ENROLLED
COMMITTEE SUBSTITUTE
FOR
Senate Bill No. 510
(Senators Minard, Jones, Helmick, Blatnik, Dittmar,
Manchin, Sharpe, Felton, Wiedebusch Bailey, Wooton
and Grubb, original sponsors)
__________
[Passed April 9, 1993; in effect ninety days from passage.]
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AN ACT to amend and reenact sections one, two and four, article
six-c, chapter thirty-three of the code of West Virginia,
one thousand nine hundred thirty-one, as amended; to amend
article fifteen of said chapter by adding thereto a new
section, designated section one-a; to amend and reenact
sections two, three, four, five, six, seven, eight, nine,
ten and twelve, article sixteen-d of said chapter; and to
further amend said chapter by adding thereto a new article,
designated article sixteen-e, all relating to accident and
sickness insurance; excepting individual limited benefits
accident and sickness insurance policies and certificates
from optional guaranteed loss ratio provisions of article
six-c, chapter thirty-three of said code; increasing the
optional minimum guaranteed loss-ratio for individual
accident and sickness insurance policies and certificates;
establishing requirements for rate increase requests after
the first day of July, one thousand nine hundred
ninety-four, for insurers issuing individual accident and
sickness insurance policies; revising certain definitions
and eliminating others relating to marketing and rate
practices for small employer accident and sickness insurance
policies; substituting the term "carrier" for "insurer";
applying the provisions of article sixteen-d of said chapter
to any health benefit plan described therein that covers one
or more employees of a small employer situate in West
Virginia; specifying additional premium rating restrictions;
eliminating provisions on the insurance commissioner
conducting a public hearing before increasing the
anticipated loss ratio for a small employer carrier;
eliminating enumerated rule-making mandates; granting
permissive rule-making authority to the insurance
commissioner; requiring disclosure of preexisting conditions
limitations in such health benefit plans; requiring
certification of compliance with statutory premium rating
provisions; creating a new article sixteen-e of said chapter
on limited benefits accident and sickness insurance policies
and certificates; defining the scope of and terms used in
said article; establishing loss ratio standards for premium
rate increase requests made after the first day of July, one
thousand nine hundred ninety-three for such policies and
certificates; establishing loss ratios requiring premiumrefunds to be made after the first day of July, one thousand
nine hundred ninety-four; requiring annual filing of
verified statements of actual loss ratio; requiring sixty
days' notice of cancellation or nonrenewal of such policies
or certificates; prohibiting preexisting conditions
limitations, waiting periods and the like upon replacement
of such policies and certificates; providing for
extraterritorial jurisdiction of the insurance commissioner
over certain policies; specifying severability of provisions
of said article; providing for the promulgation of rules;
and making technical corrections.
Be it enacted by the Legislature of West Virginia:
That sections one, two and four, article six-c, chapter
thirty-three of the code of West Virginia, one thousand nine
hundred thirty-one, as amended, be amended and reenacted; that
article fifteen of said chapter be amended by adding thereto a
new section, designated section one-a; that sections two, three,
four, five, six, seven, eight, nine, ten and twelve, article
sixteen-d of said chapter be amended and reenacted; and that said
chapter be further amended by adding thereto a new article,
designated article sixteen-e, all to read as follows:
ARTICLE 6C. GUARANTEED LOSS RATIOS AS APPLIED TO INDIVIDUAL
SICKNESS AND ACCIDENT INSURANCE POLICIES.
§33-6C-1. Loss ratio guarantees; definitions.
As used in this article:
(a) "Commissioner" means the insurance commissioner of West
Virginia;
(b) "Experience period" means, for any given rate filing for
which a loss ratio guarantee is made, the period beginning on the
first day of the calendar year during which the guaranteed rates
first take effect and ending on the last day of the calendar year
during which the insurer earns one million dollars in premiums on
the form in West Virginia or, if the annual premium earned on the
form in West Virginia is less than one million dollars, earns
nationally;
(c) "Form" means individual sickness and accident policy
forms of any insurer offering such benefits, other than a form
for a limited benefits policy or certificate as defined in
section two, article sixteen-e of this chapter;
(d) "Loss ratio" means the ratio of incurred claims to
earned premium; and
(e) "Successive experience period" means the experience
period beginning on the first day following the end of the
preceding experience period.
