Outline headings covered: Mandatory and optional provisions (entire contract; time limit on certain defenses; grace period; reinstatement; notice of claim; claim forms; proof of loss; time of payment of claims; payment of claims; physical examination and autopsy; legal actions; change of beneficiary; misstatement of age and gender; change of occupation; illegal occupation; relation of earnings to insurance); other provisions and clauses (insuring clause; free look; consideration clause; probationary period; elimination period; waiver of premium; exclusions and limitations; preexisting conditions; coinsurance; deductibles; eligible expenses; copayments; pre-authorizations and prior approval; usual, reasonable and customary charges; lifetime, annual or per cause maximums); riders (impairment/exclusions; guaranteed insurability; future increase option); rights of renewability (noncancelable; cancelable; guaranteed renewable). Printed weight: 15 of the 50 scored Accident & Health General Knowledge items.
Minnesota writes the uniform individual accident and sickness provisions into statute almost word for word. Learn the idea, then the Minnesota number. Source base: Minnesota Statutes 2025, sections 62A.01 to 62A.09, 62A.65, 62Q, 72A.20 and 72A.51-.52, and Minnesota Rules chapter 2790 (2014 compilation; confirm currency with Commerce), read in the local text. Chapter 13 teaches the same clauses from the mandate side.
9.1 How Minnesota Requires Individual Provisions (Outline: Mandatory and Optional Provisions, introduction)
In Minnesota
- Required provisions. Every individual accident and sickness policy delivered or issued for delivery in Minnesota must contain the required provisions of section 62A.04, subdivision 2, in the statute's words. The insurer may substitute commissioner-approved wording that is, in every respect, not less favorable to the insured or beneficiary. Each provision carries its caption (Minn. Stat. 62A.04, subd. 2).
- Optional provisions. The matters in subdivision 3 may appear only in the statutory words (or approved, not-less-favorable wording) (Minn. Stat. 62A.04, subd. 3). A provision that is inapplicable to, or inconsistent with, the form's coverage is omitted or modified with the commissioner's approval (subd. 4). The provisions print in statutory order, or as a unit with related provisions, provided the policy is not unintelligible, ambiguous or likely to mislead (subd. 5).
- Conflicts. A policy issued in violation of sections 62A.01 to 62A.09 is valid but construed as those sections provide; a conflicting policy provision gives way to the statute (Minn. Stat. 62A.05(b)). A provision outside section 62A.04 may not make the policy less favorable to the insured than the provisions that are subject to it (62A.05(a)).
- Health plans skip some clauses. For a "health plan" (Chapter 8.3) subdivision 2 clauses (5) to (10) and (12) and subdivision 3 clauses (1) and (3) to (7) do not apply, nor do subdivisions 6 and 10 (Minn. Stat. 62A.04, subd. 1(b)). They still govern other accident and sickness policies, such as disability income and limited-benefit policies.
- Group is outside. Sections 62A.01 to 62A.08 do not apply to group policies unless specifically referred to, nor to workers' compensation, property and casualty or reinsurance (Minn. Stat. 62A.09). Group policies carry their own required clauses (Minn. Stat. 62A.10, subd. 4) (Chapter 8.7).
- Filing. A health plan form, and any application, rider or endorsement used with it, must be filed with the commissioner with the rates; it may not be used until 60 days after filing unless approved sooner (Minn. Stat. 62A.02, subds. 1-2).
Format rules (Minn. Stat. 62A.03, subd. 1): the policy states the entire consideration and when coverage starts and ends, insures one person (an adult policyholder may add family members), uses type of at least ten point, shows renewal or cancellation terms on the first page, and carries a form number in the lower left corner of every form, rider and endorsement.
9.2 Entire Contract; Time Limit on Certain Defenses (Outline: Entire Contract; Time Limit on Certain Defenses)
Entire contract. The policy, with its endorsements and attached papers, is the whole contract. No change is valid until approved by an executive officer and endorsed or attached, and no agent can change the policy or waive a provision. A producer's promise outside the paper has no force.
Time limit on certain defenses (the health incontestable clause). After a stated period the insurer may not void the policy or deny a claim for application misstatements except fraudulent ones. It parallels the life incontestable clause (Chapter 4) but protects claims for loss that begins after the period and leaves the insurer's rights in the first period alone.
In Minnesota
- Two years. After two years from the date of issue, no misstatement in the application, except a fraudulent one, may void the policy or deny a claim for loss incurred or disability (as the policy defines it) beginning after the two years. The clause does not affect any legal requirement for avoiding a policy or denying a claim in the first two years, and does not limit the age, occupation or other-insurance provisions (Minn. Stat. 62A.04, subd. 2(2)(a)).
- Preexisting conditions. After two years from issue, no claim for loss beginning later may be reduced or denied because a disease or physical condition not excluded by name or specific description existed before the effective date of coverage (subd. 2(2)(b)).
- Incontestable alternative. A policy the insured can continue by timely premium until at least age 50 (or, if issued after age 44, for at least five years) may use the shorter caption "Incontestable": after two years in force during the insured's lifetime (excluding disability periods) it is incontestable as to application statements (subd. 2(2)).
