Title 38.2, Title 38.2. Insurance

Each person representing any insurer in the sale of industrial sick benefit insurance shall be subject to the laws governing agents of insurers.

The payments in weekly or monthly installments to the holder of any policy of industrial sick benefit insurance shall not be subject to the lien of any attachment, garnishment proceeding, writ of fieri facias, or to levy or distress in any manner, for any debt due by the holder o…

No industrial sick benefit insurance policy as defined in § 38.2-3544 shall be delivered or issued for delivery in this Commonwealth after June 30, 1987.

A. As used in this article: "Eligible dependent" means an individual who may be covered as a dependent under a group health policy or policies and who is eligible, as determined by a small employer health group cooperative, for coverage as a dependent of an eligible employee unde…

A. 1. Any person or persons may organize and maintain a small employer health group cooperative for the purpose of offering, providing, or facilitating the provision of coverage for health care services to its employer-members. 2. The membership of the small employer health group…

A. A small employer health group cooperative: 1. Shall not limit, restrict, or condition a small employer's membership in the small employer health group cooperative on any health status-related factor relating to an individual, including an employee of a small employer or a depe…

A. No group health policy shall be offered to a small employer group health cooperative that will cover a resident of the Commonwealth unless the Commission finds that: 1. The issuance of such group health policy is not contrary to Virginia's public policy and is in the best inte…

Pursuant to the authority granted by § 38.2-223, the Commission may promulgate such rules and regulations as it may deem necessary to implement this article.

As used in this chapter, unless the context requires a different meaning: "Adverse determination" means a determination by a health carrier or its designee utilization review entity that an admission, availability of care, continued stay, or other health care service that is a co…

A. This chapter shall apply to all health carriers, except that the provisions of this chapter shall not apply to a policy or certificate that provides coverage only for a specified disease, specified accident or accident-only coverage, credit, disability income, hospital indemni…

Each health carrier shall establish an internal appeal process, including a process for urgent care appeals, to consider a utilization review adverse determination or other adverse benefit determination or decision that is appealed by a covered person, his authorized representati…

A. A health carrier shall notify the covered person in writing of an adverse determination or final adverse determination and the covered person's right to request an external review within five business days after the adverse determination or final adverse determination has been…

A. A request for an external review shall not be made until the covered person has exhausted the health carrier's internal appeal process, provided that a covered person's exhaustion of the health carrier's internal appeal process shall not be required if the adverse determinatio…

A. Within 120 days after the date of receipt of a notice of the right to an external review of a final adverse determination or an adverse determination if the internal appeal process has been deemed to be exhausted or waived, a covered person or his authorized representative may…

A. A covered person or his authorized representative may make a request for an expedited external review with the Commission at the time the covered person receives: 1. An adverse determination if the adverse determination involves (i) cancer or (ii) a medical condition of the co…

A. Within 120 days after the date of receipt of a notice of the right to an external review of an adverse determination or final adverse determination that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is…

A. An external review decision is binding on the health carrier. Failure to comply with the assigned independent review organization's external review decision shall be a knowing and willful violation of this section and subject to one or more of the following: (i) punishment as …

A. An independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process and that include, at a minimum: 1. A quality assurance mechanism in place t…

A. Each independent review organization that wishes to be eligible to conduct external reviews shall submit an application to the Commission for approval or reapproval. The Commission may charge a reasonable fee for initial approval and each reapproval. B. The Commission shall ap…

No independent review organization or clinical reviewer working on behalf of an independent review organization or an employee, agent, or contractor of an independent review organization shall be liable in damages to any person for any opinions rendered or acts or omissions perfo…

A. An independent review organization shall maintain written records, in the aggregate by state and by health carrier, on all external review requests and external reviews conducted during each calendar year. Each independent review organization shall submit a report to the Commi…

The health carrier against which a request for an external review is filed shall pay the cost incurred by the independent review organization in conducting the external review.

Each health carrier shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage it provides to covered persons. The description shall include a statement that infor…

Pursuant to the authority granted by § 38.2-223, the Commission may adopt such rules and regulations as it may deem necessary to implement this chapter.

"Medicare supplement policy" means an individual or group accident and sickness insurance policy or certificate, or a health maintenance organization subscription contract or evidence of coverage, issued or issued for delivery in this Commonwealth which is (i) designed primarily …

Group Medicare supplement policies shall be expected to return to policyholders in the form of aggregate benefits at least seventy-five percent of the aggregate amount of premiums collected.

