114-11-1. General.

1.1. Scope. -- The purpose of this regulation is to assure that the
interests of prospective purchasers of life insurance will be safeguarded
by providing such persons with clear and unambiguous statements,
explanations and written proposals concerning the life insurance contracts
offered to them. This purpose can best be achieved by requiring disclosure
of certain basic information pertinent to the life insurance contract, and
specifying those acts and practices which are deceptive, or misleading or
misrepresent the terms of the contract.

1.2. Authority. -- W. Va. Code e33-2-10 and e33-11-6

1.3. Filing Date. -- March 22, 1974

1.4. Effective Date. -- April 22, 1974

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(2) The policy specifications page; or

(3) Included in the solicitation material advertising the policy.

(d) All information required to be disclosed shall be set forth prominently
in an uninterrupted sequence in one (1) location of either the separate
written proposal, the specifications page or the advertising material. No
other material shall be interspersed between any of the items required to
be disclosed by this section.

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a written statement signed by the applicant subsequent to the presentation
of the written proposal required by Section 4 of this regulation,
confirming the applicant's opinion that after a review of his insurance
needs and means, he believes the insurance applied for is suitable for him,
shall be deemed to satisfy the requirement of this subsection.

(2) Where the purchase of such insurance is recommended through a direct
response solicitation, a written statement signed by the applicant
subsequent to the presentation of the written proposal required by Section
4 of the regulation, confirming the applicant's opinion that after a review
of his insurance needs and means, he believes the insurance applied for is
suitable for him, shall be deemed to satisfy the requirement of this
subsection.

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limited to, provisions respecting limitations, exceptions, reductions or
eliminations of coverage, not otherwise specifically authorized by statute
or regulation, which policy provisions are deemed by the Commissioner to
be unjust, unreasonable or unfairly discriminatory either to the
policyholder, subscriber, beneficiary or to any person insured under the
policy.

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(e) If a policy contains a status type military service exclusion which
suspends coverage during military service, the policy shall provide, upon
receipt of written request, for refund of premiums as applicable to such
person on a pro rata basis.

(f) In the event the insurer cancels or refuses to renew, policies
providing maternity benefits shall provide for an extension of benefits as
to normal pregnancy commencing while the policy is in force and for which
benefits would have been payable had the policy remained in force.

(g) Policies providing convalescent or extended care benefits following
hospitalization shall not condition such benefits upon admission to the
convalescent or extended care facility within a period of less than
fourteen (14) days after discharge from the hospital.

(h) Any policy which provides coverage of a dependent child shall not
terminate coverage for such dependent child if upon attainment of any
limiting age set forth in the policy such child is and continues to be both
(1) incapable of self-sustaining employment by reason of mental retardation
or physical handicap and (2) chiefly dependent on the policyholder for
support and maintenance. The policy may require that within thirty-one (31)
days of the child's attainment of the limiting age the insurer receive due
proof of such incapacity in order for the insured to elect to continue the
policy in force with respect to such child. As an alternative to this
requirement, a separate converted policy may be issued to the child at the
option of the insured.

(i) Any policy providing coverage for the recipient in a transplant
operation shall also provide for the reimbursement of any medical expenses
of a live donor to the extent that benefits remain and are available under
the recipient's policy after benefits for the recipient's own expenses have
been paid.

(j) Accidental death and dismemberment benefits shall be payable if the
loss occurs within ninety (90) days from the date of the accident,
irrespective of total disability. Disability income benefits, if provided,
shall not require the loss to commence less than thirty (30) days after the
date of accident, nor shall any policy which the insurer cancels or refuses
to renew require that it be in force at the time disability commences if
the accident occurred while the policy was in force.

(k) Specific dismemberment benefits shall not be in lieu of other benefits
unless the specific benefit exceeds the other benefits.

(l) Any accident only policy providing benefits which vary according to the

type of accidental cause shall prominently set forth in the disclosure
statement the circumstances under which benefits are payable which are less
than the maximum amount payable under the policy.

(m) A policy designed solely to supplement Medicare Part A, shall include
as a benefit the initial Part A Medicare deductible as established from
time to time by the Social Security Administration.

(n) Termination of the policy by the insurer shall be without prejudice to
any continuous loss which commenced while the policy was in force, but the
extension of benefits beyond the period the policy was in force may be
predicated upon the continuous disability of the insured or limited to the
duration of the policy benefit period, if any.

4.3. Basic hospital expense coverage. -- "Basic Hospital Expense
Coverage" is a policy of accident and sickness insurance which provides
coverage for a period of not less than thirty-one (31) days during any one
period of confinement for each person insured under the policy for expenses
incurred for necessary treatment and services rendered as a result of
accident or sickness for at least the following:

(a) Daily hospital room and board in an amount not less than the lesser of
the average semi-private room rate of the confining hospital or thirty
dollars ($30.00) per day;

(b) Miscellaneous hospital service for expenses incurred for the charges
made by the hospital for services and supplies which are customarily
rendered by the hospital and provided for use only during the period of
confinement in an amount not less than either eighty percent (80%) of the
charges incurred up to at least one thousand dollars ($1,000) or ten (10)
times the daily hospital room and board benefits; and

(c) Hospital outpatient services in an amount not less than fifty dollars
($50.00) for hospital services rendered to an insured as an outpatient for
any one accident or sickness.

Benefits provided under Subdivisions (a) and (b) above may be provided
subject to a combined deductible amount not in excess of one hundred
dollars ($100).

