26-37-105. Agents of mechanical breakdown insurers.
(a) Upon issuance of a certificate of authority under W.S. 26-37-104, a licensed agent appointed to market the casualty insurance policies of the certified mechanical breakdown insurer within this state may market mechanical breakdown insurance policies of that insurer within this state without further licensing, testing or fees from the department.
(b) Agents marketing mechanical breakdown insurance shall comply with all other provisions of this code relating to the transaction of insurance as an agent.
26-37-106. Mechanical breakdown insurance organizations; applications for certificates of authority; fee; issuance.
(a) A mechanical breakdown insurance organization may file with the commissioner an application for a certificate of authority to transact mechanical breakdown insurance in this state upon a form to be furnished by the department which shall include the following:
(i) The names, addresses and all occupations of any current and anticipated principal, partner, officer and director for the preceding ten (10) years;
(ii) A certified copy of any corporate articles and bylaws, partnership agreements and other organizational agreements reasonably required by the commissioner and if previously incorporated, the corporate annual statements and reports for the three (3) most recent years;
(iii) A statement of the amount and sources of the funds available for organization expenses and the proposed arrangements for reimbursement and compensation of incorporators or other persons;
(iv) A statement of compensation of current and anticipated principals, partners, directors and officers;
(v) The forms to be used for any proposed contracts between the organization and providers of mechanical breakdown services and any corporations which perform administrative, marketing or management services concerning the provision of services to insureds;
(vi) The plan for conducting the insurance business, including the following:
(A) The geographical area in which the business is to be transacted in the first five (5) years;
(B) The types of insurance to be written in the first five (5) years including whether and to what extent repayment rather than service benefits are to be provided;
(C) The proposed marketing methods;
(D) Actuarial data or other similar statistical data, documented and verified in the manner the department may reasonably require, affirmatively demonstrating the anticipated income and expenses in the first five (5) years including without limitation, the projected expenditure for mechanical breakdown services and projected source of funds for any anticipated deficit;
(E) A complete statement concerning claims procedures.
(vii) A current statement of the assets and liabilities of the applicant;
(viii) Forms of all mechanical breakdown insurance contracts the applicant proposes to offer specifying the rates to be charged for each form of contract;
(ix) Any other documents or information the department reasonably requires.
(b) A fee of two hundred fifty dollars ($250.00) shall accompany the application filed under subsection (a) of this section.
(c) The commissioner shall issue a certificate of authority if he is satisfied that:
(i) All requirements of law are met;
(ii) All current and anticipated principals, partners, incorporators, directors and principal officers are trustworthy and competent and collectively have the competence and experience to engage in the proposed insurance business; and
(iii) The business plan is consistent with the interests of the potential insureds of the corporation and the public.
26-37-107. Mechanical breakdown insurance organizations; revocation or suspension of certificate of authority.
(a) The commissioner shall revoke or suspend the certificate of authority issued to any mechanical breakdown insurance organization under W.S. 26-37-106 if after a hearing in accordance with W.S. 26-2-125 through 26-2-129, he finds the organization:
(i) Violates any provision of this chapter or chapter 13 of this code;
(ii) Is insolvent;
(iii) Has assets less than its liabilities;
(iv) Refuses or any officer refuses to submit to an examination; or
(v) Is transacting business fraudulently.
(b) The commissioner shall give public notice of any revocation or suspension under this section in a manner he deems proper.
bond, deposit or contractual liability insurance requirement; amounts; purpose; release; modification of initial order.
(a) To assure the faithful performance of obligations under insolvency, each mechanical breakdown insurance organization certified under W.S. 26-37-106 shall deposit and maintain with the commissioner, trust securities of the type eligible as investments by insurers under chapter 7 of this code. The trust securities required by this section shall at all times have the following market value:
(i) For an organization not transacting mechanical breakdown insurance in this state prior to January 1, 1987 and before issuing a certificate of authority under this chapter and receiving premiums, an initial amount of fifty thousand dollars ($50,000.00);
(ii) For an organization transacting mechanical breakdown insurance in this state prior to January 1, 1987 and having in force less than three hundred thousand dollars ($300,000.00) of gross written premiums, membership fees or similar charges, a sum equal to fifty percent (50%) of the gross premiums in force or fifty thousand dollars ($50,000.00), whichever is less;
(iii) For an organization transacting mechanical breakdown insurance in this state prior to January 1, 1987 and having in force more than three hundred thousand dollars ($300,000.00) but less than seven hundred fifty thousand dollars ($750,000.00) of gross written premiums, membership fees or similar charges in this state, an amount not less than seventy-five thousand dollars ($75,000.00); and
(iv) For an organization transacting mechanical breakdown insurance in this state prior to January 1, 1987 and having in force seven hundred fifty thousand dollars ($750,000.00) or more of gross written premiums, membership fees or similar charges in this state, an amount equal to one hundred thousand dollars ($100,000.00).
(b) An organization may instead of depositing securities required under subsection (a) of this section and subject to the approval of the commissioner, file with the commissioner a surety bond issued by an authorized surety insurer under this code. The bond shall be for that purpose stated under subsection (a) of this section and the commissioner shall not approve any bond if the protection against insolvency is not equal to the protection afforded by those securities under subsection (a) of this section.
