Uniform Policy Provisions of Individual Accident and Health Insurance Policies
(1) Change of Occupation
If the insured be injured or contract sickness after having changed his occupation to one classified by the insurer as more hazardous than that stated in the policy, or while doing for compensation anything pertaining to an occupation so classified, the insurer will pay only such portion of the indemnities provided in the policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for such more hazardous occupation.
If the insured changes his occupation to one classified by the insurer as less hazardous than that stated in the policy, the insurer, upon receipt of proof of such change in occupation, will reduce the premium rate accordingly and will return the excess pro-rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the most recent.
In applying this provision, the classification of occupational risk and the premium rates must be such as been last filed by the insurer prior to the occurrence of the loss for which the insurer is liable or prior to the date of proof of change in occupation with the state official having supervision of insurance in the state where the insured resides at the time the policy was issued; but if such filing was not required, then the classification of occupational risk and the premium rates must be those last made effective by the insurer in such state prior to the occurrence of the loss or prior to the date of proof of such change in occupation.
(2) Misstatement of Age:
If the age of the insured has been misstated, all amounts pay’ able under the policy will be such as the premium paid would have purchased at the insured’s correct age.
(3) Other Insurance in this Insurer:
If an accident, sickness, or accident and sickness policy or policies previously issued by the insurer to the insured be concurrently in force, making the aggregate indemnity for… (insert type of coverage or coverages) in excess of $… (insert maximum limit of indemnity or indemnities) the excess in insurance will be void and all premiums paid for such excess must be returned to the insured or to his estate.
Or, in lieu thereof: Insurance effective at anyone time on the insured under a like policy or policies in the insurer is limited to the one such policy elected by the insured, his beneficiary or his estate, as the case maybe, and the insurer must return all premiums paid for all other such policies.
(4) Insurance with Other Insurers:
If there be other valid coverages not with this insurer providing benefits for the same loss on a provision of service basis or on an expense incurred basis and of which the insurer has not been given notice prior to the occurrence or commencement of a loss, the only liability under any expense incurred coverage of the policy will be for such proportion of the loss as the amount which would otherwise have been payable hereunder, plus the total of the like amounts under all valid coverages for such loss and for the return of such portion of the premiums paid as exceed the pro-rata portion for the amount so determined. For the purpose of applying this provision, when other coverages are on a provision of service basis, the “like amount” of such other coverage will be taken as the amount which the services rendered would have cost in the absence of such coverage.
(5) Insurance with Other Insurers:
If there be other valid coverage not with this insurer providing benefits for the same loss on other than an expense incurred basis and of which the insurer has not been given notice prior to the occurrence or commencement of a loss, the only liability for such benefits under this policy will be for such proportion of the indemnities otherwise of which the insurer had notice (including the indemnities under the policy) bear to the total amount of all like indemnities for such loss, and for the return of such portion of the premium paid as exceed the pro-rata portion for the indemnities thus determined.
(6) Relation of Earnings to Insurance:
If the total monthly amount of loss of time benefits promised for the same loss under all valid loss of time coverage upon the insured, whether payable on a weekly or monthly basis, exceed the monthly earnings of the insured at the time disability commenced, or his average monthly earnings for a period of two years immediately preceding a disability for which claim is made, whichever is greater, the insured will be liable only for such proportionate amount of such benefits under the policy as the amount of such monthly earnings or such average monthly earnings of the insured bears to the total amount of monthly benefits for the same loss under all coverage upon the insured at the time such disability commences, and for the return of such part of the premiums paid during such two years as shall exceed the pro-rata amount of the premiums for the benefits actually paid hereunder; but this does not operate to reduce the total monthly amount of benefits payable under all such coverage upon the insured below the sum of the monthly benefits specified in such coverages, whichever is lesser, nor does it operate to reduce benefits other than those payable for loss of time.
(7) Unpaid Premium:
Upon the payment of a claim under the policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom.
The insurer may cancel the policy at any time by written notice delivered to the insured, or mailed to his last address as shown by the records of the insurer, stating when, not less than five days thereafter, such cancellation is to be effective and, after the policy has been continued beyond its original term, the insured may cancel the policy at any time by written notice delivered or mailed to the insurer, effective upon receipt or on such later date as may be specified in the notice.
In the event of cancellation, the insurer must return promptly the unearned portion of any premium paid. If the insured cancels, the earned premium will be computed by the use of the short-rate table last filed with the state official having supervision of insurance in the state where the insured resided when the policy was issued. If the insurer cancels, the earned premium will be computed pro-rata. Cancellation will be without prejudice to any claim originating prior to the effective date of cancellation.
(9) Conformity with State Statutes:
Any provision of the policy which, on its effective date, is in conflict with the statutes of the state in which the insured resides on such date, will be amended to conform to the minimum requirements of such statutes.
(10) Illegal Occupation:
The insurer is not liable for a loss to which a contributing cause was the insured’s commission of or attempt to commit a felony, or to which a contributing cause was the insured’s being engaged in an illegal occupation.
(11) Intoxicants and Narcotics:
The insurer is not liable for most losses sustained or contracted in consequence of the insured’s being intoxicated or under the influence of any narcotic unless administered on the advice of a physician.