§33-6C-2. Insurance commissioner to establish guaranteed loss
ratios; minimum rates; participation by insurer; calculation
of ratios; minimum rate; application.
(a) The insurance commissioner shall establish a guaranteed
loss ratio which may be implemented by any insurer offering
individual sickness and accident insurance policies other than
limited benefits accident and sickness insurance policies or
certificates, which are subject to loss ratio requirements set
forth in sections three and four, article sixteen-e of this
chapter. The loss ratios shall be calculated by the commissionerand each individual insurer and shall be based upon studies and
relevant information collected from various sources, including,
but not limited to, the health care cost review authority and the
national association of insurance commissioners' rate filing
guidelines:
Provided, That the guaranteed loss ratio shall not
be less than sixty percent. The guaranteed loss ratio for each
insurer shall be published by the insurance commissioner in the
register maintained by the secretary of state.
(b) The guaranteed loss ratio shall be based upon experience
periods during which the insurer earns one million dollars in
premium in West Virginia:
Provided, That if the annual earned
premium volume in West Virginia is less than one million dollars,
the loss ratio guarantee shall be based on such other actuarially
sound methods as the commissioner may determine are appropriate,
including, but not limited to, the actual nationwide loss ratios:
Provided, however, That if the aggregate earned premium for all
states is less than one million dollars, the experience period
will be extended until the end of the calendar year in which one
million dollars of earned premium is attained.
(c) Any insurer may apply to the commissioner to operate on
a guaranteed loss ratio basis. The insurance commissioner may
review each application and, in his or her discretion, approve or
reject the same. Any insurer approved by the commissioner shall
be exempt from filing rate increase applications as required by
the commissioner and other provisions of this chapter.
§33-6C-4. Form of guarantee; requirements.
(a) Individual sickness and accident policy benefits undera policy form other than a limited benefits policy form or
certificate shall be deemed reasonable in relation to the premium
charged, as required by subdivision (e), section nine, article
six of this chapter, if the premium rates are filed pursuant to
a loss ratio guarantee which meets the requirements of this
article. The insurance commissioner shall not withdraw approval
of a form on the grounds that benefits are unreasonable in
relation to premiums charged so long as the insurer complies with
the terms of the loss ratio guarantee.
(b) Each insurer of individual sickness and accident policy
benefits other than benefits under limited benefits policy forms
or certificates shall execute and deliver to the insurance
commissioner a loss ratio guarantee, to be provided by the
commissioner, which guarantee shall be signed by an officer of
the insurer.
(c) Each loss ratio guarantee shall contain, at a minimum,
the following:
(1) A recitation of the anticipated lifetime and durational
target loss ratios contained in the original actuarial memorandum
filed with the policy form when it was originally approved;
(2) A guarantee that the actual West Virginia loss ratios
for the experience period in which the new rates take effect, and
for each experience period thereafter until new rates are filed,
will meet or exceed the anticipated lifetime and durational
target loss ratios contained in the original actuarial memorandum
noted above;
(3) A guarantee that the actual West Virginia or, ifapplicable, national, loss ratio results for the experience
period at issue will be independently audited at the insurer's
expense; that such audit will be completed in the second quarter
of the year following the end of the experience period; and that
the results of such audit will be reported to the insurance
commissioner not later than the thirtieth day of June following
the end of the experience period;
(4) A guarantee that if the actual loss ratio during an
experience period is less than the anticipated loss ratio for
that period, then West Virginia policyholders will receive a
proportional refund based on premium earned, which refunds shall
be calculated and paid pursuant to section thirty-nine of this
article; and
(5) A guarantee that the insurer does not engage in any
discriminatory practices prohibited by section four, article
eleven of this chapter or any such practice which discriminates
against any individual on the basis of his or her legal
occupation, race, religion or residence.
ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.
§33-15-1a. Premium rate increase requests; loss ratio
requirement.
To be eligible to make a premium rate increase request after
the first day of July, one thousand nine hundred ninety-four, any
insurer issuing accident and sickness insurance policies which
are subject to the provisions of this article shall have a
minimum anticipated loss ratio of sixty-five percent. In
calculating its minimum anticipated loss ratio, an insurer shallinclude in its actual incurred claims the amount of premium taxes
for the same experience period which are attributable to the
policy forms affected by this section and which were paid to the
state of West Virginia pursuant to the provisions of article
three of this chapter.
ARTICLE 16D. MARKETING AND RATE PRACTICES FOR SMALL EMPLOYER
ACCIDENT AND SICKNESS INSURANCE POLICIES.
§33-16D-2. Definitions.
As used in this article:
(a) "Actuarial certification" means a written statement by
an actuary, or other individual acceptable to the commissioner,
that a small employer carrier is in compliance with the
provisions of section five of this article, based upon that
person's examination, including a review of the appropriate
records and of the actuarial assumptions and methods utilized by
the carrier in establishing premium rates for applicable health
benefit plans.
(b) "Base premium rate" means, for each class of business as
to a rating period, the lowest premium rate charged or which
could have been charged under a rating system for that class of
business by the small employer carrier to small employers with
similar case characteristics for health benefit plans with the
same or similar coverage.
(c) "Carrier" means any person who provides accident and
sickness insurance in this state. For purposes of this article,
carrier includes a licensed insurance company; a hospital service
corporation, medical service corporation or health servicecorporation organized pursuant to article twenty-four of this
chapter; a health care corporation organized pursuant to article
twenty-five of this chapter; a health maintenance organization
organized pursuant to article twenty-five-a of this chapter; a
multiple-employer trust or multiple-employer welfare arrangement;
or any other person providing a plan of accident and sickness
insurance subject to state insurance regulations.
(d) "Case characteristics" means demographic or other
relevant characteristics of a small employer, as determined by a
small employer carrier, which are considered by the carrier in
the determination of premium rates for the small employer. Claim
experience, health status and duration of coverage since issue
are not case characteristics for the purposes of this article.
(e) "Class of business" means all or any distinct grouping
of small employers as shown on the records of the small employer
carrier, which shall be subject to the following requirements:
(1) A distinct grouping may only be established by the small
employer carrier on the basis that the applicable health benefit
plans:
(A) Are marketed and sold through individuals and
organizations which are not participating in the marketing or
sale of other distinct groupings of small employers for such
small employer carrier;
(B) Have been acquired from another small employer carrier
as a distinct grouping of plans;
(C) Are provided through an association with membership of
not less than two small employers which has been formed forpurposes other than obtaining insurance; or
(D) Are in a class of business that meets the requirements
for exception to the restrictions related to premium rates
provided in paragraph (A), subdivision (1), subsection (a),
section five of this article.
(2) A small employer carrier may establish no more than two
additional groupings under subdivision (1) of this subsection on
the basis of underwriting criteria which are expected to produce
substantial variation in the health care costs.
(3) The commissioner may approve the establishment of
additional distinct groupings upon application to the
commissioner and a finding by the commissioner that such action
would enhance the efficiency and fairness of the small employer
insurance marketplace.
(f) "Commissioner" means the insurance commissioner of West
Virginia.
(g) "Department" means the department of insurance.
(h) "Health benefit plan" means any hospital or medical
expense incurred policy; health, hospital or medical service
corporation contract; plan provided by a multiple-employer trust
or a multiple-employer welfare arrangement; health maintenance
organization contract offered by an employer; or any other policy
or plan issued by a carrier which provides health related
benefits to small employers:
Provided, That for purposes of this
article, a health benefit plan shall not include accident only,
credit, dental or disability income insurance; coverage issued as
a supplement to liability insurance; insurance arising out of aworkers' compensation or similar law; automobile medical-payment
insurance, or insurance under which benefits are payable with or
without regard to fault and which is statutorily required to be
contained in any liability insurance policy or equivalent
self-insurance.
