284-55-035  <<  284-55-040 >>   284-55-045

WAC 284-55-040

Prohibited policy provisions.

(1) No insurance policy or subscriber contract may be advertised, solicited or issued for delivery in this state as a medicare supplement policy unless such policy or contract meets the requirements of chapter 48.66 RCW, the Medicare Supplemental Health Insurance Act.
(2) No medicare supplement policy or certificate in force in this state shall contain benefits which duplicate benefits provided by medicare.
(3) No insurance policy or subscriber contract may be advertised, solicited, or issued for delivery in this state as a medicare supplement policy if such policy or subscriber contract limits or excludes coverage by type of illness, accident, treatment, or medical condition, except as follows:
(a) Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, or symptomatic complaints of the feet;
(b) Mental or emotional disorders and chemical dependency;
(c) Illness, treatment, or medical condition arising out of:
(i) War or act of war (whether declared or undeclared); participation in a felony, riot or insurrections; service in the armed forces or units auxiliary thereto;
(ii) Suicide (sane or insane), attempted suicide, or intentionally self-inflicted injury;
(iii) Aviation, other than as a fare-paying passenger on a scheduled or charter flight operated by a scheduled airline.
(d) Cosmetic surgery, except that "cosmetic surgery" shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection, or other diseases of the involved part;
(e) Care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion, or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment, or subluxation of, or in the vertebral column;
(f) Treatment provided in a governmental hospital; benefits provided under medicare or other governmental program (except medicaid), any state or federal workers' compensation, employer's liability or occupational disease law, or any motor vehicle no-fault law; services rendered by employees of hospitals, laboratories, or other institutions; services performed by a member of the covered person's immediate family and services for which no charge is normally made in the absence of insurance;
(g) Dental care or treatment;
(h) Eye glasses, hearing aids, and examination for the prescription or fitting thereof;
(i) Rest cures, custodial care, transportation, and routine physical examinations;
(j) Territorial limitations:
Provided, That medicare supplement insurance policies may not contain, when issued, limitations or exclusions of the type enumerated in (a), (e), (i) or (j) of this subsection that are more restrictive than those of medicare. Medicare supplement policies may exclude coverage for any expense to the extent of any benefit available to the insured under medicare.
(4) A "noncancellable," "guaranteed renewable," or "noncancellable and guaranteed renewable" medicare supplement insurance policy shall not provide for termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premium.
(5) Termination of a medicare supplement policy shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits. Any provision to the contrary is prohibited.
(6) No medicare supplement insurance policy shall restrict, exclude or limit benefits for a sickness through use of a probationary, or similar, provision.
(7) No insurer shall require any person covered under a medicare supplement insurance policy to purchase additional coverage in connection with the amendment thereof.
(8) The terms "medicare supplement," "Medigap," or words of similar import shall not be used to describe an insurance policy or contract unless such policy or contract is issued in compliance with chapter 48.66 RCW and this chapter.
[Statutory Authority: RCW 48.02.060 (3)(a) and 48.30.010(2). WSR 88-22-061 (Order R 88-9), § 284-55-040, filed 11/1/88. Statutory Authority: RCW 48.66.100, 48.20.470 and 1982 c 200 § 1. WSR 82-12-032 (Order R 82-3), § 284-55-040, filed 5/26/82. Statutory Authority: RCW 48.02.060, 48.44.050 and 48.46.200. WSR 82-01-016 (Order R 81-6), § 284-55-040, filed 12/9/81.]
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