Uniform Individual Accident and Sickness Policy Provisions Act

Uniform Individual Accident and Sickness Policy Provisions Act

Overview

The Uniform Individual Accident and Sickness Policy Provisions Act (often developed by the National Association of Insurance Commissioners, NAIC) sets a baseline of required and optional contract clauses that individual health insurance policies must include. Its purpose is to standardize basic policy terms, protect insureds, and clarify the rights and responsibilities of both insurers and policyholders. States adopt their own versions, so specific wording can vary.

Key points

• The model contains 12 mandatory provisions and 11 optional provisions.
• Mandatory clauses establish minimum rights and duties for insurers and insureds.
• Optional clauses permit insurers to include additional conditions—often shifting more compliance obligations onto the policyholder.
• States enact their own versions of the law, so exact requirements differ by jurisdiction.

Background

The NAIC drafted the model law as guidance for state regulators. The NAIC itself does not regulate insurers; insurance regulation is performed at the state level. When adopted, the model creates a uniform framework so consumers and companies operate under consistent, transparent policy terms.

Mandatory provisions (general themes)

Mandatory provisions define essential policy mechanics and responsibilities for both parties. Typical mandatory elements include:
* Requirement that all material policy information appear in the policy or official amendments.
* A stated grace period for late premium payments.
* Procedures for policy reinstatement after lapses.
* Timeframes and procedures for notice of claim (commonly requiring prompt notification, for example within 20 days).
* Proof of loss and claim documentation requirements.
* Policyholder obligations such as updating beneficiary information.
These provisions ensure basic consumer protections and clarify how claims and lapses are handled.

Optional provisions (common examples)

Insurers may include up to 11 optional clauses. These often place additional obligations on the insured and can affect claim entitlement. Examples include:
* Requirements to report changes in income, particularly if income change is due to a disability.
* Notification of changes in occupation or work duties (especially changes to occupations with different risk profiles).
* Consequences for misstatements about age, illegal substance use, or participation in illegal occupations, which can limit or void coverage for related claims.
Policyholders should review optional clauses carefully, because insurers commonly include them and typically control final policy terms.

Practical implications for policyholders

• Always read the policy to identify both mandatory and optional provisions that apply.
• Meet claim notice and proof-of-loss deadlines and keep beneficiary information current.
• Notify your insurer about material changes such as income or occupation when the policy requires it.
• Understand how misstatements or illegal activity can affect coverage.
• If in doubt, consult your state insurance department or a licensed insurance professional to interpret how your state’s version of the law affects your policy.

Sources

National Association of Insurance Commissioners — Uniform Individual Accident and Sickness Policy Provisions Law.