Provisions Of Health Insurance Policies

Pursuant to the Texas Insurance Code, Section 1251.101, group accident, health, and accident and health insurance policies must contain several prescribed provisions that include the following:

  1.  premiums due must be remitted on or before the due date by the premium payors as designated in the policy and within any specified grace period;
  2.  the validity of the policy may not be contested except for nonpayment of premiums after it has been in force for two years from the date issued and that, in the absence of fraud, no statement made by any person covered by the policy relating to his or her insurability may be used in contesting the validity of the insurance with respect to which such statement was made after the insurance has been in force before the contest for two years during that person’s lifetime, nor unless it is contained in an instrument signed by him or her;
  3.  the policy and any attached application constitute the entire contract between the parties;
  4.  the conditions under which the insurer reserves the right to require a person eligible for insurance to furnish evidence of individual insurability satisfactory to the insurer as a condition to part or all of the coverage;
  5.  the additional exclusions or limitations applicable under the policy with respect to a disease or physical condition of a person, not otherwise excluded from the person’s coverage by name or specific description effective on the date of that person’s loss, which existed before the effective date of the person’s coverage under the policy;
  6.  if premiums or benefits vary by age, a provision specifying an equitable adjustment of premiums or benefits, or both, to be made if the age of a covered person has been misstated;
  7.  written notice of a claim must be given to the insurer within 20 days after the occurrence or commencement of any loss covered by the policy;
  8.  the insurer will furnish to the person making claim or to the policyholder for delivery to such person such forms as are usually furnished by it for proof of loss;
  9.  in the case of a claim for loss of time due to disability, written proof of such loss must be furnished to the insurer within the 90 days after the commencement of the period for which the insurer is liable, that subsequent written proofs of the continuance of the disability must be furnished to the insurer at such intervals as the insurer may reasonably require, and that in the case of a claim for any other loss written proof must be furnished to the insurer within 90 days after the date of the loss;
  10.  all benefits payable under the policy, other than benefits for loss of time, are payable not more that 60 days after receipt of proof, that, subject to due proof of loss, all accrued benefits payable under the policy for loss of time must be paid not less frequently than monthly during the continuance of the period for which the insurer is liable, and that any balance remaining unpaid at the termination of the period must be paid as soon as possible after receipt of such proof;
  11.  benefits for loss of life of the person insured are payable to the beneficiary designated by the person insured or the assignee; and
  12.  the insurer will have the right and opportunity to examine the person for whom claim is made, when and as often as reasonably necessary during the pendency of the claim, and to make an autopsy in case of death when not prohibited by law.
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