(c) An organization may instead of any deposit of securities or filing of surety bonds required under subsections
(a) and (b) of this section and subject to approval of the commissioner, file a paid contractual liability insurance policy with the commissioner. This policy shall be issued by an insurer authorized to transact insurance in this state and shall be in an amount equal to or greater than fifty percent (50%) of gross written premiums in this state. The commissioner shall not approve any contractual liability insurance policy if the protection against insolvency is not equal to the protection afforded by those securities under subsection (a) of this section.
(d) Securities, bonds or insurance policies posted or filed pursuant to this section shall in case of insolvency or impairment of any organization, be for the benefit of and subject to action by any person sustaining any injury due to the failure of the organization to faithfully perform its obligations to its insureds.
(e) The state is responsible for the safekeeping of all securities deposited with the commissioner under this chapter. The securities are not subject to taxation but shall be held exclusively to guarantee the performance of the obligations of the organization to its insureds.
(f) The deposit, bond or insurance shall be maintained unimpaired as long as the mechanical breakdown insurance organization continues to operate in this state. If the organization ceases to do business in this state and furnishes proof satisfactory to the commissioner that it has discharged or otherwise adequately provided for all its obligations to its insureds in this state, the state shall release the deposited securities to the entitled parties on presentation of the state treasurer's receipts for those securities or shall release any filed bond or insurance policy.
(g) At any time the commissioner may enter an order increasing the amount of the deposit, bond or insurance specified under subsections (a), (b) and (c) of this section if he finds there has been a substantial change in the facts including an increase in the amount of premiums, membership fees or similar charges in force in this state on which the original determination was based. Within thirty (30) days after receipt of notice, the organization may submit a request to the commissioner for a hearing on the order for modification. The commissioner shall hold a hearing within thirty (30) days after receipt of the request. Failure to meet the modified requirements within thirty (30) days after a final decision or after expiration of the thirty (30) day period for submitting a request for hearing is grounds for rehabilitation pursuant to chapter 28 of this code.
26-37-109. Appointment of commissioner as attorney for
mechanical breakdown insurance organization; service of process. Any mechanical breakdown insurance organization desiring to transact business in this state shall file with the commissioner a duly executed instrument whereby the organization shall appoint the commissioner as the attorney of the organization upon whom all lawful process in any action or legal proceeding against it on a contract issued or cause of action arising in this state may be served. In addition, the organization shall agree that any lawful process against it which may be served upon its attorney as provided in this section shall be of the same force and validity as if served upon the organization and that the authority thereof shall continue in force irrevocably so long as any liability of the organization in the state remains outstanding.
26-37-110. Examination of mechanical breakdown insurance organizations; audited financial statement.
(a) Every mechanical breakdown insurance organization is subject to examination by the commissioner in the manner and under the conditions provided for examination of insurers pursuant to W.S. 26-2-116 through 26-2-122. In the examination, the assets of any organization are those assets determined by the commissioner to be available for the payment of the obligations of the organization. In accordance with W.S. 26-2-122, the expense of examination shall be paid by the organization.
(b) Instead of examination under subsection (a) of this section, the commissioner may accept a copy of the most recent financial statement of the organization which has been audited by an independent certified public accountant and which demonstrates that the organization is solvent as determined by generally accepted accounting principles.
26-37-111. Mechanical breakdown insurance organizations; solicitations to purchase.
No person shall solicit or aid in the solicitation of another person to purchase a policy issued by a mechanical breakdown insurance organization not having a certificate of authority procured pursuant to this act.
26-37-112. Mechanical breakdown insurance organizations; misrepresentations as to service contracts.
No mechanical breakdown insurance organization, dealer, representative or other person shall in any manner misrepresent the terms, benefits or privileges of any policy issued by the organization.
No person shall act as a mechanical breakdown insurance organization dealer in this state without first procuring a license from the commissioner in accordance with W.S. 26-37-115 through 26-37-119.
26-37-115. Mechanical breakdown insurance organizations; application for dealer's license.
(a) Application for a license as a mechanical breakdown insurance dealer shall be made to the commissioner upon forms prescribed and furnished by the commissioner. As a part of or in connection with any application, the applicant shall furnish information concerning his identity, personal history, experience, business record and other pertinent facts the commissioner may reasonably require.
(b) If the applicant is a firm, partnership or corporation, the application shall in addition to the requirements of subsection (a) of this section:
(i) Contain the names of all members and officers of the firm, partnership or corporation; and
(ii) Designate who is to exercise the powers to be conferred by the license on the firm, partnership or corporation.
(c) The commissioner shall require each individual of a firm, partnership or corporation to furnish information to the extent as if applying for an individual license.
(d) Any person willfully misrepresenting any fact required to be disclosed in any application is subject to the penalties provided by W.S. 26-1-107.
general conditions for issuance or renewal of dealer's license.
(a) For the protection of the people of this state, the commissioner shall not issue or renew any mechanical breakdown insurance dealer's license:
(i) Unless the applicant is in compliance with this chapter;
(ii) To any person found untrustworthy or incompetent or who has not established to the satisfaction of the commissioner that he is qualified in accordance with this chapter.