4.4. Basic medical-surgical expense coverage. -- "Basic Medical-Surgical
Expense Coverage" is a policy of accident and sickness insurance which
provides coverage for each person insured under the policy for the expenses
incurred for the necessary services rendered by a physician for treatment
of an injury or sickness for at least the following:

(a) Surgical services:

(1) In amounts not less than those provided on a fee schedule based on an
acceptable relative value scale of surgical procedures, up to a maximum of
five hundred dollars ($500) for any one procedure; or

(2) Not less than eighty percent (80%) of the reasonable charges.

(b) Anesthesia services, consisting of administration of necessary general
anesthesia and related procedures in connection with covered surgical
service rendered by a physician other than the physician (or his assistant)
performing the surgical services:

(1) In an amount not less than eighty percent (80%) of the reasonable
charges; or

(2) Fifteen percent (15%) of the surgical service benefit.

(c) In-hospital medical services, consisting of physician services rendered
to a person who is a bed patient in a hospital for treatment of sickness or
injury other than that for which surgical care is required, in an amount
not less than eighty percent (80%) of the reasonable charges; or five
dollars ($5.00) per call, one (1) call per day, for at least twenty-one
(21) such calls during one period of confinement.

4.5. Hospital confinement indemnity coverage. -- "Hospital Confinement
Indemnity Coverage" is a policy of accident and sickness insurance which
provides daily benefits for hospital confinement on an indemnity basis in
an amount not less than thirty dollars ($30.00) per day and not less than
thirty-one (31) days during any one (1) period of confinement for each
person insured under the policy.

4.6. Major medical expense coverage. -- "Major Medical Expense Coverage"
is an accident and sickness insurance policy which provides hospital,
medical and surgical expense coverage, to an aggregate maximum of not less
than ten thousand dollars ($10,000); copayment by the covered person not to
exceed twenty-five percent (25%) of covered charges; a deductible stated on
a per person, per family, per illness, per benefit period, or per year
basis, or a combination of such basis not to exceed five percent (5%) of
the aggregate maximum limit under the policy, unless the policy is written
to complement underlying hospital and medical insurance in which case such
deductible may be increased by the amount of the benefits provided by such
underlying insurance, for each covered person for at least:

(a) Daily hospital room and board, as defined in Subdivision (a) of
Subsection 4.3 of these rules;

(b) Miscellaneous hospital services, as defined in Subdivision (b) of
Subsection 4.3 of these rules;

(c) Surgical services, as defined in Subdivision (a) of Subsection 4.4 of
these rules;

(d) Anesthesia services, as defined in Subdivision (b) of Subsection 4.4 of
these rules;

(e) In-hospital medical services, as defined in Subdivision (c) of
Subsection 4.4 of these rules.

(f) Out of hospital care, consisting of physicians' services rendered on an
ambulatory basis where coverage is not provided elsewhere in the policy for
diagnosis and treatment of sickness or injury, and diagnostic X ray,
laboratory services, radiation therapy and hemodialysis order by a
physician; and

(g) Prosthetic appliances, meaning artificial limbs or other prosthetic
appliances (except replacements thereof) and rental of durable medical
equipment required for therapeutic use.

4.7. Disability income protection coverage. -- "Disability Income
Protection Coverage" is either an accident or sickness insurance policy or
a combination thereof which:

(a) Provides for periodic payments in an amount of at least one hundred
dollars ($100) per month payable at issue ages up to sixty-two (62) and
fifty dollars ($50.00) per month payable at ages after sixty-two (62).

(b) Contains an elimination period no greater than:

(1) Ninety (90) days in the case of a coverage providing a benefit period
of one year or less;

(2) Three hundred sixty-five (365) days if the benefit is payable for not
less than two (2) years and is payable in an amount of at least two hundred
dollars ($200) per month; or

(3) One hundred eighty (180) days in all other cases during the continuance
of disability resulting from sickness or injury.

(c) Has a maximum period of time for which it is payable during disability
of at least six (6) months except in the case of a policy covering
disability arising out of pregnancy, childbirth, or miscarriage in which
case the disability period may be one (1) month. No reduction in benefits
shall be put into effect because of an increase in Social Security or
similar benefits during a benefit period. This provision does not apply to
those policies providing business buy out coverage.

4.8. Accident only coverage. -- "Accident Only Coverage" is a policy of
accident insurance which provides coverage, singly or in combination, for
death, dismemberment, disability or hospital and medical care caused by
accident. Accidental death and double dismemberment amounts under such a
policy shall be at least one thousand dollars ($1,000) and a single
dismemberment amount shall be at least five hundred dollars ($500).

4.9. Specified disease and specified accident coverage.

(a) "Specified Disease Coverage" is a policy which provides coverage for
each person insured under the policy for a specifically named disease (or
diseases) with a deductible amount not in excess of two hundred fifty
dollars ($250) and an overall aggregate benefit limit of no less than five
thousand dollars ($5,000) and a benefit period of not less than two (2)
years for at least the following incurred expenses:

(1) Hospital room and board and any other hospital furnished medical
services or supplies;

(2) Treatment by a legally qualified physician or surgeon;

(3) Private duty services of a registered nurse (R.N.);

(4) X ray, radium and other therapy procedures used in diagnosis and
treatment;

(5) Professional ambulance for local service to or from a local hospital;

(6) Blood transfusions, including expense incurred for blood donors;

(7) Drugs and medicines prescribed by a physician;

(8) The rental of an iron lung or similar mechanical apparatus;

(9) Braces, crutches and wheel chairs as are deemed necessary by the
attending physician for the treatment of the disease;

(10) Emergency transportation if in the opinion of the attending physician
it is necessary to transport the insured to another locality for treatment
of the disease; and

(11) May include coverage of any other expenses necessarily incurred in the
treatment of the disease.