Medicare supplement policies sold on an individual basis shall be expected to return to policyowners in the form of aggregate benefits at least sixty-five percent of the aggregate amount of premiums collected.

Notwithstanding the provisions of § 38.2-3502, Medicare supplement policies shall have printed on the policy a notice stating substantially: "RIGHT TO RETURN POLICY WITHIN THIRTY DAYS. If for any reason you are not satisfied with your policy you may return this policy to the comp…

Notwithstanding subdivision 2 (b) of § 38.2-3503 or the provisions of § 38.2-3514.1, an insurer that issues a Medicare supplement policy shall not deny a claim for losses incurred more than six months from the effective date of coverage on the grounds that a condition existed pri…

Pursuant to the authority granted in § 38.2-223, the Commission may issue rules and regulations that may (i) require that an outline of coverage for Medicare supplement policies be delivered to the insured at the time the application is made and (ii) prescribe the format and cont…

A. The provisions of §§ 38.2-3418.1, 38.2-3604, 38.2-3605, 38.2-3606 and 38.2-3516 through 38.2-3520 shall be applicable to group Medicare supplement policies. The term "policy" as used in this article shall include a certificate issued under a group Medicare supplement policy wh…

A. The Commission may issue regulations to establish minimum standards for processing and payment of claims under Medicare supplement policies, marketing practices, compensation arrangements, requirements for loss ratio refunds or credits, Medicare select policies and certificate…

Every insurer, health service plan or health maintenance organization providing Medicare supplement insurance or benefits in this Commonwealth shall file with the Commission a copy of any Medicare supplement advertisement intended for use in this Commonwealth whether through writ…

A. An insurer, health services plan, or health maintenance organization issuing Medicare supplement policies or certificates in the Commonwealth, including policies or certificates issued on an individual or group basis or through a group trust, shall offer the opportunity of enr…

A. An insurer, health services plan, or health maintenance organization issuing individual Medicare supplement policies or certificates in the Commonwealth, including policies or certificates issued on an individual basis through a non-employer group trust, plan, or association, …

All life insurance and all accident and sickness insurance issued or sold in connection with loans or other credit transactions shall be subject to the provisions of this chapter except: 1. Such insurance issued in connection with a loan or other credit transaction of more than t…

For the purposes of this chapter: "Commission" means the State Corporation Commission. "Creditor" means the lender of money or vendor or lessor of goods, services, or property, rights or privileges, for which payment is arranged through a credit transaction, or any successor to t…

A. Credit life insurance and credit accident and sickness insurance shall be issued only in the following forms: 1. Individual policies of life insurance issued to debtors on the term plan; 2. Individual policies of accident and sickness insurance issued to debtors on a term plan…

A. Credit life insurance. 1. Where an indebtedness is repayable in substantially equal installments, the amount of credit life insurance shall at no time exceed the actual amount of unpaid indebtedness. 2. Notwithstanding the provisions of subdivision A 1, insurance on agricultur…

A. The term of any policy or certificate of credit life insurance or credit accident and sickness insurance shall, subject to acceptance by the insurer, commence on the date when the debtor becomes obligated to the creditor; except that where a group policy provides coverage with…

A. Notwithstanding the terms of § 38.2-3720, if the credit transaction provides for a variable interest rate and the insurance premiums are calculated and charged on a single premium basis, the initial amount of insurance coverage shall not exceed the scheduled amounts of unpaid …

A. Each insurer licensed to write credit life insurance in the Commonwealth shall establish and maintain reserves on all its credit life insurance. The minimum standard for the valuation for such reserves: 1. For both male and female insureds shall be the 2001 Commissioners' Stan…

A. Credit life insurance and credit accident and sickness insurance shall be evidenced by an individual policy, or in the case of group insurance by a certificate of insurance. The policy or certificate of insurance shall: (i) be a document separate and apart from the loan or cre…

A. No form shall be delivered or issued for delivery in this Commonwealth until a copy of each form has been filed with and approved by the Commission. B. If a group policy of credit life or credit accident and sickness insurance is delivered in another state, the insurer shall b…

A. The benefits provided by any credit life insurance form shall be deemed reasonable in relation to the premium charged or to be charged if the rates do not exceed the rates set forth below, except as such rates are modified pursuant to the requirements of § 38.2-3730: 1. $.7519…

A. The Commission shall, based on a morbidity study, promulgate seven-, fourteen- and thirty-day retroactive and nonretroactive credit accident and sickness insurance premium rates which will reasonably be expected to produce the loss ratio as required by subsection E of § 38.2-3…