26-37-117. Mechanical breakdown insurance organizations; qualifications for dealer's license.
(a) In addition to conditions specified under W.S. 26-37-116, the commissioner shall issue a mechanical breakdown insurance dealer's license only to an individual otherwise complying with this chapter furnishing evidence satisfactory to the commissioner that he:
(i) Is an adult;
(ii) Has been a bona fide resident of this state for at least three (3) months;
(iii) Is a trustworthy person with a good reputation; and
(iv) Has never been convicted of a felony that relates to the mechanical breakdown insurance profession or to the ability to practice as a mechanical breakdown insurance dealer. The commissioner shall have discretion as to whether to issue a license if there has been a relevant conviction.
26-37-118. Mechanical breakdown insurance organizations; form and content of dealer's license.
(a) The commissioner shall prescribe the form of the mechanical breakdown insurance dealer's license which shall contain the:
(i) Name of the licensee and his business address;
(ii) Date of issuance and the date of expiration; and
(iii) Name of the represented mechanical breakdown insurance organization.
grounds for suspension, revocation or refusal to renew dealer's license generally.
(a) The commissioner may suspend, revoke or refuse to renew any mechanical breakdown insurance dealer's license issued under this chapter for any cause specified by this chapter including the following:
(i) A violation or willful participation in a violation of this chapter;
(ii) Obtainment of any license through misrepresentation or fraud;
(iii) Misappropriation, conversion for the use of the licensee or illegal withholding of monies required to be held in a fiduciary capacity;
(iv) Material misrepresentation of the terms or effect of any contract or the engagement in any fraudulent transaction;
(v) A conviction by final judgment of a felony that relates to the mechanical breakdown insurance profession or to the ability to practice as a mechanical breakdown insurance dealer;
(vi) Incompetency, untrustworthiness or a source of injury or loss to the public as demonstrated in the conduct of affairs under a license;
(vii) Misrepresentation of the qualifications of the licensee's representatives;
(viii) Permitting any individual not registered as a representative with the commissioner to act as a representative;
(ix) Any cause of license suspension or revocation provided under W.S. 26-9-211.
grounds for suspension, revocation or refusal of dealer's license of firm, partnership or corporation. A mechanical breakdown insurance dealer's license issued to any firm, partnership or corporation may be suspended, revoked or refused for any cause relating to any individual designated in the license to exercise its powers.
26-37-122. Mechanical breakdown insurance organizations; surrender of revoked or suspended license certificate.
The holder of any mechanical breakdown insurance dealer's license which has been revoked or suspended shall immediately surrender the license certificate to the commissioner.
26-37-123. Mechanical breakdown insurance organizations; representatives of dealers; registration required.
No person shall act as the representative of a dealer for a mechanical breakdown insurance organization unless he has first been registered with the commissioner pursuant to W.S. 26-37-124.
representatives of dealers; registration requirements; fee; renewal; suspension or revocation.
(a) Any dealer for a mechanical breakdown insurance organization shall register its representatives with the commissioner by filing an application for registration stating the:
(i) Name and address of the registrant;
(ii) Registrant has been a resident of this state for at least thirty (30) days preceding the date of application;
(iii) Registrant is a trustworthy person with a good reputation; and
(iv) Registrant is familiar with the benefits, costs, coverage and claims procedure of the mechanical breakdown insurance marketed by the dealer.
(b) The dealer shall pay a registration fee of ten dollars ($10.00) for each individual registered under this section.
(c) Upon payment of a renewal fee of ten dollars ($10.00), representative registrations are renewable on the first day of August of each year unless sooner suspended or revoked.
(d) Representative registrations may be suspended or revoked for those causes and subject to the procedure applicable to dealers under this chapter or to agents of insurers under this code.
26-37-125. Types of mechanical breakdown insurance; policy
and certificate forms; issuance of policies and certificates.
(a) A mechanical breakdown insurer and a mechanical breakdown insurance organization may write mechanical breakdown insurance as individual, group, blanket or franchise insurance. Each contractual obligation for mechanical breakdown insurance shall be evidenced by a policy. Any insured person under a group policy shall be issued a certificate of coverage.
(b) No policy or certificate of mechanical breakdown insurance shall be issued in this state unless a copy of the form has been filed with and approved by the commissioner.
(c) The commissioner shall not approve any form that does not meet the following requirements:
(i) Policies shall contain a list and description of the mechanical breakdown payments promised or the mechanical breakdowns for which expenses are to be reimbursed, any limits on the amounts to be paid or reimbursed and procedures to be followed by the insured and the insurer in the event of a claim;
(ii) Policies and certificates shall indicate the name of the insurer and the full address of its principal place of business;
(iii) Certificates issued under group policies shall contain a full statement of the benefits provided, any exceptions and claim procedures but may summarize the other terms of the master policy; and
(iv) No policy except a policy issued by a mutual or reciprocal insurance company may provide for assessments on policyholders or for reduction of benefits for the purpose of maintaining the insurer's solvency.
(d) The department may disapprove a policy or certificate form if it finds that it:
(i) Is unfair, unfairly discriminatory, misleading, ambiguous or encourages misrepresentation or misunderstanding of the contract;
(ii) Provides coverage or benefits or contains other provisions that endanger the insurer's solvency; or
(iii) Is contrary to law.