(b) "Specified Accident Coverage" is an accident insurance policy which
provides coverage for a specifically identified kind of accident (or
accidents) for each person insured under the policy for accidental death or
accidental death and dismemberment combined, with a benefit amount of no
less than one thousand dollars ($1,000) for accidental death; one thousand
dollars ($1,000) for double dismemberment and five hundred dollars
($500) for single dismemberment. 114-12-5. Required Disclosure Provisions.

5.1. General rules.

(a) Each individual policy of accident and sickness insurance or hospital,
medical or dental service corporation subscriber contract shall include a
renewal, continuation or nonrenewal provision. The language or
specifications of such provision must be consistent with the type of
contract to be issued. Such provision shall be appropriately captioned,
shall appear on the first page of the policy, and shall clearly state the
duration, where limited, of renewability and the duration of the term of
coverage for which the policy is issued and for which it may be renewed.

(b) The terms "Noncancelable" or "Guaranteed Renewable" shall not be used
without further explanatory language. The term "Noncancelable" shall not
be used unless the insured has the right to continue the policy in force by
the timely payment of premiums until age sixty-five (65) or to eligibility
for Medicare, during which period the insurer may not unilaterally make any
change in the policy provisions while the policy is in force. The insurer
shall not reserve the right to change rates in connection with the term
"Guaranteed Renewable" except on a class basis unless this limitation is
clearly set forth on the first page of the policy and identified as a
limitation of the term "Guaranteed Renewable." The insurer may include a
policy provision for termination or nonrenewal of disability income
policies prior to age sixty-five (65), subject to approval by the
Commissioner, where:

(1) The insured is receiving retirement income; and

(2) The insured is no longer subject to the risk of loss of income as a
result of accident or sickness.

(c) Where a separate additional premium is charged for benefits provided in
connection with riders or endorsements, such premium charge shall be set
forth in the policy.

(d) A policy which provides for the payment of benefits based on standards
described as "Usual and Customary," "Reasonable and Customary," or words of
similar import, shall include an explanation of such terms within both the
policy and its accompanying disclosure statement.

(e) Any provisions limiting or excluding coverage of preexisting
conditions shall be labeled as such, shall appear in a separate paragraph
on the first page of the policy, and shall be included in the disclosure
statement.

(f) All accident only policies shall contain as an overlay on the first
page of the policy, in contrasting color, a prominent statement as follows:

"This is an accident only policy and it does not pay benefits for loss from
sickness."

(g) All policies shall have a notice prominently displayed on the first
page of the policy stating in substance that the policyholder shall have
the right to return the policy within ten (10) days of its delivery and to
have the premium refunded if after examination of the policy the
policyholder is not satisfied for any reason.

(h) If age is to be used as a factor in reducing the maximum aggregate
benefits made available in the policy as originally issued, such fact must
be prominently set forth in the disclosure statement.

(i) If a policy contains a conversion privilege, it shall comply, in
substance, with the following: The caption of the provisions shall be
"Conversion Privilege," or words of similar import. The provision shall
indicate the persons eligible for conversion, the circumstances applicable
to the conversion privilege, including any limitations on the conversion,
and the person by whom the conversion privilege may be exercised. The
provision shall specify the benefits to be provided on conversion or may
state that the converted coverage will be as provided on a policy form then
being used by the insurer for that purpose.

5.2. Disclosure requirements for individual coverages. -- No individual
accident and sickness insurance policy or hospital, medical or dental
service corporation subscriber contract shall be delivered or issued for
delivery in this State unless an appropriate disclosure statement, as
prescribed in Subdivisions (c) through (j) of this Subsection, is completed

as to such policy or contract, and:

(a) In the case of a direct response insurance product is delivered with
the policy; or

(b) In all other cases is delivered to the applicant at the time
application is made and acknowledgment of receipt or certification of
delivery of such disclosure statement is provided to the insurer.

In the event that a policy or contract is issued on a basis other than that
applied for, a disclosure statement properly describing the policy or
contract must accompany the policy or contract when it is delivered and
contain the following statement, in no less than twelve (12) point type,
immediately above the company name: "NOTICE: Read this disclosure
statement carefully. It is not identical to the disclosure statement
provided upon application and the coverage originally applied for has not
been issued."

The appropriate disclosure statement for policies or contracts providing
hospital coverage which only meets the standards of Subsection 4.9 of these
rules, shall be that statement contained in Subdivision (j) of these rules.
The appropriate disclosure statement for policies providing coverage which
meets the standards of both Subsections 4.3 and 4.4 of these rules shall be
the statement contained in Subdivision (e) of these rules. The appropriate
disclosure statement for policies providing coverage which meets the
standards of both Subsections 4.3 and 4.6 or Subsections 4.4 and 4.6 or
Subsections 4.3, 4.4 and 4.6 of these rules shall be the statement
contained in Subdivision (g) of these rules.

Appropriate changes in terminology shall be made in disclosure statements
in the case of contracts of hospital, medical or dental service
corporations. In any other case where the prescribed disclosure statement
is inappropriate for the coverage provided by the policy or contract, an
alternate disclosure statement shall be submitted to the Commissioner for
prior approval. Should the Commissioner deem it appropriate to approve
policies or contracts containing less than the prescribed minimum standards
for benefits as provided in Subsection 4.1 of these rules, the disclosure
statement issued in connection with any such policy or contract shall be
approved prior to use and shall prominently state that the coverages
therein described do not meet the minimum standards for benefits
established for that category of coverage.

