§ 44-710.03 — Sickness and accident insurance; standard policy form; mandatory provisions

Nebraska § 44-710.03

• Jurisdiction: Nebraska
• Ch. 44: Insurance

Text

Except as provided
in section 44-710.05 , each policy of sickness and accident insurance delivered
or issued for delivery to any person in this state shall contain the provisions
specified in this section in the words in which the provisions appear
in this section, except that the insurer may, at its option, substitute for
one or more of such provisions corresponding provisions of different wording
approved by the Director of Insurance which are in each instance not less
favorable in any respect to the insured or the beneficiary. Such provisions
shall be preceded individually by the caption appearing in this section or,
at the option of the insurer, by such appropriate individual or group captions
or subcaptions as the Director of Insurance may approve.
(1) A provision as follows: ENTIRE CONTRACT: CHANGES: This policy, including
the endorsements and the attached papers, if any, constitutes the entire contract
of insurance. No change in this policy shall be valid until approved by an
executive officer of the insurer and unless such approval be endorsed hereon
or attached hereto. No agent has authority to change this policy or to waive
any of its provisions.
(2) A provision as follows: TIME LIMIT ON CERTAIN DEFENSES: (a) After
two years from the date of issue of this policy no misstatements, except fraudulent
misstatements, made by the applicant in the application for such policy shall
be used to void the policy or to deny a claim for loss incurred or disability,
as defined in the policy, commencing after the expiration of such two-year
period. The foregoing policy provision shall not be so construed as to affect
any legal requirement for avoidance of a policy or denial of a claim during
such initial two-year period nor to limit the application of subdivisions
(1) through (5) of section 44-710.04 in the event of misstatement with respect
to age or occupation or other insurance. A policy which the insured has the
right to continue in force subject to its terms by the timely payment of premium
until at least age fifty or, in the case of a policy issued after age forty-four,
for at least five years from its date of issue, may contain in lieu of the
foregoing the following provision, from which the clause "as defined in the
policy" may be omitted at the insurer's option, under the caption INCONTESTABLE:
After this policy has been in force for a period of two years during the lifetime
of the insured, excluding any period during which the insured is disabled,
it shall become incontestable as to the statements contained in the application.
(b) No claim for loss incurred or disability, as defined in the policy, commencing
after two years from the date of issue of this policy shall be reduced or
denied on the ground that disease or physical condition not excluded from
coverage by name or specific description effective on the date of loss had
existed prior to the effective date of coverage of this policy.
(3) A provision as follows: GRACE PERIOD: A grace period of .........
(insert a number not less than 7 for weekly premium policies, 10 for monthly
premium policies, and 31 for all other policies) days will be granted for
the payment of each premium falling due after the first premium, during which
grace period the policy shall continue in force. A policy which contains a
cancellation provision may add, at the end of the above provision: Subject
to the right of the insurer to cancel in accordance with the cancellation
provision hereof. A policy in which the insurer reserves the right to refuse
any renewal shall have, at the beginning of the above provision: Unless not
less than thirty days prior to the premium due date the insurer has delivered
to the insured or has mailed to his or her last address as shown by the records
of the insurer written notice of its intention not to renew this policy beyond
the period for which the premium has been accepted.
(4) A provision as follows: REINSTATEMENT: If any renewal premium be
not paid within the time granted the insured for payment, a subsequent acceptance
of premium by the insurer or by any agent duly authorized by the insurer to
accept such premium, without requiring in connection therewith an application
for reinstatement, shall reinstate the policy, except that if the insurer
or such agent requires an application for reinstatement and issues a conditional
receipt for the premium tendered, the policy will be reinstated upon approval
of such application by the insurer or, lacking such approval, upon the forty-fifth
day following the date of such conditional receipt unless the insurer has
previously notified the insured in writing of its disapproval of such application.
The reinstated policy shall cover only loss resulting from such accidental
injury as may be sustained after the date of reinstatement and loss due to
such sickness as may begin more than ten days after such date. In all other
respects the insured and insurer shall have the same rights thereunder as
they had under the policy immediately before the due date of the defaulted
premium, subject to any provisions endorsed hereon or attached hereto in connection
with the reinstatement. Any premium accepted in connection with a reinstatement
shall be applied to a period for which premium has not been previously paid
but not to any period more than sixty days prior to the date of reinstatement.
(The last sentence of the above provision may be omitted from any policy which
the insured has the right to continue in force subject to its terms by the
timely payment of premiums (a) until at least age fifty or (b) in the case
of a policy issued after age forty-four, for at least five years from its
date of issue.)
(5) A provision as follows: NOTICE OF CLAIM: 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 as soon thereafter as is reasonably possible.
Notice given by or on behalf of the insured or the beneficiary to the insurer
at ........... (insert the location of such office as the insurer may designate
for the purpose), or to any authorized agent of the insurer, with information
sufficient to identify the insured, shall be deemed notice to the insurer.
In a policy providing a loss-of-time benefit which may be payable for at least
two years, an insurer may at its option insert the following between the first
