There is a newer version of the Iowa Code
2009 Iowa Code
Title 13 - Commerce
Subtitle 1 - Insurance and Related Regulation
CHAPTER 514A - ACCIDENT AND HEALTH INSURANCE
514A.3 - ACCIDENT AND SICKNESS POLICY PROVISIONS.
514A.3 ACCIDENT AND SICKNESS POLICY PROVISIONS.
1. Required provisions. Except as provided in subsection 3
of this section each such policy delivered or issued for delivery to
any person in this state shall contain the provisions specified in
this subsection in the words in which the same appear in this
section; provided, however, that the insurer may, at its option,
substitute for one or more of such provisions corresponding
provisions of different wording approved by the commissioner 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 subsection or, at the option of the
insurer, by such appropriate individual or group captions or
subcaptions as the commissioner may approve.
a. 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.
b. A provision as follows:
Time limit on certain defenses: (1) 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 this 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 subsection 2, paragraphs "a", "b", "c", "d" and
"e", 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 (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, may
contain in lieu of the foregoing the following provision (from which
the clause in parentheses 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.)
(2) 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 a 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.
c. 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 five days prior to the premium due date the
insurer has delivered to the insured or has mailed to the insured's
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.)
d. 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; provided,
however, 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 (1) until at least age
fifty or, (2) in the case of a policy issued after age forty-four,
for at least five years from its date of issue.)
e. 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, the insured shall, at least once
in every six months after having given notice of claim, give to the
insurer notice of continuance of said 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.)
f. 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.
g. A provision as follows:
Proofs of loss: Written proof of loss must be furnished to
the insurer at its said office in case of claim for loss for which
this 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, provided 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.
h. 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.
i. 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:
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 one 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.
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.)
j. 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.
k. 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.
l. 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 or 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.)
m. A provision as follows:
Right to return policy: The insured has the right, within ten
days after receipt of this policy, to return it to the company at its
home office or branch office or to the agent through whom it was
purchased, and if so returned the premium paid will be refunded and
the policy will be void from the beginning and the parties shall be
in the same position as if a policy had not been issued.
The foregoing provision shall be prominently printed on the first
page of the policy or attached to the policy.
The provisions of this paragraph "m" shall apply to any
insurance policy which is delivered or issued for delivery or renewed
in this state on or after July 1, 1978.
2. Other provisions. Except as provided in subsection 3 of
this section, no such policy delivered or issued for delivery to any
person in this state shall contain provisions respecting the matters
set forth below unless such provisions are in the words in which the
same appear in this section; provided, however, that the insurer may,
at its option, use in lieu of any such provision a corresponding
provision of different wording approved by the commissioner which is
not less favorable in any respect to the insured or the beneficiary.
Any such provision contained in the policy shall be preceded
individually by the appropriate caption appearing in this subsection
or, at the option of the insurer, by such appropriate individual or
group captions or subcaptions as the commissioner may approve.
a. A provision as follows:
Change of occupation: If the insured be injured or contract
sickness after having changed the insured's occupation to one
classified by the insurer as more hazardous than that stated in this
policy or while doing for compensation anything pertaining to an
occupation so classified, the insurer will pay only such portion of
the indemnities provided in this policy as the premium paid would
have purchased at the rates and within the limits fixed by the
insurer for such more hazardous occupation. If the insured changes
the insured's occupation to one classified by the insurer as less
hazardous than that stated in this policy, the insurer, upon receipt
of proof of such change of occupation, will reduce the premium rate
accordingly, and will return the excess pro rata unearned premium
from the date of change of occupation or from the policy anniversary
date immediately preceding receipt of such proof, whichever is the
more recent. In applying this provision, the classification of
occupational risk and the premium rates shall be such as have been
last filed by the insurer prior to the occurrence of the loss for
which the insurer is liable or prior to date of proof of change in
occupation with the state official having supervision of insurance in
the state where the insured resided at the time this policy was
issued; but if such filing was not required, then the classification
of occupational risk and the premium rates shall be those last made
effective by the insurer in such state prior to the occurrence of the
loss or prior to the date of proof of change in occupation.
b. A provision as follows:
Misstatement of age: If the age of the insured has been
misstated, all amounts payable under this policy shall be such as the
premium paid would have purchased at the correct age.
c. A provision as follows:
Other insurance in this insurer: If an accident or sickness
or accident and sickness policy or policies previously issued by the
insurer to the insured be in force concurrently herewith, making the
aggregate indemnity for ... (insert type of coverage or coverages)
in excess of $... (insert maximum limit of indemnity or indemnities)
the excess insurance shall be void and all premiums paid for such
excess shall be returned to the insured or to the insured's estate.