26-37-126. Filing and approval of contracts; annual reports by organizations.
(a) Contracts made between the organization and its dealers and representatives and contracts with other providers of services under the mechanical breakdown insurance policy shall be filed with and approved by the commissioner.
(b) Organizations shall annually report to the commissioner in reasonably required detail, the number and geographical distribution of providers of services covered by the mechanical breakdown insurance policy with whom it maintains contractual relations and the nature of the relations. For individual insurers or groups of insurers, the commissioner may require more frequent reports.
After notice and hearing, the commissioner may promulgate rules and regulations necessary to carry out this chapter. Rules and regulations promulgated under this chapter are subject to review in accordance with W.S. 28-9-101 through 28-9-108.
The requirements of this article shall apply to policies delivered or issued for delivery in this state on or after the effective date of this article. This article is not intended to supersede the obligations of entities subject to this article to comply with the substance of other applicable insurance laws insofar as they do not conflict with this article, except that laws and regulations designed and intended to apply to medicare supplement insurance policies shall not be applied to long-term care insurance. A policy which is not advertised, marketed or offered as long-term care insurance or nursing home insurance need not meet the requirements of this article.
(a) As used in this article:
(i) "Applicant" means:
(A) In the case of an individual long-term care insurance policy, the person who seeks to contract for benefits;
(B) In the case of a group long-term care insurance policy, the proposed certificate holder.
(ii) "Certificate" means any certificate issued under a group long-term care insurance policy, which policy has been delivered or issued for delivery in this state;
(iii) "Commissioner" means the insurance commissioner of this state;
(iv) "Group long-term care insurance" means a long-term care insurance policy which is delivered or issued for delivery in this state and issued to:
(A) One (1) or more employers or labor organizations, or to a trust or to the trustees of a fund established by one (1) or more employers or labor organizations, or a combination thereof, for employees or former employees or a combination thereof or for members or former members or a combination thereof, of the labor organizations;
(B) Any professional, trade or occupational association for its members or former or retired members, or combination thereof, if the association:
(I) Is composed of individuals all of whom are or were actively engaged in the same profession, trade or occupation; and
(II) Has been maintained in good faith for purposes other than obtaining insurance; or
(C) An association or a trust or the trustee of a fund established, created or maintained for the benefit of members of one (1) or more associations. Prior to advertising, marketing or offering the policy within this state, the association or associations, or the insurer of the association or associations, shall file evidence with the commissioner that the association or associations has met the organizational requirements of this subparagraph. Thirty (30) days after filing, the association or associations will be deemed to satisfy the organizational requirements unless the commissioner makes a finding that the association or associations do not satisfy those organizational requirements. The evidence filed shall establish that the association or associations has at the outset a minimum of one hundred (100) persons and has been organized and maintained in good faith for purposes other than that of obtaining insurance, has been in active existence for at least one (1) year and has a constitution and bylaws which provide that:
(I) The association or associations hold regular meetings not less than annually to further purposes of the members;
(II) Except for credit unions, the association or associations collect dues or solicit contributions from members; and
(III) The members have voting privileges and representation on the governing board and committees.
(D) A group other than as described in subparagraphs (A), (B) and (C) of this paragraph, subject to a finding by the commissioner that:
(I) The issuance of the group policy is in the best interest of the public;
(II) The issuance of the group policy will result in economies of acquisition or administration; and
(III) The benefits are reasonable in relation to the premiums charged.
(v) "Long-term care insurance" means any insurance policy or rider advertised, marketed, offered or designed to provide coverage for not less than twelve (12) consecutive months for each covered person on an expense incurred, indemnity, prepaid or other basis, for one (1) or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance or personal care services, provided in a setting other than an acute care unit of a hospital. The term includes group and individual annuities and life insurance policies or riders which provide directly or which supplement long-term care insurance. The term also includes a policy or rider which provides for payment of benefits based upon cognitive impairment or the loss of functional capacity. The term shall also include qualified long-term care contracts. Long-term care insurance may be issued by insurers, fraternal benefit societies, nonprofit health, hospital and medical service corporations, prepaid health plans, health maintenance organizations or any similar organization to the extent the entity is otherwise authorized to issue life or health insurance. Long-term care insurance shall not include any insurance policy which is offered primarily to provide basic Medicare supplement coverage, basic hospital expense coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income or related asset protection coverage, accident only coverage, specified disease or specified accident coverage or limited benefit health coverage. With regard to life insurance, the term "long-term care insurance" does not include life insurance policies which accelerate the death benefit specifically for one (1) or more of the qualifying events of terminal illness, medical conditions requiring extraordinary medical intervention, or permanent institutional confinement, and which provide the option of a lump-sum payment for those benefits and in which neither the benefits nor the eligibility for the benefits is conditioned upon the receipt of long-term care. Notwithstanding any other provision contained in this article, other than W.S. 26-38-109(e), any product advertised, marketed or offered as long-term care insurance shall be subject to the provisions of this article;
