§ 4029. Required standard policy provisions
Except as provided in section 4031 of this title, each health insurance policy delivered or issued for delivery to any person in this
State shall contain the provisions specified in this section using the language set
forth in this section; provided, however, that a health insurer may, at its option,
substitute different language approved by the Commissioner for one or more provisions,
provided the substituted language is not less favorable in any respect to the insured
or covered individual than the language used in this section. The provisions specified
in this section shall be preceded individually by the caption appearing in this section
or, at the option of the health insurer, by such appropriate captions or subcaptions
as the Commissioner may approve:
(1) ENTIRE CONTRACT; CHANGES: This policy, including the endorsements and the attached
papers, if any, constitutes the entire contract of insurance. No change in this policy
shall be valid until approved by an executive officer of the insurer and unless such
approval be endorsed hereon or attached hereto. No agent has authority to change this
policy or to waive any of its provisions.
(2) TIME LIMIT ON CERTAIN DEFENSES:
(a) 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.
(The foregoing 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 subdivisions 4030(1)–(5) of this title in the event of misstatement with respect to age or occupation or other insurance.) (A policy which the insured has the right to continue in force subject to its terms by the timely payment of premium (1) until at least age 50, or (2) in the case of a policy issued after age 44, 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.
(3) GRACE PERIOD: A grace period of . . . . (insert a number not less than “7” for weekly
premium policies, “10” for monthly premium policies and “31” for all other policies)
days will be granted for the payment of each premium falling due after the first premium,
during which grace period the policy shall continue in force.
(A policy which contains a cancellation provision may add, at the end of the above provision,
subject to the right of the insurer to cancel in accordance with the cancellation provision hereof,
A policy in which the insurer reserves the right to refuse any renewal shall have, at the beginning of the above provision,
Unless not less than five days prior to the premium due date the insurer has delivered to the insured or has mailed to his or her last address as shown by the records of the insurer written notice of its intention not to renew this policy beyond the period for which the premium has been accepted.)
(4) REINSTATEMENT: If any renewal premium be not paid within the time granted the insured
for payment, a subsequent acceptance of premium by the insurer or by any agent duly
authorized by the insurer to accept such premium, without requiring in connection
therewith an application for reinstatement, shall reinstate the policy; provided,
however, that if the insurer or such agent requires an application for reinstatement
and issues a conditional receipt for the premium tendered, the policy will be reinstated
upon approval of such application by the insurer or, lacking such approval, upon the
45th day following the date of such conditional receipt unless the insurer has previously
notified the insured in writing of its disapproval of such application. The reinstated
policy shall cover only loss resulting from such accidental injury as may be sustained
after the date of reinstatement and loss due to such sickness as may begin more than
ten days after such date. In all other respects the insured and insurer shall have
the same rights thereunder as they had under the policy immediately before the due
date of the defaulted premium, subject to any provisions endorsed hereon or attached
hereto in connection with the reinstatement. Any premium accepted in connection with
a reinstatement shall be applied to a period for which premium has not been previously
paid, but not to any period more than sixty days prior to the date of reinstatement.
(The last sentence of the above provision may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums (1) until at least age 50, or (2) in the case of a policy issued after age 44, for at least five years from its date of issue.)
(5) NOTICE OF CLAIM: Written notice of claim must be given to the insurer within 20 days
after the occurrence or commencement of any loss covered by the policy, or as soon
thereafter as is reasonably possible. Notice given by or on behalf of the insured
or the beneficiary to the insurer at . . . . (insert the location of such office as
the insurer may designate for the purpose), or to any authorized agent of the insurer,
with information sufficient to identify the insured, shall be deemed notice to the
insurer.
(In a policy providing a loss-of-time benefit which may be payable for at least two
years, an insurer may at its option insert the following between the first and second
sentences of the above provision:
Subject to the qualifications set forth below, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least two years, he or she shall, at least once in every six months after having given notice of claim, give to the insurer notice of continuance of said disability, except in the event of legal incapacity. The period of six months following any filing of proof by the insured or any payment by the insurer on account of such claim or any denial of liability in whole or in part by the insurer shall be excluded in applying this provision. Delay in the giving of such notice shall not impair the insured’s right to any indemnity which would otherwise have accrued during the period of six months preceding the date on which such notice is actually given.)
(6) CLAIM FORMS: The insurer, upon receipt of a notice of claim, will furnish to the claimant
such forms as are usually furnished by it for filing proofs of loss. If such forms
are not furnished within 15 days after the giving of such 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, written
proof covering the occurrence, the character and the extent of the loss for which
claim is made.
(7) PROOFS OF LOSS: Written proof of loss must be furnished to the insurer at its said
office in case of claim for loss for which this policy provides any periodic payment
contingent upon continuing loss within 90 days after the termination of the period
for which the insurer is liable and in case of claim for any other loss within 90
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 such proof is furnished as soon as reasonably possible
and in no event, except in the absence of legal capacity, later than one year from
the time proof is otherwise required.
(8) TIME OF PAYMENT OF CLAIMS: Indemnities payable under this policy for any loss other
than loss for which this policy provides any periodic payment will be paid immediately
upon receipt of due written proof of such loss. Subject to due written proof of loss,
all accrued indemnities for loss for which this policy provides periodic payment will
be paid . . . . (insert period for payment which must not be less frequently than
monthly) and any balance remaining unpaid upon the termination of liability will be
paid immediately upon receipt of due written proof.
(9) PAYMENT OF CLAIMS: Indemnity for loss of life will be payable in accordance with the
beneficiary designation and the provisions respecting such payment which may be prescribed
herein and effective at the time of payment. If no such designation or provision is
then effective, such indemnity shall be payable to the estate of the insured. Any
other accrued indemnities unpaid at the insured’s death may, at the option of the
insurer, be paid either to such beneficiary or to such estate. All other indemnities
will be payable to the insured.
(The following provisions, or either of them, may be included with the foregoing provision
at the option of the insurer:
If any indemnity of this policy shall be payable to the estate of the insured, or to an insured or beneficiary who is a minor or otherwise not competent to give a valid release, the insurer may pay such indemnity, up to an amount not exceeding $. . . . . . (insert an amount which shall not exceed $1,000.00), to any relative by blood or connection by civil marriage of the insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any payment made by the insurer in good faith pursuant to this provision shall fully discharge the insurer to the extent of such payment.
Subject to any written direction of the insured in the application or otherwise all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical, or surgical services may, at the insurer’s option and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the service be rendered by a particular hospital or person.)
(10) PHYSICAL EXAMINATIONS AND AUTOPSY: The insurer at its own expense shall have the right
and the opportunity to examine the person of the insured when and as often as it may
reasonably require during the pendency of a claim hereunder and to make an autopsy
in case of death where it is not forbidden by law.
(11) LEGAL ACTIONS: No action at law or in equity shall be brought to recover on this policy
prior to the expiration of 60 days after written proof of loss has been furnished
in accordance with the requirements of this policy. No such action shall be brought
after the expiration of three years after the time written proof of loss is required
to be furnished.
(12) CHANGE OF BENEFICIARY: Unless the insured makes an irrevocable designation of beneficiary,
the right to change of beneficiary is reserved to the insured and the consent of the
beneficiary or beneficiaries shall not be requisite to surrender or assignment of
this policy or to any change of beneficiary or beneficiaries, or to any other changes
in this policy.
(The first clause of this provision, relative to the irrevocable designation of beneficiary, may be omitted at the insurer’s option.) (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)