(i) "Index rate" means for each class of business for small
employers with similar case characteristics the arithmetic
average of the applicable base premium rate and the corresponding
highest premium rate.
(j) "New business premium rate" means, for each class of
business as to a rating period, the premium rate charged or
offered by the small employer carrier to small employers with
similar case characteristics for newly issued health benefit
plans with the same or similar coverage.
(k) "Rating period" means the calendar period of at least
twelve months for which premium rates established by a small
employer carrier are assumed to be in effect, as determined by
the small employer carrier.
(l) "Small employer" means any person, firm, corporation,
partnership or association actively engaged in business in the
state of West Virginia for at least one year who, on at least
fifty percent of its working days during the preceding year,
employed no more than sixty or not fewer than two eligible
employees:
Provided, That companies which are affiliated
companies or which are eligible to file a combined tax return for
state tax purposes shall be considered one employer.
(m) "Small employer carrier" means any carrier which offershealth benefit plans covering the employees of a small employer
situate within the state of West Virginia.
§33-16D-3. Health insurance plans subject to this article.
The provisions of this article apply to any health benefit
plan which provides coverage to one or more eligible employees of
a small employer situate in the state of West Virginia:
Provided, That the provisions of this article shall not apply to
individual health insurance policies which are subject to policy
form and premium rate approval as required by article sixteen-b
of this chapter.
§33-16D-4. Discrimination in marketing prohibited; annual filing
with commissioner; violations and penalties.
(a) All carriers subject to this article are strictly
prohibited from marketing their product to a specific group,
legal occupation, locale, zip code, neighborhood, race, religion,
or any discriminatory group.
(b) All carriers subject to this article shall file any
marketing information upon request of the commissioner. The
commissioner shall review said information and shall have the
authority to take appropriate action to eliminate discriminatory
marketing practices, including imposing fines on violators of
this section of not more than ten thousand dollars. Upon a
second violation of this section, the commissioner shall have the
authority to revoke the violator's license to transact insurance.
§33-16D-5. Premium rates for small employers; classes; maximum
rates; eligibility for rate increases.
(a) Premium rates for health benefit plans subject to thisarticle shall be subject to the following provisions:
(1) The index rate for a rating period for any class of
business shall not exceed the index rate for any other class of
business by more than twenty percent:
Provided, That this
subdivision shall not apply to a class of business if all of the
following apply:
(A) The class of business is one for which the carrier does
not reject, and never has rejected, small employers included
within the definition of employers eligible for the class of
business or otherwise eligible employees and dependents who
enroll on a timely basis, based upon their claim experience or
health status;
(B) The carrier does not involuntarily transfer, and never
has involuntarily transferred, a health benefits plan into or out
of the class of business; and
(C) The class of business is currently available for
purchase.
(2) For a class of business, the premium rates charged
during a rating period to small employers with similar case
characteristics for the same or similar coverage, or the rates
which could be charged to such employers under the rating system
for that class of business, shall not vary from the index rate by
more than twenty-five percent of the index rate.
(3) The percentage increase in the premium rate charged to
a small employer for a new rating period may not exceed the sum
of the following:
(A) The percentage change in the new business premium ratemeasured from the first day of the prior rating period to the
first day of the new rating period. In the case of a class of
business for which the small employer carrier is not issuing new
policies, the carrier shall use the percentage change in the base
premium rate;
(B) An adjustment, not to exceed fifteen percent annually
and adjusted pro rata for rating periods of less than one year,
due to the claim experience, health status or duration of
coverage of the employees or dependents of the small employer as
determined from the carrier's rate manual for the class of
business; and
(C) Any adjustment due to change in coverage or change in
the case characteristics of the small employer as determined from
the carrier's rate manual for the class of business.