(vi) "Policy" means any policy, contract, subscriber agreement, certificate, rider or endorsement delivered or issued for delivery in this state by an insurer, fraternal benefit society, nonprofit health, hospital or medical service corporation, prepaid health plan, health maintenance organization or any similar organization;
(vii) "Preexisting condition" means a condition for which medical advice, diagnosis, care or treatment was recommended by, or received from a provider of health care services, within six (6) months preceding the effective date of coverage of an insured person;
(viii) "Qualified long-term care insurance contract" means any life insurance contract which provides long-term care coverage by rider or as part of the contract so long as it is in compliance with the applicable provisions of section 7702B of the Internal Revenue Code, as amended. The term also means any other individual or group insurance contract if it meets the requirements of section 7702(B) of the Internal Revenue Code, as amended, and if:
(A) The only insurance protection provided under the contract is coverage of qualified long-term care services;
(B) The contract does not pay or reimburse expenses incurred for services or items to the extent that such expenses are reimbursable under Title XVIII of the Social Security Act, as amended, or would be so reimbursable but for the application of a deductible or coinsurance amount. The requirements of this subparagraph do not apply to contracts in which Medicare is a secondary payor, or if the contract makes per diem or other periodic payments without regard to expenses;
(C) The contract is guaranteed renewable;
(D) The contract does not provide for a cash surrender value or other money that can be paid, assigned, pledged as collateral for a loan or borrowed. All refunds of premiums, and all policyholder dividends or similar amounts, under such contract are to be applied as a reduction in future premiums or to increase future benefits, except that a refund of the aggregate premium paid under the contract may be allowed in the event of death of the insured or a complete surrender or cancellation of the contract; and
(E) The contract contains the consumer protection provisions set forth in section 7702B(g) of the Internal Revenue Code.
(ix) "Qualified long-term care services" means necessary diagnostic, preventive, therapeutic, curing, treating, mitigating, and rehabilitative services, and maintenance for personal care services to which an insured is eligible for under a qualified long-term care insurance contract, and which are provided pursuant to a plan of care prescribed by a licensed health care practitioner.
26-38-104. Limits of group long-term care insurance.
No group long-term care insurance coverage may be offered to a resident of this state under a group policy issued in another state to a group described in W.S. 26-38-103(a)(iv)(D), unless this state or another state having statutory and regulatory long-term care insurance requirements substantially similar to those adopted in this state has made a determination that those requirements have been met.
26-38-105. Disclosure and performance standards for long- term care insurance.
(a) The commissioner shall adopt regulations that include standards for full and fair disclosure setting forth the manner, content and required disclosures for the sale of long-term care insurance policies, terms of renewability, initial and subsequent conditions of eligibility, nonduplication of coverage provisions, coverage of dependents, preexisting conditions, termination of insurance, probationary periods, limitations, exceptions, reductions, elimination periods, requirements for replacement, recurrent conditions and definitions of terms.
(b) No long-term care insurance policy shall:
(i) Be cancelled, nonrenewed or otherwise terminated on the grounds of the age or the deterioration of the mental or physical health of the insured individual or certificate holder;
(ii) Contain a provision establishing a new waiting period in the event existing coverage is converted to or replaced by a new or other form within the same company, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder; or
(iii) Contain coverage for skilled nursing care only or contain coverage that provides significantly more skilled care in a facility than coverage for lower levels of care.
(c) No long-term care insurance policy or certificate shall use a definition of "preexisting condition" which is more restrictive than the definition provided in this article.
(d) No long-term care insurance policy shall exclude coverage for a loss or confinement which is the result of a preexisting condition unless the loss or confinement begins within six (6) months following the effective date of coverage of an insured person.
(e) The commissioner may extend the limitation periods set forth in subsections (c) and (d) of this section as to specific age group categories in specific policy forms upon finding that the extension is in the best interest of the public.
(f) The definition of "preexisting condition" does not prohibit an insurer from using an application form designed to elicit the complete health history of an applicant, and, on the basis of the answers on that application, from underwriting in accordance with that insurer's established underwriting standards. Unless otherwise provided in the policy, a preexisting condition, regardless of whether it is disclosed in the application, need not be covered until the waiting period described in subsection (d) of this section expires. No long-term care insurance policy may exclude or use waivers or riders of any kind to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions beyond the waiting period described in subsection (d) of this section.
(g) No long-term care insurance policy may be delivered or issued for delivery in this state if the policy:
(i) Conditions eligibility for any benefits on a prior hospitalization requirement;
(ii) Conditions eligibility for benefits provided in an institutional care setting on the receipt of a higher level of institutional care;
(iii) Conditions eligibility for any benefits, other than waiver of premium, post-confinement, post-acute care or recuperative benefits, on a prior institutionalization requirement; or
(iv) Fails to meet any of the following requirements:
(A) A long-term care insurance policy containing post-confinement, post-acute care or recuperative benefits shall clearly label in a separate paragraph of the policy or certificate entitled "limitations or conditions on eligibility for benefits" the limitations or conditions, including any required number of days of confinement;
(B) A long-term care insurance policy or rider which conditions eligibility of noninstitutional benefits on the prior receipt of institutional care shall not require a prior institutional stay of more than five (5) days;
(C) No long-term care insurance policy or rider which provides benefits only following institutionalization shall condition the benefits upon admission to a facility for the same or related conditions within a period of less than thirty (30) days after discharge from the institution.
