§975. Health and accident policy provisions
A. Required provisions. Each policy shall contain in substance the following provisions or, at the option of the insurer, provisions which in the opinion of the commissioner of insurance are not less favorable to the policyholder; provided that, except as permitted by R.S. 22:972(C), no time limitation with respect to the filing of notice or proof of loss or within which suit may be brought upon the policy shall differ from the time limitations of the following provisions:
(1) Entire contract: Changes: This policy, including the endorsements and the attached papers, if any, and in case of industrial insurance, the written application, constitutes the entire contract of insurance. No producer has authority to change this policy or to waive any of its provisions. No change in this policy shall be valid until approved by an executive officer of the insurer and unless such approval be endorsed on or attached to the policy.
(2) Reinstatement: If default is made in the payment of any agreed premium for this policy, the subsequent acceptance of the defaulted premium by the insurer or by any producer authorized by the insurer to accept such premium, shall reinstate the policy; however, the reinstated policy shall cover only loss resulting from accidental injury thereafter sustained or loss due to sickness beginning more than ten days after the date of such acceptance.
(3) Notice of claim: Written notice of claim for injury or for sickness must be given to the insurer within twenty days after the date of the accident causing an injury or the commencement of the disability from such sickness, except that in case of industrial policies such notice of claim must be given to the insurer within ten days in such cases. In the event of accidental death, immediate notice must be given to the insurer. Such notice given by or on behalf of the insured or the beneficiary to the insurer at the location of such office as the insurer may designate for that purpose, or to any authorized agent of the insurer, with information sufficient to identify the insured, shall be deemed notice to the insurer. Failure to give notice within such time shall not invalidate nor reduce any claim if it was not reasonably possible to give notice within the time required, provided written notice of claim is given as soon as reasonably possible. In this Paragraph, the requirement relating to immediate notice of claim in event of accidental death may be omitted at the option of the insurer.
(4) Claim forms: The insurer, upon receipt of a notice of claim, will furnish to the claimant forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within fifteen days after the giving of notice, the claimant shall be deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in the policy for filing proofs of loss, affirmative written proof covering the occurrence, the character and the extent of the loss for which claim is made.
(5) Proof of loss: Affirmative written proof of loss must be furnished to the insurer at its office in case of claim for loss of time from disability within ninety days after the termination of the period for which the insurer is liable and in case of claim for any other loss within ninety days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided proof is furnished as soon as reasonably possible and in no event later than one year from the time proof is otherwise required. Any policy may also provide, at the insurer's option that written notice or proof of continuance of disability must be furnished not less frequently than each ninety days during the continuance of disability.
(6) Time of payment of claims: Indemnity claims payable under this policy for any loss other than loss of time on account of disability will be paid immediately upon receipt of written proof of such loss. Subject to written proof of loss, accrued indemnity claims for loss of time on account of disability will be paid (insert period of payment which must not be less frequently than monthly) and any balance remaining unpaid upon the termination of liability will be paid immediately.
(7) Payment of claims: Indemnity for loss of life and any other accrued indemnity claims unpaid at the insured's death will be paid to the beneficiary, if surviving the insured, and otherwise to the estate of the insured. All other indemnity claims will be paid to the insured. The policy may, at the insurer's option, provide that if there is no beneficiary, or the beneficiary is the estate of the insured, or the insured or beneficiary is a minor or not competent to give a valid release, the insurer may pay any amount not exceeding one thousand dollars, otherwise payable to the insured or his estate to any relative by blood or connection by marriage of the insured appearing to the insurer to which they may be equitably entitled, and may make payment of any amount not exceeding one thousand dollars, otherwise payable to the beneficiary to any relative by blood or connection by marriage of such beneficiary appearing to the insurer to which they may be equitably entitled. The policy may, at the insurer's option, also provide that all or a portion of any indemnities provided by any such policy on account of hospital, nursing, medical, or surgical services may be paid directly to the hospital or person rendering such services; however, the policy may not require that the services be rendered by a particular hospital or person.
(8) Physical examinations: The insurer shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim and to make an autopsy in case of death where it is not forbidden by law.