(4) In the case of health benefit plans issued prior to the
effective date of this article, a premium rate for a rating
period may exceed the ranges described in subdivision (1) or (2)
of this subsection for a period of five years following the
effective date of this article. In that case, the percentage
increase in the premium rate charged to a small employer in such
a class of business for a new rating period may not exceed the
sum of the following:
(A) The percentage change in the new business premium rate
measured from the first day of the prior rating period to the
first day of the new rating period. In the case of a class of
business for which the small employer carrier is not issuing new
policies, the carrier shall use the percentage change in the basepremium rate; and
(B) Any adjustment due to change in coverage or change in
the case characteristics of the small employer as determined from
the carrier's rate manual for the class of business.
(b) Nothing in this section is intended to affect the use by
a small employer carrier of legitimate rating factors other than
claim experience, health status or duration of coverage in the
determination of premium rates. Small employer carriers shall
apply rating factors, including case characteristics,
consistently with respect to all small employers in a class of
business.
(c) Adjustments in rates for claim experience, health status
and duration of coverage may not be charged to individual
employees or dependents. Any such adjustment shall be applied
uniformly to the rates charged for all employees and dependents
of the small employer.
(d) A small employer carrier shall utilize industry as a
case characteristic in establishing premium rates:
Provided, That
the highest rate factor associated with any industry
classification shall not exceed the lowest rate factor associated
with any industry classification by more than fifteen percent.
(e) Small employer carriers shall apply rating factors,
including case characteristics, consistently with respect to all
small employers in a class of business. Rating factors shall
produce premiums for identical groups which differ only by
amounts attributable to plan design and do not reflect
differences due to the nature of the groups assumed to selectparticular health benefit plans.
(f) A small employer carrier may not involuntarily transfer
a small employer into or out of a class of business. A small
employer carrier may not offer to transfer a small employer into
or out of a class of business unless such offer is made to
transfer all small employers in the class of business without
regard to case characteristics, claim experience, health status
or duration since issue.
(g) To be eligible to make a rate increase request after the
first day of July, one thousand nine hundred ninety-three, a
carrier shall have a minimum anticipated loss ratio of
seventy-three percent. In calculating its minimum anticipated
loss ratio, an insurer shall include in its actual incurred
claims the amount of premium taxes for the same experience period
which are attributable to the policy forms or certificates
affected by this section and which were paid to the state of West
Virginia pursuant to the provisions of article three of this
chapter.
(h) All insurance carriers subject to this article,
effective the first day of July, one thousand nine hundred
ninety-three, shall be prohibited from distinguishing more than
four classes of business within its small group insurance
coverage.
(i) If any health benefit plan is provided by a carrier
through an association of small employers not in the business of
selling insurance and with not fewer than two hundred cumulative
employees, and if such association is rated on the basis of thenumber of employees and not on the basis of the individual small
employers, such association or group is exempt from the
provisions of this article.
§33-16D-6. Insurance commissioner to promulgate rules.
Pursuant to chapter twenty-nine-a of this code, the
insurance commissioner may promulgate rules necessary to
implement the provisions of this article.
§33-16D-7. Renewability of coverage; exceptions.
(a) A health benefit plan subject to this article shall be
renewable to all eligible employees at the option of the small
employer:
Provided, That a carrier may refuse to renew a health
benefit plan for any of the following reasons:
(1) Nonpayment of required premiums;
(2) Fraud or misrepresentation by the small employer or by
the insured individual;
(3) Noncompliance with plan provisions;
(4) The number of individuals covered under the plan is
fewer than the number or less than the percentage of eligible
individuals necessary pursuant to the percentage requirements
under the plan; or
(5) The small employer is no longer actively engaged in the
business in which it was engaged on the effective date of the
plan.
(b) A small employer carrier may cease to renew all plans
under a class of business. Upon the small employer's election of
nonrenewal, the carrier shall provide notice of such election not
to renew to all affected health benefit plans and to thecommissioner in each state in which an affected insured
individual is known to reside at least ninety days prior to
termination of coverage.