and second sentences of the above provision: Subject to the qualifications
set forth below, if the insured suffers loss of time on account of disability
for which indemnity may be payable for at least two years, he or she shall,
at least once in every six months after having given notice of claim, give
to the insurer notice of continuance of such disability, except in the event
of legal incapacity. The period of six months following any filing of proof
by the insured or any payment by the insurer on account of such claim or any
denial of liability in whole or in part by the insurer shall be excluded in
applying this provision. Delay in the giving of such notice shall not impair
the insured's right to any indemnity which would otherwise have accrued during
the period of six months preceding the date on which such notice is actually
given.
(6) A provision as follows: CLAIM FORMS: The insurer, upon receipt of
a notice of claim, will furnish to the claimant such forms as are usually
furnished by it for filing proofs of loss. If such forms are not furnished
within fifteen days after the giving of such notice, the claimant shall be
deemed to have complied with the requirements of this policy as to proof of
loss upon submitting, within the time fixed in the policy for filing proofs
of loss, written proof covering the occurrence, the character, and the extent
of the loss for which claim is made.
(7) A provision as follows: PROOFS OF LOSS: Written proof of loss must
be furnished to the insurer at its office in case of claim for loss for which
the policy provides any periodic payment contingent upon continuing loss within
ninety days after the termination of the period for which the insurer is liable
and in case of claim for any other loss within ninety days after the date
of such loss. Failure to furnish such proof within the time required shall
not invalidate nor reduce any claim if it was not reasonably possible to give
proof within such time and if such proof is furnished as soon as reasonably
possible and in no event, except in the absence of legal capacity, later than
one year from the time proof is otherwise required.
(8) A provision as follows: TIME OF PAYMENT OF CLAIMS: Indemnities payable
under this policy for any loss other than loss for which this policy provides
any periodic payment will be paid immediately upon receipt of due written
proof of such loss. Subject to due written proof of loss, all accrued indemnities
for loss for which this policy provides periodic payment will be paid ................
(insert period for payment which must not be less frequently than monthly)
and any balance remaining unpaid upon the termination of liability will be
paid immediately upon receipt of due written proof.
(9) A provision as follows: PAYMENT OF CLAIMS: Indemnity for loss of
life will be payable in accordance with the beneficiary designation and the
provisions respecting such payment which may be prescribed herein and effective
at the time of payment. If no such designation or provision is then effective,
such indemnity shall be payable to the estate of the insured. Any other accrued
indemnities unpaid at the insured's death may, at the option of the insurer,
be paid either to such beneficiary or to such estate. All other indemnities
will be payable to the insured. The following provisions, or either of them,
may be included with the foregoing provision at the option of the insurer:
(a) If any indemnity of this policy shall be payable to the estate of the
insured, or to an insured or beneficiary who is a minor or otherwise not competent
to give a valid release, the insurer may pay such indemnity, up to an amount
not exceeding $.......... (insert an amount which shall not exceed five thousand
dollars), to any relative by blood or connection by marriage of the insured
or beneficiary who is deemed by the insurer to be equitably entitled thereto.
Any payment made by the insurer in good faith pursuant to this provision shall
fully discharge the insurer to the extent of such payment. (b) Subject to
any written direction of the insured in the application or otherwise all or
a portion of any indemnities provided by this policy on account of hospital,
nursing, medical, or surgical services may, at the insurer's option and unless
the insured requests otherwise in writing not later than the time of filing
proofs of such loss, be paid directly to the hospital or person rendering
such services; but it is not required that the service be rendered by a particular
hospital or person.
(10) A provision as follows: PHYSICAL EXAMINATIONS AND AUTOPSY: The
insurer at its own expense shall have the right and opportunity to examine
the person of the insured when and as often as it may reasonably require during
the pendency of a claim hereunder and to make an autopsy in case of death
where it is not forbidden by law.
(11) A provision as follows: LEGAL ACTIONS: No action at law or in equity
shall be brought to recover on this policy prior to the expiration of sixty
days after written proof of loss has been furnished in accordance with the
requirements of this policy. No such action shall be brought after the expiration
of three years after the time written proof of loss is required to be furnished.
(12) A provision as follows: CHANGE OF BENEFICIARY: Unless the insured
makes an irrevocable designation of beneficiary, the right to change of beneficiary
is reserved to the insured and the consent of the beneficiary or beneficiaries
shall not be requisite to surrender or assignment of this policy, to any change
of beneficiary or beneficiaries, or to any other changes in this policy. The
first clause of this provision, relating to the irrevocable designation of
beneficiary, may be omitted at the insurer's option.
(13) A provision as follows:
CONFORMITY WITH STATE AND FEDERAL LAW: Any provision of this policy which,
on its effective date, is in conflict with the law of the federal government
or the state in which the insured resides on such date is hereby amended to
conform to the minimum requirements of such law.

Legislative History

Source: Laws 1957, c. 188, § 4, p. 644; Laws 1989, LB 92, § 133; Laws 2011, LB72, § 3. Annotations: In accordance with section 44-767, a group health insurance policy may contain contractual limitations periods so long as they are not "less favorable to the insured than would be permitted" under this section. Brodine v. Blue Cross Blue Shield, 272 Neb. 713, 724 N.W.2d 321 (2006).