Or, in lieu thereof:
Insurance effective at any one time on the insured under a like
policy or policies in this insurer is limited to the one such policy
elected by the insured, or the insured's beneficiary or estate, as
the case may be, and the insurer will return all premiums paid for
all other such policies.
d. A provision as follows:
Insurance with other insurers: If there be other valid
coverage, not with this insurer, providing benefits for the same loss
on a provision of service basis or on an expense incurred basis and
of which this insurer has not been given written notice prior to the
occurrence or commencement of loss, the only liability under any
expense incurred coverage of this policy shall be for such proportion
of the loss as the amount which would otherwise have been payable
hereunder plus the total of the like amounts under all such other
valid coverages for the same loss of which this insurer had notice
bears to the total like amounts under all valid coverages for such
loss, and for the return of such portion of the premiums paid as
shall exceed the pro rata portion for the amount so determined. For
the purpose of applying this provision when other coverage is on a
provision of service basis, the "like amount" of such other coverage
shall be taken as the amount which the services rendered would have
cost in the absence of such coverage.
(If the foregoing policy provision is included in a policy which
also contains the next following policy provision there shall be
added to the caption of the foregoing provision the phrase " --
expense incurred benefits". The insurer may, at its option, include
in this provision a definition of "other valid coverage", approved as
to form by the commissioner, which definition shall be limited in
subject matter to coverage provided by organizations subject to
regulation by insurance law or by insurance authorities of this or
any other state of the United States or any province of Canada, and
by hospital or medical service organizations, and to any other
coverage the inclusion of which may be approved by the commissioner.
In the absence of such definition such term shall not include group
insurance, automobile medical payments insurance, or coverage
provided by hospital or medical service organizations or by union
welfare plans or employer or employee benefit organizations. For the
purpose of applying the foregoing policy provision with respect to
any insured, any amount of benefit provided for such insured pursuant
to any compulsory benefit statute (including any workers'
compensation or employer's liability statute) whether provided by a
governmental agency or otherwise shall in all cases be deemed to be
"other valid coverage" of which the insurer has had notice. In
applying the foregoing policy provision no third party liability
coverage shall be included as "other valid coverage".)
e. A provision as follows:
Insurance with other insurers: If there be other valid
coverage, not with this insurer, providing benefits for the same loss
on other than an expense incurred basis and of which this insurer has
not been given written notice prior to the occurrence or commencement
of loss, the only liability for such benefits under this policy shall
be for such proportion of the indemnities otherwise provided
hereunder for such loss as the like indemnities of which the insurer
had notice (including the indemnities under this policy) bear to the
total amount of all like indemnities for such loss, and for the
return of such portion of the premium paid as shall exceed the pro
rata portion for the indemnities thus determined.
(If the foregoing policy provision is included in a policy which
also contains the next preceding policy provision there shall be
added to the caption of the foregoing provision the phrase " --
other benefits". The insurer may, at its option, include in this
provision a definition of "other valid coverage", approved as to form
by the commissioner, which definition shall be limited in subject
matter to coverage provided by organizations subject to regulation by
insurance law or by insurance authorities of this or any other state
of the United States or any province of Canada, and to any other
coverage the inclusion of which may be approved by the commissioner.
In the absence of such definition such term shall not include group
insurance, or benefits provided by union welfare plans or by employer
or employee benefit organizations. For the purpose of applying the
foregoing policy provision with respect to any insured, any amount of
benefit provided for such insured pursuant to any compulsory benefit
statute (including any workers' compensation or employer's liability
statute) whether provided by a governmental agency or otherwise shall
in all cases be deemed to be "other valid coverage" of which the
insurer has had notice. In applying the foregoing policy provision
no third party liability coverage shall be included as "other valid
coverage".)
f. A provision as follows:
Relation of earnings to insurance: If the total monthly
amount of loss of time benefits promised for the same loss under all
valid loss of time coverage upon the insured, whether payable on a
weekly or monthly basis, shall exceed the monthly earnings of the
insured at the time disability commenced or the insured's average
monthly earnings for the period of two years immediately preceding a
disability for which claim is made, whichever is the greater, the
insurer will be liable only for such proportionate amount of such
benefits under this policy as the amount of such monthly earnings or
such average monthly earnings of the insured bears to the total
amount of monthly benefits for the same loss under all such coverage
upon the insured at the time such disability commences and for the
return of such part of the premiums paid during such two years as
shall exceed the pro rata amount of the premiums for the benefits
actually paid hereunder; but this shall not operate to reduce the
total monthly amount of benefits payable under all such coverage upon
the insured below the sum of two hundred dollars or the sum of the
monthly benefits specified in such coverages, whichever is the
lesser, nor shall it operate to reduce benefits other than those
payable for loss of time.