The disclosure statements required by this subsection shall be plainly
printed in light-faced type of a style in general use, the size of which
shall be uniform and not less than ten (10) point with a lower-case

unspaced alphabet length not less than one hundred twenty (120) point.

In the disclosure statement forms that follow, only the material appearing
in brackets is to be composed by the insurer in language appropriate for
the coverage provided. All other material shall appear in exactly the form
set forth in this regulation.

(c) Basic hospital expense coverage (disclosure statement). -- A
disclosure statement, in the form prescribed below, shall be issued in
connection with policies meeting the standards of Subsection 4.3 of this
regulation. The items included in the disclosure statement must appear in
the sequence prescribed:

(Company Name)

Basic Hospital Expense

Coverage-Required Disclosure Statement

(1) Read your policy carefully. -- This disclosure statement provides a
very brief description of the important features of your policy. This is
not the insurance contract and only the actual policy provisions will
control. The policy itself sets forth in detail the rights and obligations
of both you and your insurance company. It is, therefore, important that
you READ YOUR POLICY CAREFULLY!

(2) Basic hospital expense coverage. -- Policies of this category are
designed to provide, to persons insured, coverage for hospital expenses
incurred as a result of a covered accident or sickness. Coverage is
provided for daily hospital room and board, miscellaneous hospital services
and hospital outpatient services, subject to any limitations set forth in
the policy. Coverage is not provided for physicians or surgeons fees or
unlimited hospital expenses. (Note: Final sentence may be appropriately
modified, if necessary, to reflect coverage provided).

(3) A brief specific description of the benefits contained in this policy,
in the following order:

(A) Daily hospital room and board;

(B) Miscellaneous hospital services;

(C) Hospital outpatient services; and (D) Other benefits, if any.

Note: The above description of benefits shall be stated clearly and

concisely and shall include a description of any deductible or copayment
provision applicable to the benefits described.

(4) A description of any policy provisions which exclude, eliminate,
restrict, reduce, limit, delay or in any other manner operate to qualify
payment of the benefits described in Subdivision (3) above.

(5) A description of policy provisions respecting renewability or
continuation of coverage, including age restrictions or any reservation of
right to change premiums.

(d) Basic medical-surgical expense coverage (disclosure statement). -- A
disclosure statement, in the form prescribed below, shall be issued in
connection with policies meeting the standards of Subsection 4.4 of this
regulation. The items included in the disclosure statement must appear in
the sequence prescribed:

(Company Name)

Basic Medical-Surgical Expense Coverage

Required Disclosure Statement

(1) Read your policy carefully. -- This disclosure statement provides a
very brief description of the important features of your policy. This is
not the insurance contract and only the actual policy provisions will
control. The policy itself sets forth in detail the rights and obligations
of both you and your insurance company. It is, therefore, important that
you READ YOUR POLICY CAREFULLY!

(2) Basic medical-surgical expense coverage. -- Policies of this category
are designed to provide, to persons insured, coverage for
medical-surgical expenses incurred as a result of a covered accident or
sickness. Coverage is provided for surgical services, anesthesia services
and in-hospital medical services, subject to any limitations set forth in
the policy. Coverage is not provided for hospital expenses or unlimited
medical-surgical expenses. (Note: Final sentence may be appropriately
modified, if necessary, to reflect coverage provided.)

(3) A brief specific description of the benefits contained in this policy,
in the following order:

(A) Surgical services;

(B) Anesthesia services;

(C) In-hospital medical services; and

(D) Other benefits, if any.

Note: The above description of benefits shall be stated clearly and
concisely and shall include a description of any deductible or copayment
provision applicable to the benefits described.

(4) A description of any policy provisions which exclude, eliminate,
restrict, reduce, limit, delay or in any other manner operate to qualify
payment of the benefits described in Subdivision (3) above.

(5) A description of policy provisions respecting renewability or
continuation coverage, including age restrictions or any reservation of
right to change premiums.

(e) Basic hospital and medical-surgical expense coverage (disclosure
statement). -- A disclosure statement, in the form prescribed below, shall
be issued in connection with policies meeting the standards of Subsections
4.3 and 4.4 of this regulation. The items included in the disclosure
statement must appear in the sequence prescribed.

(Company Name)

Basic Hospital And Medical-Surgical

Expense Coverage Required Disclosure Statement

(1) Read your policy carefully. -- This disclosure statement provides a
very brief description of the important features of your policy. This is
not the insurance contract and only the actual policy provisions will
control. The policy itself sets forth in detail the rights and obligations
of both you and your insurance company. It is, therefore, important that
you READ YOUR POLICY CAREFULLY!

(2) Basic hospital and medical-surgical expense coverage. -- Policies of
this category are designed to provide, to persons insured, coverage for
hospital and medical-surgical expenses incurred as a result of a covered
accident or sickness. Coverage is provided for daily hospital room and
board, miscellaneous hospital services, hospital outpatient services,
surgical services, anesthesia services and in-hospital medical services,
subject to any limitations set forth in the policy. Coverage is not
provided for unlimited hospital or medical-surgical expenses. (Note:
Final sentence may be appropriately modified, if necessary, to reflect

coverage provided.)

(3) A brief specific description of the benefits contained in this policy,
in the following order:

(A) Daily hospital room and board;

(B) Miscellaneous hospital services;

(C) Hospital outpatient services;

(D) Surgical services;

(E) Anesthesia services;

(F) In-hospital medical services; and (G) Other benefits, if any.