(9) Cancellation by insured: If the insured shall at any time change his occupation to one classified by the insurer as less hazardous than that stated in the policy, the insurer, upon written request of the insured, and at the insured's option, will either cancel the policy upon its surrender and refund the unearned premium or will reduce the premium rate accordingly and refund the excess pro rata unearned premium from the date of receipt of proof of such change of occupation.
(10) Consent of beneficiary: Consent of the beneficiary shall not be required for the surrender or assignment of this policy, nor for change of beneficiary, nor for any other changes in this policy.
(11) Legal action: No legal action shall be brought to recover on this policy prior to the expiration of sixty days after proof of loss has been filed in accordance with the requirements of this policy. No legal action shall be brought after the expiration of one year after the time proof of loss is required to be filed.
(12) Extension of time limitations: If any limitation of this policy with respect to giving notice of claim, furnishing proof of loss, or bringing any action on this policy is less than that permitted by law of the state, district, or territory in which the insured resides at the time this policy is issued, such limitation is extended to agree with the minimum period permitted by such law.
(13) Time limit on certain defenses:
(a)(i) After three years from the date of issue of this policy, no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or to deny a claim for loss incurred or disability, as defined in the policy, commencing after the expiration of such three-year period. This policy provision shall not be so construed as to affect any legal requirement for avoidance of a policy or denial of a claim during such initial three-year period, nor to limit the application of Paragraphs (B)(1), (2), (3), and (4) of this Section in the event of misstatement with respect to age or occupation or other insurance.
(ii) A policy which the insured has the right to continue in force subject to its terms by the timely payment of premium either until at least age fifty, or, in the case of a policy issued after age forty-four, for at least five years from its date of issue, may contain in lieu of the foregoing the following provision, from which the clause in parentheses may be omitted at the insurer's option, under the caption:
"INCONTESTABLE
After this policy has been in force for a period of three years during the lifetime of the insured, excluding any period during which the insured is disabled, it shall become incontestable as to the statements contained in the application."
(b) No claim for loss incurred or disability, as defined in the policy, commencing after three years from the date of issue of this policy shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss had existed prior to the effective date of coverage of this policy.
(14) Uniform claim forms: Notwithstanding any other law to the contrary, including Paragraph (4) of this Subsection, all claims shall be processed in conformity with the uniform claim form issued by the Department of Insurance pursuant to R.S. 22:1824.
B. Other optional provisions. No such policy shall be delivered or issued for delivery containing provisions respecting the matters set forth in this Subsection unless such provisions are, in substance, in the following forms, or, at the option of the insurer, in forms which in the written opinion of the commissioner of insurance are not less favorable to the policyholder:
(1) Change of occupation: If the insured suffers injury or sickness after having changed his occupation to one classified by the insurer as more hazardous than that stated in this policy or while performing services for compensation in any trade, business, or occupation so classified, the insurer will pay only such portion of the indemnity provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for such more hazardous trade, business, or occupation. In applying this Paragraph, the classification of occupational risk and the premium rates shall be such as have been last filed by the insurer prior to the occurrence of the loss for which the insurer is liable or prior to date of proof of change in occupation with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued; however, if such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the insurer in such state prior to the occurrence of the loss.
(2) Misstatement of age: If the age of the insured has been misstated, any amount payable or any indemnity accruing under this policy shall be determined as based on the correct age. If because of a misstatement of age, this policy was issued at an age or was continued or renewed beyond an age at which it would not have been issued, continued, or renewed under the insurer's underwriting rules in effect at the date of issue, the amount payable, because of the loss occurring after such age, shall be limited to a return of the premiums paid thereafter.
(3) Other insurance with this insurer: An insurer may do either of the following:
(a) If a like policy or policies previously issued by this insurer to the insured are in force concurrently with this policy, making the aggregate indemnity for (insert type of coverage) in excess of (insert maximum limit of indemnity), the excess insurance shall be void and all premiums paid for such excess shall be returned to the insured or to his estate.
(b) Insurance effective at any one time on the insured under a like policy or policies in this insurer is limited to one such policy, and the insurer will return to the insured or to his estate all premiums paid for such policies in excess thereof.