(h) The commissioner shall adopt regulations establishing loss ratio standards for long-term care insurance policies provided that a specific reference to long-term care insurance policies is contained in the regulation.
(j) Long-term care insurance policyholders or certificate holders, shall have the right to return the policy or certificate within thirty (30) days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the policyholder or certificate holder is not satisfied for any reason. Long-term care insurance policies and certificates shall have a notice prominently printed on the first page of the policy and certificate or attached thereto stating in substance that the policyholder or certificate holder shall have the right to return the policy within thirty (30) days of its delivery and to have the premium refunded if, after examination of the policy or certificate, other than a certificate issued pursuant to a policy issued to a group defined in W.S. 26-38-103(a)(iv)(A), the policyholder or certificate holder is not satisfied for any reason. The premium shall be refunded within ten (10) days, excluding Saturdays, Sundays and legal holidays, from the date the policy or certificate is returned. If the premium required to be refunded under this subsection is not refunded within the time periods specified it shall draw interest at the maximum rate allowed for a credit service charge under W.S. 40-14-212(b). No company issuing a long-term care insurance policy shall be required to pay any claim under the terms of the policy until the expiration of the thirty (30) day period. If an application for a qualified long-term care contract is denied, the issuer shall refund to the applicant any premium refund within thirty (30) days of the denial.
(k) An outline of coverage shall be delivered to a prospective applicant at the time of the initial solicitation through means which prominently direct the attention of the recipient to the document and its purpose. The commissioner shall prescribe a standard format of the outline of coverage, including style, arrangement, overall appearance and content. In the case of agent solicitations, an agent shall deliver the outline of coverage prior to the presentation of an application or enrollment form. In the case of direct response solicitations, the outline of coverage shall be presented in conjunction with any application or enrollment form. In the case of a group policy, the outline shall be delivered to certificate holders when the certificate is delivered. The outline of coverage shall include:
(i) A description of the principal benefits and coverage provided in the policy;
(ii) A statement of the principal exclusions, reductions and limitations contained in the policy;
(iii) A statement of the terms under which the policy or certificate, or both, may be continued in force or discontinued, including any reservation in the policy of a right to change premium. Continuation or conversion provisions of group coverage shall be specifically described;
(iv) A statement that the outline of coverage is a summary only, not a contract of insurance, and that the policy or group master policy contains governing contractual provisions;
(v) A description of the terms under which the policy or certificate may be returned and premium refunded;
(vi) A brief description of the relationship of cost of care and benefits; and
(vii) If the policy or certificate is intended to be a qualified long-term care insurance contract, a statement that discloses to the policyholder or certificate holder that the policy is intended to be a qualified long-term care insurance contract.
(m) Repealed by Laws 1993, ch. 212, § 3.
(n) Repealed by Laws 1993, ch. 212, § 3.
(o) The issuer of a long-term care insurance contract shall deliver to the applicant, policyholder or certificate holder, the contract or certificate of insurance no later than thirty (30) days after the date of approval. At the time of policy delivery, a policy summary shall be delivered for an individual life insurance policy which provides long-term care benefits within the policy or rider. In the case of direct response solicitations, the insurer shall deliver the policy summary upon the applicant's request, but regardless of request shall make the delivery no later than at the time of policy delivery. In addition to complying with all applicable requirements, the summary shall also include:
(i) An explanation of how the long-term care benefit interacts with other components of the policy, including deductions from death benefits;
(ii) An illustration of the amount of benefits, the length of benefits, and guaranteed lifetime benefits if any, for each covered person;
(iii) Any exclusions, reductions and limitations on benefits of long-term care; and
(iv) If applicable to the policy type, the summary shall also include:
(A) A disclosure of the effects of exercising other rights under the policy;
(B) A disclosure of guarantees related to long-term care costs of insurance charges; and
(C) Current and projected maximum lifetime benefits.
(p) If any long-term care benefit, funded through a life insurance vehicle by the acceleration of the death benefit, is in benefit payment status, a monthly report shall be provided to the policyholder. The report shall include:
(i) Any long-term care benefits paid out during the month;
(ii) An explanation of any changes in the policy, including, but not limited to, death benefits or cash values, due to long-term care benefits; and
(iii) The amount of long-term care benefits existing or remaining.
(q) If a claim under a long-term care insurance contract is denied, the issuer shall, within sixty (60) days of the date of a written request by the policyholder, or certificate holder or an authorized representative:
(i) Provide a written explanation of the reason for the denial; and
(ii) Make available all information directly related to the denial.
(r) Long-term care insurance premium rate increases shall be based on accepted actuarial principles and practices. All long-term care insurance premium rate increases shall be subject to the approval of the commissioner.
(a) For a long-term care insurance policy or certificate that has been in force for less than six (6) months, an insurer may rescind the policy or certificate or deny any otherwise valid long-term care insurance claim upon a showing of misrepresentation that is material to the acceptance of coverage.
(b) For a long-term care insurance policy or certificate that has been in force for at least six (6) months but less than two (2) years, an insurer may rescind the policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is both material to the acceptance for coverage and which pertains to the conditions for which benefits are sought.