Note: The above description of benefits shall be stated clearly and
concisely and shall include a description of any deductible or copayment
provision applicable to the benefits described.

(4) A description of any policy provisions which exclude, eliminate,
restrict, reduce, limit, delay or in any other manner operate to qualify
payment of the benefits described in Subdivision (3) above.

(5) A description of policy provisions respecting renewability or
continuation of coverage, including age restrictions or any reservation of
right to change premiums.

(f) Hospital confinement indemnity coverage (disclosure statement). -- A
disclosure statement, in the form prescribed below, shall be issued in
connection with policies meeting the standards of Subsection 4.5 of this
regulation. The items included in the disclosure statement must appear in
the sequence prescribed:

(Company Name)

Hospital Confinement Indemnity

Coverage Required Disclosure Statement

(1) Read your policy carefully. -- This disclosure statement provides a
very brief description of the important features of your policy. This is
not the insurance contract and only the actual policy provisions will
control. The policy itself sets forth in detail the rights and obligations

of both you and your insurance company. It is, therefore, important that
you READ YOUR POLICY CAREFULLY!

(2) Hospital confinement indemnity coverage. -- Policies of this category
are designed to provide, to persons insured, coverage in the form of a
fixed daily benefit during periods of hospitalization resulting from a
covered accident or sickness, subject to any limitations set forth in the
policy. Such policies do not provide any benefits other than the fixed
daily indemnity for hospital confinement. (Note: Final sentence may be
appropriately modified, if necessary, to reflect coverage provided.)

(3) A brief specific description of the benefits contained in this policy,
in the following order:

(A) Daily benefit payable during hospital confinement; and

(B) Duration of benefit described in Subdivision (a) above.

Note: The above description of benefits shall be stated clearly and
concisely and shall include a description of any deductible or copayment
provision applicable to the benefits described.

(4) A description of any policy provisions which exclude, eliminate,
restrict, reduce, limit, delay or in any other manner operate to qualify
payment of the benefits described in Subdivision (3) above.

(5) A description of policy provisions respecting renewability or
continuation of coverage, including age restrictions or any reservation of
right to change premiums.

(g) Major medical expense coverage (disclosure statement). -- A
disclosure statement, in the form prescribed below, shall be issued in
connection with policies meeting the standards of Subsection 4.6 of this
regulation. The items included in the disclosure statement must appear in
the sequence prescribed:

(Company Name)

Major Medical Expense Coverage

Required Disclosure Statement

(1) Read your policy carefully. -- This disclosure statement provides a
very brief description of the important features of your policy. This is
not the insurance contract and only the actual policy provisions will

control. The salary itself sets forth in detail the rights and obligations
of both you and your insurance company. It is, therefore, important that
you READ YOUR POLICY CAREFULLY!

(2) Major medical expense coverage. -- Policies of this category are
designed to provide, to persons insured, coverage for major hospital,
medical and surgical expenses incurred as a result of a covered accident or
sickness. Coverage is provided for daily hospital room and board,
miscellaneous hospital services, surgical services, anesthesia services,
in-hospital medical services, out of hospital care and prosthetic
appliances, subject to any deductibles, copayment provisions or other
limitations which may be set forth in the policy. Basic hospital or basic
medical insurance coverage is not provided. (Note: Final sentence may be
appropriately modified, if necessary, to reflect coverage provided.)

(3) A brief specific description of the benefits contained in this policy,
in the following order:

(A) Daily hospital room and board;

(B) Miscellaneous hospital services;

(C) Surgical services;

(D) Anesthesia services;

(E) In-hospital medical services;

(F) Out of hospital care;

(G) Prosthetic appliances; and

(H) Other benefits, if any. Note: The above description of benefits shall
be stated clearly and concisely and shall include a description of any
deductible or copayment provision applicable to the benefits described.

(4) A description of any policy provisions which exclude, eliminate,
restrict, reduce, limit, delay or in any other manner operate to qualify
payment of the benefits described in Subdivision (3) above.

(5) A description of policy provisions respecting renewability or
continuation of coverage, including age restrictions or any reservation of
right to change premiums.

(h) Disability income protection coverage (disclosure statement). -- A

disclosure statement, in the form prescribed below, shall be issued in
connection with policies meeting the standards of Subsection 4.7 of this
regulation. The items included in the disclosure statement must appear in
the sequence prescribed:

(Company Name)

Disability Income Protection Coverage

Required Disclosure Statement

(1) Read your policy carefully. -- This disclosure statement provides a
very brief description of the important features of your policy. This is
not the insurance contract and only the actual policy provisions will
control. The policy itself sets forth in detail the rights and obligations
of both you and your insurance company. It is, therefore, important that
you READ YOUR POLICY CAREFULLY!

(2) Disability income protection coverage. -- Policies of this category
are designed to provide, to persons insured, coverage for disabilities
resulting from a covered accident or sickness, subject to any limitations
set forth in the policy. Coverage is not provided for basic
medical-surgical or major-medical expenses. (Note: Final sentence may be
appropriately modified, if necessary, to reflect coverage provided.)

(3) A brief specific description of the benefits contained in this policy:

Note: The above description of benefits shall be stated clearly and
concisely and shall include a description of any deductible or copayment
provision applicable to the benefits described.

(4) A description of any policy provisions which exclude, eliminate,
restrict, reduce, limit, delay or in any other manner operate to qualify
payment of the benefits described in Subdivision (3) above.

(5) A description of policy provisions respecting renewability or
continuation of coverage, including age restrictions or any reservation of
right to change premiums.