(4) Insurance with other insurers: If the insured carries with one or more insurers other valid insurance covering the same loss without having given written notice thereof to this insurer prior to the occurrence of loss, the only liability under this policy shall be for such proportion of the indemnity otherwise provided hereunder as the indemnity of which the insurer had notice, including the indemnity under this policy, bear to the total amount of like indemnity in all policies covering such loss, and for the return of such portion of the premium paid as shall exceed the pro rata portion for the indemnity thus determined.
(5) Relation of earnings to insurance: If the total monthly amount of loss of time indemnity promised in all policies or certificates of accident, health, or disability insurance upon the insured, whether payable on a weekly or monthly basis, shall exceed the average monthly earnings of the insured at the time disability commenced or for the period of two years immediately preceding a disability for which claim is made, whichever is the greater, the insurer will be liable only for such proportionate amount of the indemnity specified in the policy as the amount of such monthly earnings of the insured bears to the total amount of monthly indemnity promised under all such policies or certificates upon the insured at the time of such disability and for the return of such part of the premiums paid during such two years as shall exceed the pro rata amount of the premiums for the indemnity actually paid hereunder; but this shall not operate to reduce the total monthly amount of indemnity payable under all such policies or certificates upon the insured below the sum of one hundred dollars or the sum of the monthly indemnity specified in such policies or certificates, whichever is the lesser.
(6) Unpaid premium: Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted from such payment.
(7) Cancellation: The insurer may cancel this policy at any time subject to the provisions of R.S. 22:1012. Such cancellation shall be by written notice, delivered to the insured, or mailed to his last address as shown by the records of the insurer, shall refund the pro rata unearned portion of any premium paid, and shall comply with the provisions of R.S. 22:887(F). Such cancellation shall be without prejudice to any claim for benefits accrued or expenses incurred for services rendered prior to cancellation. Benefits and expenses incurred shall be as defined and limited by the terms of the policy. The insured may likewise cancel this policy on the terms specified in this Paragraph. Upon cancellation by the insurer, however, the insurer shall only be liable for any claim for benefits accrued, or for expenses incurred for services rendered, subsequent to the cancellation date if the subsequent claim is for an illness or condition which was the basis of any claim prior to cancellation and for which the insurer had notice and if the policy of insurance is cancelled for reasons other than failure of the policyholder to pay premiums or failure of the insured to maintain eligibility as provided in the policy. Upon the written request of the named insured, the insurer shall provide to the insured in writing the reasons for cancellation of the policy. There shall be no liability on the part of and no cause of action of any nature shall arise against any insurer or its agents, employees, or representatives for any action taken by them to provide the reasons for cancellation as required by this Paragraph.
(8) Conformity with state statutes: Any provision of this policy which, on the date of issue, is in conflict with the statutes of the state in which the insured resides at the date of issue is understood to be amended to conform to such statutes.
(9) Illegal occupation: The insurer shall not be liable for any loss to which a contributing cause was the insured's commission of or attempt to commit a felony or to which a contributing cause was the insured's being engaged in an illegal occupation.
(10) Intoxicants and narcotics: The insurer shall not be liable for any loss sustained or contracted in consequence of the insured's being intoxicated or under the influence of narcotics unless administered on the advice of a physician.
C. If any provision of this Section is inapplicable to or is inconsistent with any risk covered by a particular form of policy the insurer may, subject to the approval of the commissioner of insurance, omit from such policy such inapplicable provision or modify such inconsistent provision in such manner as to make it consistent with the coverage provided by the policy.
D. Repealed by Acts 1995, No. 730, §1.
Acts 1958, No. 125. Amended by Acts 1958, No. 97, §1; Acts 1982, No. 760, §1; Acts 1985, No. 249, §1; Acts 1987, No. 510, §1; Acts 1989, No. 269, §1; Acts 1989, No. 426, §1; Acts 1990, No. 886, §2; Acts 1991, No. 777, §1, eff. Sept. 30, 1991; Acts 1993, No. 57, §1; Acts 1993, No. 653, §1; Acts 1995, No. 730, §1; Redesignated from R.S. 22:213 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2010, No. 919, §1, eff. Jan. 1, 2011.