(c) After a long-term care insurance policy or certificate has been in force for two (2) years it is not contestable upon the grounds of misrepresentation, unless the insured knowingly and intentionally misrepresented relevant facts relating to the insured's health.
(d) No long-term care insurance policy or certificate may be field issued based on medical or health status. For purposes of this section, "field issued" means a policy or certificate issued by an agent or a third party administrator pursuant to the underwriting authority granted to the agent or third party administrator by an insurer.
(e) If an insurer has paid benefits under the long-term care insurance policy or certificate, the benefit payments may not be recovered by the insurer in the event that the policy or certificate is rescinded.
(f) An insurer shall rescind a long-term care policy or certificate for misrepresentation only as provided in this section.
(a) Each insurer offering long-term care insurance shall, as a protection against unintentional lapse, comply with the following:
(i) No individual long-term care policy or certificate shall be issued until the insurer has received from the applicant either a written designation of at least one (1) person, in addition to the applicant, who is to receive notice of lapse or termination of the policy or certificate for nonpayment of premium, or a written waiver dated and signed by the applicant electing not to designate additional persons to receive notice. The applicant has the right to designate at least one (1) person who is to receive the notice of termination, in addition to the insured. A designation shall not constitute acceptance of any liability by the third party for services provided to the insured. The form used for the written designation shall provide space clearly designated for listing at least one (1) person. The designation shall include each person's full name and home address. In the case of an applicant who elects not to designate an additional person, the waiver shall state: "Protection against unintended lapse." "I understand that I have the right to designate at least one (1) person other than myself to receive notice of lapse or termination of this long-term care insurance policy for nonpayment of premium. I understand that notice will not be given until thirty (30) days after a premium is due and unpaid. I elect not to designate any person to receive such notice." The insurer shall notify the insured of the right to change the written designation, no less than once every two (2) years;
(ii) When the policyholder or certificate holder pays premium for a long-term care insurance policy or certificate through a payroll or pension deduction plan, the requirements contained in paragraph (a)(i) of this section need not be met until sixty (60) days after the policyholder or certificate holder is no longer enrolled in the payment plan. The application or enrollment form for such policies or certificates shall clearly indicate the payment plan selected by the applicant;
(iii) No long-term care policy or certificate shall lapse or be terminated for nonpayment of premium unless the insurer, at least thirty (30) days before the effective date of the lapse or termination, has given notice to the insured and to those persons designated pursuant to paragraph (a)(i) of this section, at the address provided by the insured, to receive notice of lapse or termination. Notice shall be given by first class United States mail, postage prepaid. Notice shall not be given until thirty (30) days after a premium is due and unpaid. Notice shall be deemed to have been given as of five (5) days after the date of mailing.
(b) In addition to the requirements in subsection (a) of this section, a long-term care insurance policy or certificate shall include a provision which provides for reinstatement of coverage, in the event of lapse if the insurer is provided proof of cognitive impairment or the loss of functional capacity. This option shall be available to the insured if requested within five (5) months after termination and shall allow for the collection of past due premium, where appropriate. The standard of proof of cognitive impairment or loss of functional capacity shall not be more stringent than the benefit eligibility criteria on cognitive impairment or the loss of functional capacity, if any, contained in the policy or certificate.
(a) Subject to subsection (g) of this section, an insurer that offers a long-term care insurance policy or certificate in this state shall offer a nonforfeiture protection provision as an option. The nonforfeiture benefit shall be made available in the event of a default in the payment of any premiums, or upon the surrender of the policy or certificate by the policyholder or certificate holder.
(b) Subject to subsection (g) of this section, the nonforfeiture provision offered for a policy which is not intended to be a qualified long-term insurance contract, shall be appropriately captioned and shall provide at least one (1) of the following:
(i) Reduced paid-up insurance;
(ii) Extended term insurance;
(iii) Cash surrender values;
(iv) A return of premium;
(v) A shortened benefit period; or
(vi) Other offerings as approved by the commissioner.
(c) Nonforfeiture benefits shall be computed in an actuarially sound manner, using a methodology that has been filed with and approved by the commissioner. At the time of lapse, or upon request by the policyholder or certificate holder, the insurer shall disclose the then-accrued nonforfeiture values. At the time the policy or certificate is issued, the insurer shall provide to the policyholder or certificate holder schedules demonstrating estimated values of nonforfeiture benefits. The schedules shall state that the estimated values are not to be construed as guaranteed nonforfeiture values.
(d) The amount of nonforfeiture benefits shall be adjusted subsequent to being initially granted only as necessary to reflect changes in claims, persistency and interest as reflected in changes in rates for premium paying policies approved by the commissioner for the same policy form.
(e) This section does not apply to life insurance policies or riders containing accelerated long-term care benefits.
(f) Nonforfeiture benefits for qualified long-term care insurance contracts shall include at least a reduced paid-up insurance benefit, an extended term insurance benefit, the offer of a shortened benefit period, or other similar offerings approved by the secretary of the treasury, and shall be provided as specified in regulations. The issuer of such a contract may refund premiums upon complete surrender or cancellation of the contract or policy, as long as the refund does not exceed the aggregate premiums paid for the contract or policy.