(i) Accident only coverage (disclosure statement). -- A disclosure
statement, in the form prescribed below, shall be issued in connection with
policies meeting the standards of Subsection 4.8 of this regulation. The
items included in the disclosure statement must appear in the sequence
prescribed:

(Company Name)

Accident Only Coverage

Required Disclosure Statement

(1) Read your policy carefully. -- This disclosure statement provides a
very brief description of the important features of your policy. This is
not the insurance contract and only the actual policy provisions will
control. The policy itself sets forth in detail the rights and obligations
of both you and your insurance company. It is, therefore, important that
you READ YOUR POLICY CAREFULLY!

(2) Accident only coverage. -- Policies of this category are designed to
provide, to persons insured, coverage for certain losses resulting from a
covered accident only, subject to any limitations contained in the policy.
Coverage is not provided for basic hospital, basic medical-surgical or
major-medical expenses. (Note: Final sentence may be appropriately
modified, if necessary, to reflect coverage provided.)

(3) A brief specific description of the benefits contained in this policy:

Note: The above description of benefits shall be stated clearly and
concisely and shall include a description of any deductible or copayment
provision applicable to the benefits described.

(4) A description of any policy provisions which exclude, eliminate,
restrict, reduce, limit, delay or in any other manner operate to qualify
payment of the benefits described in Subdivision (3) above.

(5) A description of policy provisions respecting renewability or
continuation of coverage, including age restrictions or any reservation of
right to change premiums.

(j) Specified disease or specified accident coverage (disclosure
statement). -- A disclosure statement, in the form prescribed below, shall
be issued in connection with policies meeting the standards of Subsection
4.9 of this regulation. The coverage shall be identified by the appropriate
bracketed title. The items included in the disclosure statement must appear
in the sequence prescribed:

(Company Name)

(Specified Disease) (Specified Accident)

Coverage Required Disclosure Statement

(1) Read your policy carefully. -- This disclosure statement provides a
very brief description of the important features of your policy. This is
not the insurance contract and only the actual policy provisions will
control. The policy itself sets forth in detail the rights and obligations
of both you and your insurance company. It is, therefore, important that
you READ YOUR POLICY CAREFULLY!

(2) (Specified disease) (specified accident) coverage. -- Policies of this
category are designed to provide, to persons insured, coverage paying
benefits only when certain losses occur as a result of (specified diseases)
or (specified accidents). Coverage is not provided for basic hospital,
basic medical-surgical or major medical expenses. (Note: Final sentence
may be appropriately modified, if necessary, to reflect coverage provided.)

(3) A brief specific description of the benefits contained in this policy:

Note: The description of benefits shall be stated clearly and concisely and
shall include a description of any deductible or copayment provisions
applicable to the benefits described.

(4) A description of any policy provisions which exclude, eliminate,
restrict, reduce, limit, delay or in any other manner operate to qualify
payment of the benefits described in Subdivision (3) above.

(5) A description of policy provisions respecting renewability or
continuation of coverage, including age restrictions or any reservation of
right to change premiums.

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topic no 93 Topic Name : Series 14, Unfair Trade Practices
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on an application may provide a basis for the company to deny any future
claims and to refund your premium as though your policy had never been in
force. After the application has been completed and before you sign it,
reread it carefully to be certain that all information has been properly
recorded. (Note: Final sentence may, for direct response insurers, be
changed to read as follows: "Carefully reread your application, as attached
to the policy issued, to be certain that all information has been properly
recorded.")

The above "Notice to Applicant" was delivered to me on:




_______________________ (Date)

_______________________ (Applicant's Signature)

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Entry # : 2064 prepared Apr 3 17:26:34 1995

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topic no 93 Topic Name : Series 14, Unfair Trade Practices
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Subject :114-13-1
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topic no 93 Topic Name : Series 14, Unfair Trade Practices
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topic no 93 Topic Name : Series 14, Unfair Trade Practices
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Subject :114-13-3
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topic no 93 Topic Name : Series 14, Unfair Trade Practices
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(b) Answers may be filed by personal delivery to the Commissioner or by
certified mail, return receipt requested.

(c) Answers, where filed, shall contain a general or specific affirmation
or denial of each and every charge, allegation or matter asserted in the
notice; or a denial of any knowledge or information thereof sufficient to
form a belief. An answer may also contain a statement of any matter
believed to constitute a defense.

(d) Any charge, allegation or matter asserted in the notice which is not
denied or admitted in the answer, unless the respondent shall state in the
answer that he is without knowledge or information, shall be deemed
admitted.

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(b) All evidence, including papers, records and documents in the possession
of the Commissioner, of which he desires to avail himself, shall be offered
and made a part of the record in the case and no other factual information
or evidence shall be considered in the determination of the case.
Documentary evidence may be received in the form of copies or excerpts or
by incorporation by reference.

6.5. Stipulations. -- Written stipulations may be introduced in evidence,
if signed by the persons sought to be bound thereby or by their attorneys.
Oral stipulations may be made on the record as permitted by the Hearings
Examiner.

6.6. Motions and objections. -- Motions made during a hearing and
objections with respect to the conduct of a hearing, including objections
to the introduction of evidence, shall be preserved in the record.

6.7. Memorandums and briefs. -- The Hearings Examiner may permit parties
to submit legal memorandums or briefs within such time as he shall deem
appropriate.

6.8. Improper conduct. -- The Hearings Examiner may exclude from the
place of hearing or from further participation in the hearing any person
who engages in improper conduct.

6.9. Continuation and adjournment. -- The Hearings Examiner may continue a
hearing from one day to another or adjourn it to a later date or to a
different place by announcement thereof at the hearing or by appropriate
notice to all parties.