(c) A carrier which exercises its right to cease to renew
all plans in a class of business may not:
(1) Establish a new class of business for a period of five
years after the nonrenewal of the plans without prior approval of
the commissioner; or
(2) Transfer or otherwise provide coverage to any of the
employers from the nonrenewed class of business unless the
carrier offers to transfer or provide coverage to all affected
employers and eligible employees without regard to case
characteristics, claim experience, health status or duration of
coverage.
§33-16D-8. Disclosure of rating practices and renewability
provisions.
(a) Each small employer carrier shall make reasonable
disclosure in solicitation and sales materials provided to small
employers of the following:
(1) The extent to which premium rates for a specific small
employer are established or adjusted due to the claim experience,
health status or duration of coverage of the employees of the
small employer;
(2) The provisions concerning the carrier's right to change
premium rates and the factors, including case characteristics,
which affect changes in premium rates;
(3) A description of the class of business in which thesmall employer is or will be included, including the applicable
grouping of plans;
(4) The provisions relating to renewability of coverage;
(5) The provisions relating to any preexisting conditions
limitations; and
(6) An explanation, if applicable, that the small employer
is purchasing a minimum benefits plan issued pursuant to article
sixteen-c of this chapter.
(b) All disclosure statements shall be presented in clear
and understandable form and format and shall be separate from any
policy, certificate or evidence of coverage otherwise provided.
§33-16D-9. Maintenance of records.
(a) Each small employer carrier shall maintain at its
principal place of business a complete and detailed description
of its rating practices and renewal underwriting practices,
including information and documentation which demonstrate that
its rating methods and practices are based upon commonly accepted
actuarial principles.
(b) Each small employer carrier shall file each first day of
March with the commissioner an actuarial certification that the
carrier is in compliance with the provisions of section five of
this article and that the rating methods of the carrier are
actuarially sound. A copy of such certification shall be
retained by the carrier at its principal place of business.
(c) A small employer carrier shall make the information and
documentation described in subsection (a) of this section
available to the commissioner upon request.
§33-16D-10. Suspension of requirements.
The insurance commissioner may suspend all or part of the
requirements of this article applicable to one or more health
benefit plans for one or more rating periods upon a filing by the
small employer carrier and a finding by the commissioner that
either the suspension is reasonable in light of the financial
condition of the carrier or that the suspension would enhance the
efficiency and fairness of the marketplace for small employer
health insurance.
§33-16D-12. Equality of terms; preexisting conditions;
continuous coverage restrictions.
Health benefit plans and, to the extent permitted by the
federal Employee Retirement Income Security Act (ERISA), other
benefit arrangements covering small employers shall be subject to
the following provisions:
(a) Preexisting conditions provisions may not exclude
coverage for a period beyond twelve months following an
individual's effective date of coverage and may only relate to
conditions which had, during the twelve months immediately
preceding the effective date of coverage, manifested themselves
in such a manner as would cause an ordinarily prudent person to
seek medical advice, diagnosis, care or treatment or for which
medical advice, diagnosis, care or treatment was recommended or
received, or as to a pregnancy existing on the effective date of
coverage.
(b) In determining whether a preexisting condition
limitation provision applies to an eligible employee ordependent, all health benefit plans shall credit the time such
person was covered under a previous employer-based health benefit
plan, a comparable individual health benefit plan, or a
self-insured plan if the previous coverage was continuous to a
date not more than thirty days prior to the effective date of the
new coverage, exclusive of any applicable waiting period under
such plan.
(c) Subject to subsections (a) and (b) of this section, when
a small group employer converts its health benefit plan from one
health benefit plan to another health benefit plan or from one
carrier to another carrier, all eligible employees who at the
time of conversion are covered by the health benefit plan shall
be offered health benefits coverage under the subsequent plan,
and no employee who at the time of conversion is covered by a
health benefit plan offered by said employer may be treated any
differently relative to other covered employees under the new
health benefit plan than he or she is treated under the current
health benefit plan.
