31.11.10.05

.05 Blanket Health Insurance Standard Provisions.

A. Each blanket health insurance contract shall contain in substance the provisions set forth in Regulation .04A, C, D, G, H, I, and L of this chapter.

B. Statements in Applications. Each blanket health insurance contract shall contain a provision that:

(1) Absent fraud, each statement made by the group policyholder is considered to be a representation and not a warranty; and

(2) A statement made by the group policyholder may not be used in defense to a claim under the policy unless the statement is contained in a written application.

C. Proofs of Loss. Each blanket health insurance contract shall contain a provision that:

(1) If a claim is for loss of time because of disability, written proof of loss shall be submitted to the insurer within 30 days after the beginning of the period for which the insurer is liable, and subsequent written proofs that the disability continues shall be submitted to the insurer at the intervals that the insurer reasonably requires;

(2) If a claim is for a loss other than loss of time because of disability, written proof of loss shall be submitted to the insurer within 90 days after the date of the loss; and

(3) Failure to submit proof of loss within the time required does not invalidate or reduce a claim if it is shown that it was not reasonably possible to submit the proof of loss within the time required, and that proof of loss was submitted as soon as was reasonably possible.

D. Time of Payment of Claims. Each blanket health insurance contract shall contain a provision that:

(1) Benefits payable under the policy, other than benefits for loss of time, are payable immediately on the insurer's receipt of written proof of loss; and

(2) Subject to proof of loss:

(a) Accrued benefits payable under the policy for loss of time are payable not later than at the end of each period of 30 days during the period for which the insurer is liable, and

(b) Any balance remaining unpaid at the end of the period set forth in žD(2)(a) of this regulation is payable immediately on the insurer's receipt of proof of loss.