6.10. Subpoenas. -- In accordance with the provisions of West Virginia
Code section four, article two, chapter thirty-three, the Commissioner, or
any person conducting a hearing by his authority, shall have power to issue
subpoenas and subpoenas duces tecum. Such process shall be issued in
conformity with the provisions of section five, six, seven and eight,
article two, chapter thirty-three of the West Virginia Code and section
one-b, article five, chapter twenty-nine of the said Code.

6.11. Failure to appear. -- Notwithstanding the failure of any party to
appear at a hearing in accordance with notice provided, the Commissioner
may proceed to hold a hearing at the time and place specified in said
notice and may make findings of fact and conclusions of law and enter an
order upon the testimony and evidence taken at the hearing.

6.12. Rehearing. -- In the discretion of the Commissioner, a rehearing may
be granted to any party to a hearing upon written request filed with the

Commissioner within thirty (30) days of the entry of an order.

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topic no 93 Topic Name : Series 14, Unfair Trade Practices
current date Wed Jul 9 09:42:11 1997
Entry # : 2073 prepared Apr 4 10:45:42 1995

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Subject :114-13-6
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topic no 93 Topic Name : Series 14, Unfair Trade Practices
current date Wed Jul 9 09:42:11 1997
Entry # : 2074 prepared Apr 4 10:46:33 1995

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Subject :114-13-7
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topic no 93 Topic Name : Series 14, Unfair Trade Practices
current date Wed Jul 9 09:42:11 1997
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Subject :114-13-8
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current date Wed Jul 9 09:42:11 1997
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Subject :114-13-9
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topic no 93 Topic Name : Series 14, Unfair Trade Practices
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policy or insurance contract. This shall include, but not be limited to,
the requiring or preparing of repair estimates.

2.10. "Insurance Policy or Insurance Contract" means the contract effecting
insurance, or the certificate thereof, by whatever name called, and
includes all clauses, riders, endorsements and papers issued under the
terms of the policy or contract.

2.11. "Claim" means any communication by a claimant to an insurer or its
agent which reasonably apprises the insurer or agent of an occurrence which
might give rise to liability under a policy or contract of insurance.

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current date Wed Jul 9 09:42:12 1997
Entry # : 2079 prepared Apr 4 10:48:52 1995

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Subject :114-14-3
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after receipt by the insurer of a properly executed proof of loss.

6.6. Liability of others. -- Insurers shall not fail to settle first
party claims on the basis that responsibility for payment should be assumed
by others except as may otherwise be provided by policy provisions.

6.7. Denial of claims for failure to exhibit property. -- No insurer shall
deny a claim for failure to exhibit the insured property without proof of
demand by the insurer and refusal by the claimant to exhibit said property.

6.8. Separation of claims. -- In any case where there is no dispute as to
one (1) or more elements of a claim, payment for such element(s) shall be
made notwithstanding the existence of disputes as to other elements of the
claim where such payment can be made without prejudice to either party.

6.9. Time for payment of claims. -- Every insurer shall pay any amount
finally agreed upon in settlement of all or part of any claim not later
than fifteen (15) working days from the receipt of such agreement by the
insurer or from the date of the performance by the claimant of any
condition set by such agreement, whichever is later.

6.10. Notice of applicable time limitations. -- No person shall negotiate
for settlement of a claim with a claimant who is neither an attorney nor
represented by an attorney without giving the claimant written notice that
the claimant's rights may be affected by a statute of limitations or a
policy or contract time limit. Such notice shall be given to first party
claimants thirty (30) days and to third party claimants sixty (60) days
before the date on which such time limit may expire.

6.11. Avoidance of payment. -- Where liability and damages are reasonably
clear, no person shall recommend that third party claimants make claim
under their own policies solely to avoid paying claims under an insurer's
insurance policy or insurance contract.

6.12. Unreasonable travel. -- No person shall require a claimant to
travel unreasonably either to inspect a replacement motor vehicle, to
obtain a repair estimate or to have the motor vehicle repaired at a
specific repair shop.

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Subject :114-14-6
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(b) If an insurer prepares an estimate of the cost of the motor vehicle
repairs, such estimate shall be in an amount for which it may be reasonably
expected the damage can be satisfactorily repaired. The insurer shall give
a copy of the estimate to the insured and may furnish to the insured the
names of one or more conveniently located repair shops that will perform
the repairs for the amount tendered in settlement of the claim;

(c) If the insurer intends to exercise its rights to inspect damages prior
to repair, it shall have seven (7) working days from the date of receipt of
notice of loss to inspect the insured's damaged motor vehicle at a place
and time reasonably convenient to the insured. In addition, negotiations
shall commence and a good faith offer of settlement shall be made within
the aforesaid seven (7) day period;

(d) If the insured's motor vehicle is repaired at a repair shop of the
insurer's choice, for a sum estimated by the insurer as the reasonable cost
to repair the vehicle, the insurer shall, at no additional cost to the
claimant and within a reasonable period of time, cause the damaged vehicle
to be restored to the condition it was in prior to the loss if the repair
shop it recommended does not so repair the damaged motor vehicle;

(e) Deductions for betterment and/or depreciation are permitted only for
parts normally subject to repair and replacement during the useful life of
the insured motor vehicle. Deductions for betterment and/or depreciation
shall be limited to an amount equal to the proportion that the expired life
of the part to be repaired or replaced bears to the normal useful life of
that part. Calculations for betterment, depreciation and normal useful life
must be included in the insurer's claim file;

(f) Deductions for previous damage or prior condition of the motor vehicle
must be measurable, discernible, itemized and specified as to dollar
amount, and such deductions must be detailed in the claim file;

(g) The insurer must mail or hand deliver to the insured or his or her
designated representative its proof of loss or payment within ten (10)
working days after the insured has accepted the insurer's offer;

(h) If the insurer does not perform its own physical inspection, it is
nevertheless bound by all the applicable requirements of this regulation.