ARTICLE 16E. LIMITED BENEFITS ACCIDENT AND SICKNESS INSURANCE
POLICIES AND CERTIFICATES.
§33-16E-1. Scope of article.
The provisions of this article shall apply to all limited
benefits policies and certificates in force on the effective date
of this article, as well as to any limited benefits policy or
certificate delivered or issued for delivery in this state after
the effective date hereof.
§33-16E-2. Definitions.
For purposes of this article:
(a) "Limited benefits policy or certificate" means any
individual or group accident and sickness insurance policy that
is not required to offer or provide all benefits mandated by any
other applicable provision of this chapter. Such policies
include, but are not limited to, accident and sickness
disability, accident only, sickness only disability, sickness
only, accident only disability, hospital indemnity, specified
disease, and travel accident insurance policies:
Provided, That
the following types of policies and certificates are excluded
from the definition of "limited benefits policy or certificate"
for purposes of this article:
(1) Credit accident and sickness insurance;
(2) Long-term care insurance;
(3) Medicare supplement insurance; and
(4) Minimum benefits accident and sickness insurance issued
pursuant to section fifteen, article fifteen or article sixteen-c
of this chapter.
(b) "Experience period" means the period beginning on the
first day of the calendar year during which a premium rate first
takes effect and ending on the last day of the calendar year
during which the insurer earns five hundred thousand dollars in
premiums on the form in West Virginia or, if the annual premium
earned on the form in West Virginia is less than five hundred
thousand dollars, earns nationally.
(c) "Successive experience period" means the experience
period beginning on the first day following the end of thepreceding experience period.
§33-16E-3. Premium rate increase requests; loss ratio
requirements.
(a) To be eligible to make a premium rate increase request
after the first day of July, one thousand nine hundred
ninety-three, any insurer offering a limited benefits policy form
or certificate form in West Virginia shall be expected to return
to policyholders and certificateholders in the form of five-year
aggregate loss ratios under the policy form or certificate form:
(1) At least seventy-five percent of the earned premiums in
the case of a group policy or certificate;
(2) At least sixty-five percent of the earned premiums in
the case of an individual policy; and
(3) At least fifty-five percent of the earned premiums in
the case of an individual or group accident and sickness
disability policy or certificate.
(b) With respect to a policy form or certificate form which
has been offered by an insurer in West Virginia or nationally for
five years or less the insurer may use the anticipated loss ratio
filed with and approved by the commissioner for that form to
determine compliance with the requirements of this section.
(c) For purposes of this section, limited benefits policies
and certificates issued as a result of solicitation of
individuals through the mail or mass media advertising, including
both print and broadcast advertising, shall be treated as
individual policies.
§33-16E-4. Premium refunds; calculation of refunds; payments.
(a) Beginning on the first day of July, one thousand nine
hundred ninety-four, any insurer offering a limited benefits
policy or certificate in West Virginia shall make premium refunds
to policyholders and certificateholders if it fails to return to
such policyholders and certificateholders in the form of annual
loss ratios under the policy or certificate:
(1) At least sixty-five percent of the earned premiums in
the case of a group policy or certificate;
(2) At least fifty-five percent of the earned premiums in
the case of an individual policy; and
(3) At least forty-five percent of the earned premiums in
the case of an individual or group accident and sickness
disability policy or certificate.
(b) With respect to a policy form or certificate form which
has been offered by an insurer either in West Virginia or
nationally for more than five years, refunds to West Virginia
policyholders or certificateholders made pursuant to the
requirements of this section and based upon annual earned premium
volume in West Virginia shall be calculated by multiplying the
anticipated loss ratio by the applicable earned premium during
the experience period and subtracting from that result the actual
incurred claims during the experience period.