(g) Within fifteen (15) business days following receipt of written proof of the death of an insured, an insurer under this chapter shall refund unearned premiums paid for any period beyond the death of the insured. The amount of the refund shall be pro rata from the date of death.
In addition to any other penalties provided by the laws of this state, any insurer or agent who violates any requirement of this state relating to the regulation of long-term care insurance or the marketing of such insurance shall be subject to a civil penalty not to exceed three (3) times the amount of any commissions paid for each policy involved in the violation or ten thousand dollars ($10,000.00), whichever is greater. The penalty shall be assessed by the commissioner in accordance with W.S. 26-1-107.
(a) As used in this act:
(i) "Applicant" means:
(A) In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance benefits; and
(B) In the case of a group Medicare supplement policy, the proposed certificate holder.
(ii) "Certificate" means any certificate delivered or issued for delivery in this state under a group Medicare supplement policy;
(iii) "Certificate form" means the form on which the certificate is delivered or issued for delivery by the issuer;
(iv) "Issuer" includes insurance companies, fraternal benefit societies, health care service plans, health maintenance organizations and any other entity delivering or issuing for delivery in this state Medicare supplement policies or certificates;
(v) "Medicare supplement policy" means a group or individual disability insurance policy or a subscriber contract of hospital and medical service associations or health maintenance organizations other than a policy issued pursuant to a contract under section 1876 of the federal Social Security Act, or an issued policy under a demonstration project specified in 42 U.S.C. 1395ss(g)(1), which is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare;
(vi) "Medicare" means the "Health Insurance for the Aged Act," Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended;
(vii) "Policy form" means the form on which the policy is delivered or issued for delivery by the issuer;
(viii) "This act" means W.S. 26-38-201 through 26-38-209.
(a) Except as otherwise specifically provided, this act shall apply to:
(i) All Medicare supplement policies delivered or issued for delivery in this state on or after the effective date of this act; and
(ii) All certificates issued under group Medicare supplement policies which have been delivered or issued for delivery in this state.
(b) This act shall not apply to a policy issued to one (1) or more employers or labor organizations, or to the trustees of a fund established by one (1) or more employers or labor organizations, or combination thereof, for employees or former employees or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.
(c) Except as provided by regulations adopted pursuant to W.S. 26-38-206(e), the provisions of this act are not intended to prohibit or apply to insurance policies or health care benefit plans, including group conversion policies, provided to Medicare eligible persons which policies are not marketed or held to be Medicare supplement policies or benefit plans.
(a) No Medicare supplement insurance policy or certificate in force in the state shall contain benefits which duplicate benefits provided by Medicare.
(b) The commissioner shall adopt reasonable regulations to establish specific standards for policy provisions of Medicare supplement policies and certificates. The standards shall be in addition to and in accordance with applicable laws of this state. No requirement of the code relating to minimum required policy benefits, other than the minimum standards contained in this act, shall apply to Medicare supplement policies and certificates. The standards may cover, but are not limited to:
(i) Terms of renewability;
(ii) Initial and subsequent conditions of eligibility;
(iii) Nonduplication of coverage;
(iv) Probationary periods;
(v) Benefit limitations, exceptions and reductions;
(vi) Elimination periods;
(vii) Requirements for replacement;
(viii) Recurrent conditions; and
(ix) Definitions of terms.
(c) The commissioner shall adopt reasonable regulations that specify prohibited policy provisions not otherwise specifically authorized by statute which, in the opinion of the commissioner, are unjust, unfair or unfairly discriminatory to any person insured or proposed for coverage under a Medicare supplement policy or certificate.
(d) Notwithstanding any other provision of law or contract, a Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than ninety (90) days from the effective date of coverage because the loss involved a preexisting condition. The policy or certificate shall not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within ninety (90) days before the effective date of coverage.
(a) The commissioner shall adopt reasonable regulations to establish minimum standards for benefits, claims payment, marketing practices, compensation arrangements and reporting practices for Medicare supplement policies and certificates.
(b) The commissioner may adopt reasonable regulations necessary to conform Medicare supplement policies and certificates to the requirements of federal law and regulations, including but not limited to:
(i) Requiring refunds or credits if the policies or certificates do not meet loss ratio requirements;
(ii) Establishing a uniform methodology for calculating and reporting loss ratios;
(iii) Assuring public access to policies, premiums and loss ratio information of issuers of Medicare supplement insurance;
(iv) Establishing a process for approving or disapproving policy forms and certificate forms and restricting premium increases if loss ratio requirements are not met;
(v) Establishing a policy for holding public hearings prior to approval of premium increases; and
(vi) Establishing standards for Medicare select policies and certificates.
(a) Repealed by Laws 1992, ch. 57, § 2.
(b) Medicare supplement policies shall return to policyholders benefits which are reasonable in relation to the premium charged. The commissioner shall issue reasonable regulations to establish minimum standards for loss ratios of Medicare supplement policies on the basis of incurred claims experience, or incurred health care expenses where coverage is provided by a health maintenance organization on a service rather than reimbursement basis, and earned premiums in accordance with accepted actuarial principles and practices.