7.4. Adjustment of total losses. -- The following subdivisions shall
govern the conduct of insurers in the adjustment of total losses:

(a) If the insurer elects to make a cash settlement: (1) It must use the
most recent publication of an "Official Used Car Guide" approved by the

Commissioner and uniformly and regularly used by the company, as a guide
for setting the minimum value of the motor vehicle which is the subject of
the claim. Any deviation downward from the guide's retail valuation must
be supported by documentation that gives detailed information about the
vehicle's condition, and any deductions must be measurable, discernible,
itemized and specified concerning dollar amount, and they shall be
appropriate in amount;

(2) If the retail value of the specific motor vehicle is not published in
the most recent publication of an "Official Used Car Guide" approved by the
Commissioner and which is used uniformly and regularly by the company, the
company must secure dealer quotations on the retail value of similar
vehicles and base the settlement upon them. The offer must enable the
insured to purchase the substantially similar vehicle for the case
settlement and any deviation from this practice must be supported by
documentation giving particular information about the motor vehicle's
condition. The source of the dealer quotations must be maintained in the
claim file;

(3) The company shall provide a reasonable written explanation to the
concerned parties when case settlement offers, as set forth in Subdivisions
(1) and (2) above are made. The explanation must specify the dollar amount
of the base figure and identify the actual source. Any additions or
subtractions from the base dollar figure must be identified and explained;
and

(4) In addition to any cash settlement value agreed to by the claimant,
there must be added an amount equal to five percent (5%) of such cash
settlement value, as reimbursement to the claimant for the excise tax
imposed by the state.

(b) If the insurer elects to replace the vehicle, the replacement vehicle
must be an immediately available, substantially similar vehicle that is
both furnished and paid for by the insurer, subject to the deductible, if
any.

(c) If the insured vehicle is a private passenger automobile of the current
model year, meaning that it has not been superseded in the marketplace by
an officially introduced succeeding model, the insurer shall utilize one of
the following methods in the settlement of the loss, except where the
method used would be detrimental to the interests of the insured as
compared with utilization of the methods described in Subsections (a) and
(b) above:

(1) The insurer shall pay to the insured the reasonable purchase price on

the date of loss of a substantially similar vehicle, less any applicable
deductible and an allowance for depreciation in accordance with an official
used car guide which has been approved by the Commissioner and is used
regularly by the insurer; or

(2) The insurer shall furnish the insured with a substantially similar
replacement vehicle, and charge the insured for any applicable deductible
and for depreciation in accordance with said official used car guide.

(d) If the insurer, in the process of adjusting a total loss, makes a
deduction for the salvage value of the insured vehicle, the insurer must
furnish the insured with the name and address of a salvage dealer who will
purchase the salvage for the amount deducted.

(e) All applicable provisions of Subsection 7.3 of this section
"Adjustment of Partial Losses" also shall apply to the adjustment of total
losses, except that the insurer shall be allowed an additional five (5)
working days to comply with the requirements set out in Subsection 7.3 of
these rules. Any letter of explanation or rejection of any element of a
claim shall contain the identity and claims processing address of the
insurer, the insured's policy number and the claim number.

7.5. Unreasonable delay. -- If any element of a physical damage claim
remains unresolved more than fifteen (15) working days from the date of
receipt of proofs of loss by the insurer, the insurer shall provide the
insured with a written explanation of the specific reasons for the delay in
the claim settlement unless reasonable grounds exist to suspect fraud or
arson. An updated letter of explanation shall be sent every thirty (30)
calendar days thereafter until all elements of the claim are either honored
or rejected.

7.6. Repair estimates. -- If an insurer requires that its insured obtain
an estimate or estimates of vehicle damage, the reasonable charges, if any,
of such estimates shall be borne by the insurer.

7.7. Notice of right to reimbursement for transportation expenses. -- In
the event of the theft of the entire vehicle, it shall be the duty of the
insurer at the time of notification of loss to advise the insured of his
right under the policy to be reimbursed for transportation expenses. Such
notification must be confirmed in writing immediately after receipt of
notice of theft. All conditions and benefits related to this coverage as
stated in the policy must be contained in the notification to the insured.

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This user is : connie
topic no 93 Topic Name : Series 14, Unfair Trade Practices
current date Wed Jul 9 09:42:12 1997
Entry # : 2083 prepared Apr 4 10:51:55 1995

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Subject :114-14-7
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Creation System Name : TechNet

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topic no 93 Topic Name : Series 14, Unfair Trade Practices
current date Wed Jul 9 09:42:12 1997
Entry # : 2084 prepared Apr 4 10:52:17 1995

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Subject :114-14-8
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topic no 93 Topic Name : Series 14, Unfair Trade Practices
current date Wed Jul 9 09:42:12 1997
Entry # : 2085 prepared Apr 4 10:52:46 1995

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Subject :114-14-9
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Creation System Name : TechNet

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This user is : connie
topic no 93 Topic Name : Series 14, Unfair Trade Practices
current date Wed Jul 9 09:42:12 1997
Entry # : 2086 prepared Apr 4 10:53:07 1995

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Subject :114-15-1
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