(c) With respect to a policy form or certificate form which
has been offered by an insurer for more than five years, refunds
to West Virginia policyholders or certificateholders made
pursuant to the requirements of this section and based upon
national annual earned premium volume shall be calculated by:
(1) Multiplying the anticipated loss ratio by the applicable
earned premium during the experience period and subtracting from
that result the actual incurred claims during the experience
period; and
(2) Multiplying the results of subdivision (1) of this
subsection by the total earned premium during the experience
period from all West Virginia policyholders or certificateholders
eligible for refunds; and
(3) Dividing the results of subdivision (2) of this
subsection by the total earned premium during that period in all
states on the policy form.
(d) With respect to a policy form or certificate form which
has been offered by an insurer in West Virginia or nationally for
five years or less, the insurer may use the anticipated loss
ratio filed with and approved by the commissioner to determine
the amount of premium refunds, if any, that must be made pursuant
to subsection (a) of this section.
(e) Refunds shall be made to all West Virginia policyholders
and certificateholders who are insured under the applicable
policy form or certificate as of the last day of the experience
period. Such refund shall include interest, at the current
accident and health reserve interest rate established by the
national association of insurance commissioners, from the end of
the experience period until the date of payment. Payment shall
be made during the third quarter of the year following the
experience period for which a refund is determined to be due.
(f) Refunds of less than ten dollars shall be aggregated andheld by the insurer in a policyholders' and certificateholders'
liability fund and shall be used to offset any future rate
increases.
§33-16E-5. Statement of actual loss ratios to be filed with
commissioner; form; examinations.
(a) Every insurer offering limited benefits policy forms or
certificate forms which have been in effect for five years or
more in West Virginia shall file with the commissioner, on or
before the first day of September of each year, a statement of
the actual loss ratios for each policy form or certificate form
issued in this state. Such statement shall be made under the
oath of the insurer's president or other authorized officer on a
form prescribed by the commissioner.
(b) The commissioner shall have the authority to examine the
records and files of any insurer offering limited benefits policy
forms or certificate forms in West Virginia to determine
compliance with the provisions of this article.
§33-16E-6. Notice of cancellation or nonrenewal.
No insurer may cancel or nonrenew a limited benefits policy
or certificate unless written notice of such cancellation or
nonrenewal is forwarded to the policyholder or certificateholder
not less than sixty days prior to the expiration date of the
policy or certificate.
§33-16E-7. Prohibition against preexisting conditions, waiting
periods, elimination periods and probationary periods in
replacement policies or certificates.
(a) If a limited benefits policy or certificate replacesanother limited benefits policy or certificate providing similar
coverage, the replacing insurer shall waive any time periods
applicable to preexisting conditions, waiting periods,
elimination periods and probationary periods in the new limited
benefits policy or certificate to the extent that such time was
spent under the original policy or certificate.
(b) If a limited benefits policy or certificate replaces
another limited benefits policy or certificate providing similar
coverage that has been in effect for at least six months, the
replacing policy may not provide any time periods applicable to
preexisting conditions, waiting periods, elimination periods and
probationary periods.
§33-16E-8. Extraterritorial jurisdiction.
(a) No limited benefits policy or certificate may be offered
to a resident of this state under a policy issued in another
state, unless this state or another state having statutory and
regulatory limited benefits policy or certificate requirements
substantially similar to those adopted in this state has made a
determination that such requirements have been met.
(b) Any such limited benefits policy form or certificate
form offered to a resident of this state under a policy issued in
another state shall be filed with the insurance commissioner.
§33-16E-9. Applicability of other provisions.
Except as otherwise provided, and except where the context
clearly requires otherwise, all the provisions of article fifteen
of this chapter are applicable to individual limited benefits
policies and all provisions of article sixteen of this chapterare applicable to group limited benefits policies and
certificates.
§33-16E-10. Commissioner to promulgate rules.
The commissioner may promulgate rules in accordance with the
provisions of chapter twenty-nine-a of this code regarding the
implementation, regulation and enforcement of the provisions of
this article.
§33-16E-11. Severability.
If any provision of this article or the application thereof
to any person or circumstance is for any reason held to be
invalid, the remainder of the article and application of such
provision to other persons or circumstances shall not be affected
thereby.
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