable provision or part of a provision, and shall modify any
inconsistent provision or part of the provision to make the provision contained in the policy or
contract consistent with the coverage provided by the policy or contract:
1. A provision that the policyholder or contractholder is entitled to a grace period of
thirty-one days for the payment of any premium due except the first, during which the
policy or contract continues in force, unless the policyholder or contractholder has
given the insurer written notice of discontinuance in advance of the date of
discontinuance and in accordance with the terms of the policy or contract. The policy
or contract may provide that the policyholder or contractholder is liable to the insurer
for the payment of a pro rata premium for the time the policy or contract was in force
during the grace period.
2. A provision that the validity of the policy or contract may not be contested except for
nonpayment of premiums, after it has been in force for two years from its date of issue;
and that the validity of the policy or contract may not be contested on the basis of a
statement made relating to insurability by any person covered under the policy or
contract after the insurance has been in force for two years during the person's lifetime
unless the statement is contained in a written instrument signed by the person making
the statement; provided, however, that no such provision precludes the assertion at
any time of defenses based upon the person's ineligibility for coverage under the
policy or contract.
3. A provision that a copy of the application, if any, of the policyholder or contractholder
will be attached to the policy or contract when issued, that all statements made by the
policyholder or contractholder or by the persons insured are deemed representations
and not warranties, and that no statement made by any insured person may be used
in any contest unless a copy of the instrument containing the statement is or has been

furnished to that person or, in the event of the death or incapacity of the insured
person, to the individual'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 individual's
coverage.
5. A provision specifying the additional exclusions or limitations, if any, applicable under
the policy or contract with respect to a disease or physical condition of a person, not
otherwise excluded from the person's coverage by name or specific description
effective on the date of the person's loss, which existed prior to the effective date of
the person's coverage under the policy or contract. Any such exclusion or limitation
may only apply to a disease or physical condition for which medical advice or
treatment was received by the person during the twelve months before the effective
date of the person's coverage. The exclusion or limitation may not apply to loss
incurred or disability commencing after the earlier of the end of a continuance period of
twelve months commencing on or after the effective date of the person's coverage
during all of which the person has received no medical advice or treatment in
connection with such disease or physical condition, or the end of the two-year period
commencing on the effective date of the person's coverage.
6. If the premiums or benefits vary by age, a provision specifying an equitable adjustment
of premiums or of benefits, or both, to be made in the event the age of a covered
person has been misstated. The provision must contain a clear statement of the
method of adjustment to be used.
7. A provision that the insurer will issue to the policyholder or contractholder for delivery
to each person insured a certificate setting forth a statement as to the insurance
protection to which that person is entitled, to whom the insurance benefits are payable,
and a statement as to any family member's or dependent's coverage.
8. A provision that written notice of claim must be given to the insurer within twenty days
after the occurrence or commencement of any loss covered by the policy or contract.
Failure to give notice within this time does not invalidate nor reduce any claim if it is
shown that it was not reasonably possible to give the notice and that notice was given
as soon as was reasonably possible.
9. A provision that the insurer will furnish to the person making claim, or to the
policyholder or contractholder for delivery to the person making claim, the forms
usually furnished for filing proof of loss. If the forms are not furnished before the
expiration of fifteen days after the insurer receives notice of any claim under the policy
or contract, the person making the claim is deemed to have complied with the
requirements of the policy or contract as to proof of loss upon submitting within the
time fixed in the policy or contract for filing proof of loss, written proof covering the
occurrence, character, and extent of the loss for which claim is made.
10. A provision that in the case of claim for loss of time for disability, written proof of loss
must be furnished to the insurer within ninety days after the commencement of the
period for which the insurer is liable, and that subsequent written proof of continuance
of the disability must be furnished to the insurer at intervals the insurer may
reasonably require, and that in the case of claim for any other loss, written proof of
loss must be furnished to the insurer within ninety days after the date of loss. Failure to
furnish the proof within this time does not invalidate nor reduce any claim if it was not
reasonably possible to furnish the proof within that time, provided the proof is
furnished as soon as reasonably possible and in no event, except in the absence of
legal capacity of the claimant, later than one year from the time proof is otherwise
required.
11. A provision that all benefits payable under the policy or contract other than benefits for
loss of time or unless subject to section 26.1-36-37.1 will be payable not more than
sixty days after receipt of due proof of loss. All accrued benefits payable under the
policy or contract for loss of time will be paid at least monthly during the continuance of

the period for which the insurer is liable, and that any balance remaining unpaid at the
termination of that period will be paid as soon as possible after receipt of proof of loss.
12. A provision that benefits for loss of life of the person insured will be payable to the
beneficiary designated by the insured person. If the policy or contract contains
conditions pertaining to family status, however, the beneficiary may be the family
member specified by the policy or contract terms. In either case, payment of these
benefits is subject to the provisions of the policy or contract in the event the
designated or specified beneficiary is not living at the death of the insured person. All
other benefits of the policy or contract are payable to the insured person. The policy or
contract 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 not exceeding five thousand dollars, to any
relative by blood or connection by marriage of the person deemed by the insurer to be
equitably entitled to the benefit.
13. A provision that the insurer may examine the individual for whom claim is made when
and so often as it may reasonably require during the pendency of claim under the
policy or contract and also may make an autopsy in case of death when the autopsy is
not prohibited by law.
14. A provision that no action may be brought to recover on the policy or contract prior to
the expiration of sixty days after proof of loss has been filed in accordance with the
requirements of the policy or contract and that the action may not be brought at all
unless brought within three years from the expiration of the time which proof of loss is
required by the policy or contract.
15. A provision that except as otherwise provided under this subsection, the insurer is not
liable for any loss to which a contributing cause was the insured's commission of or
attempt to commit a crime or to which a contributing cause was the insured's
engagement in an illegal occupation. However, under this subsection the insurer is
liable for a loss to the extent the crime committed was a misdemeanor violation of
section 39-08-01.