(The foregoing policy provision may be inserted only in a policy
which the insured has the right to continue in force subject to its
terms by the timely payment of premiums (1) until at least age fifty
or, (2) in the case of a policy issued after age forty-four, for at
least five years from its date of issue. The insurer may, at its
option, include in this provision a definition of "valid loss of time
coverage", approved as to form by the commissioner, which definition
shall be limited in subject matter to coverage provided by
governmental agencies or by organizations subject to regulation by
insurance law or by insurance authorities of this or any other state
of the United States or any province of Canada, or to any other
coverage the inclusion of which may be approved by the commissioner
or any combination of such coverages. In the absence of such
definition such term shall not include any coverage provided for such
insured pursuant to any compulsory benefit statute (including any
workers' compensation or employer's liability statute), or benefits
provided by union welfare plans or by employer or employee benefit
organizations.)
g. A provision as follows:
Unpaid premium: Upon the payment of a claim under this
policy, any premium then due and unpaid or covered by any note or
written order may be deducted therefrom.
h. A provision as follows:
Cancellation: The insurer may cancel this policy at any time
by written notice delivered to the insured, or mailed to the
insured's last address as shown by the records of the insurer,
stating when, not less than five days thereafter, such cancellation
shall be effective; and after the policy has been continued beyond
its original term the insured may cancel this policy at any time by
written notice delivered or mailed to the insurer, effective upon
receipt or on such later date as may be specified in such notice. In
the event of cancellation, the insurer will return promptly the
unearned portion of any premium paid. If the insured cancels, the
earned premium shall be computed by the use of the short-rate table
last filed with the state official having supervision of insurance in
the state where the insured resided when the policy was issued. If
the insurer cancels, the earned premium shall be computed pro rata.
Cancellation shall be without prejudice to any claim originating
prior to the effective date of cancellation.
i. A provision as follows:
Conformity with state statutes: Any provision of this policy
which, on its effective date, is in conflict with the statutes of the
state in which the insured resides on such date is hereby amended to
conform to the minimum requirements of such statutes.
j. A provision as follows:
Illegal occupation: The insurer shall not be liable for any
loss to which a contributing cause was the insured's commission of or
attempt to commit a felony or to which a contributing cause was the
insured's being engaged in an illegal occupation.
k. A provision as follows:
Intoxicants and narcotics: The insurer shall not be liable
for any loss sustained or contracted in consequence of the insured's
being intoxicated or under the influence of any narcotic unless
administered on the advice of a physician. This provision shall not
be used with respect to a medical expense policy. For purposes of
this provision, "medical expense policy" means an accident and
sickness insurance policy that provides hospital, medical, and
surgical expense coverage.
3. Inapplicable or inconsistent provisions. 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 the insurer, with the approval of the commissioner, shall omit
from such policy any inapplicable provision or part of a provision,
and shall modify any inconsistent provision or part of the provision
in such manner as to make the provision as contained in the policy
consistent with the coverage provided by the policy.
4. Order of certain policy provisions. The provisions which
are the subject of subsections 1 and 2 of this section, or any
corresponding provisions which are used in lieu thereof in accordance
with such subsections, shall be printed in the consecutive order of
the provisions in such subsections or, at the option of the insurer,
any such provision may appear as a unit in any part of the policy,
with other provisions to which it may be logically related, provided
the resulting policy shall not be in whole or in part unintelligible,
uncertain, ambiguous, abstruse, or likely to mislead a person to whom
the policy is offered, delivered or issued.
5. Third party ownership. The word "insured", as used in
this chapter, shall not be construed as preventing a person other
than the insured with a proper insurable interest from making
application for and owning a policy covering the insured or from
being entitled under such a policy to any indemnities, benefits and
rights provided therein.
6. Requirements of other jurisdictions.
a. Any policy of a foreign or alien insurer, when delivered
or issued for delivery to any person in this state, may contain any
provision which is not less favorable to the insured or the
beneficiary than the provisions of this chapter and which is
prescribed or required by the law of the state under which the
insurer is organized.
b. Any policy of a domestic insurer may, when issued for
delivery in any other state or country, contain any provision
permitted or required by the laws of such other state or country.
7. Filing procedure. The commissioner may make such
reasonable rules and regulations concerning the procedure for the
filing or submission of policies subject to this chapter as are
necessary, proper or advisable to the administration of this chapter.
This provision shall not abridge any other authority granted the
commissioner by law. Section History: Early Form
[S13, § 1820; C24, 27, 31, 35, 39, § 8775; C46, 50, § 511.36;
C54, 58, 62, 66, 71, 73, 75, 77, 79, 81, § 514A.3] Section History: Recent Form
90 Acts, ch 1234, § 31; 2002 Acts, ch 1111, §15; 2002 Acts, ch
1119, §68
Referred to in § 514A.2, 514A.4, 514A.12, 514D.3, 514D.6, 514D.7
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