- Application statements. An insured is not bound by an application statement unless a copy of the application is attached to or endorsed on the policy. On request, the insurer must give a copy of a reinstatement or renewal application within 15 days or lose the right to use it in evidence. A false statement bars recovery only if it materially affected acceptance of the risk or the hazard assumed. No one but the applicant may alter the application without written consent; insurer insertions are for administrative purposes only and must be clearly marked (Minn. Stat. 62A.06, subds. 1-3).
9.3 Grace Period, Renewal Notice and Reinstatement (Outline: Grace Period; Reinstatement)
Grace period. The time after a premium due date during which the policy stays in force although the premium is unpaid. It applies to each premium after the first.
In Minnesota
- Length by mode. At least 7 days for weekly premium policies, 10 days for monthly premium policies and 31 days for all other policies. The clause adds that a policy with a cancellation provision is "subject to the right of the insurer to cancel in accordance with the cancellation provision" (Minn. Stat. 62A.04, subd. 2(3)(a)).
- Right to refuse renewal. A policy in which the insurer reserves the right to refuse any renewal begins its grace clause with "unless, not less than five days prior to the premium due date, the insurer has delivered or mailed written notice of its intention not to renew." The notice period is five days, not the 30 days used in some national summaries (subd. 2(3)).
- MNsure subsidy plans. For qualified health plans sold through MNsure to people receiving advance payments of the premium tax credit, the grace period must comply with the Affordable Care Act and be no less restrictive than it; no day count is printed (subd. 2(3)(b)).
- Final notice before lapse. No insurer on an individual health policy or individual nonprofit health service plan contract may cancel or fail to renew for nonpayment unless it mails or delivers a final notice at least 30 days before lapse; proof of mailing is enough. The rule does not apply to a policy with monthly or more frequent premiums that carries a statutory grace period (Minn. Stat. 72A.20, subd. 24(b)-(d)).
Reinstatement. A policy lapses if the renewal premium is not paid within the grace period. The uniform clause provides:
- If the insurer or an authorized agent later accepts the premium without requiring an application for reinstatement, the policy is reinstated.
- If it requires an application and issues a conditional receipt, the policy is reinstated on approval, or, lacking approval, on the forty-fifth day after the receipt unless the insurer has already notified the insured in writing of disapproval.
- The reinstated policy covers accidental injury after the reinstatement date and sickness that begins more than 10 days after it.
- Premium accepted is applied to a period not already paid, but not to a period more than 60 days before reinstatement.
In Minnesota
The last sentence (the 10-day sickness gap) may be omitted from a policy the insured can continue to at least age 50 (or, if issued after 44, for at least five years). For Medicare supplement-type health plans (Chapter 14), the insurer must accept the renewal premium and reinstate if the insured applies within 60 days after the due date, unless the insured left the state or service area or has applied for reinstatement twice before (Minn. Stat. 62A.04, subd. 2(4)).
Exam shorthand: accidents covered at once, sickness after a 10-day gap.
9.4 Claim Provisions (Outline: Notice of Claim through Legal Actions)
The claim provisions run in time order from loss to lawsuit. All of the steps below are required clauses (Minn. Stat. 62A.04, subd. 2), though a "health plan" omits clauses 5 to 10 (9.1).
| Step | Provision | Minnesota rule |
|---|---|---|
| 1 | Notice of claim | Written notice within 20 days of the loss, or as soon as reasonably possible; notice to the insurer's office or any authorized agent, with information to identify the insured, counts. A policy paying loss-of-time benefits for at least two years may require notice of continued disability every six months |
| 2 | Claim forms | The insurer furnishes forms on notice; if none within 15 days, the claimant may instead submit written proof of the occurrence, character and extent of loss |
| 3 | Proofs of loss | Within 90 days after the end of the period of liability for periodic-payment claims, or within 90 days after the loss for others; late proof is excused if not reasonably possible, but never later than one year after it was due (except legal incapacity) |
| 4 | Time of payment | Non-periodic indemnity is paid immediately on due written proof; periodic indemnity is paid at stated intervals, no less often than monthly |
| 5 | Payment of claims | Death indemnity goes to the designated beneficiary, or to the estate if none; other accrued unpaid indemnity may go to the beneficiary or estate; all other indemnity to the insured. Optional: up to $1,000 to a relative if payable to the estate or a minor; direct payment to the hospital or provider unless the insured asks otherwise in writing by proof of loss |
| 6 | Physical examination and autopsy | At the insurer's expense, when and as often as reasonably required during a claim, and an autopsy where the law allows |
| 7 | Legal actions | No suit until 60 days after written proof of loss; no suit more than three years after proof was required |
In Minnesota
- No waiver by investigating. An insurer's acknowledgment of notice, furnishing of forms, acceptance of proofs or investigation of a claim is not a waiver of its defenses (Minn. Stat. 62A.07).
- Prompt pay. A health plan company or third-party administrator must pay or deny a clean claim from a provider within 30 calendar days of receipt or pay interest at 1.5 percent per month (or part of a month) from the day after the due date. A provider must generally submit charges within six months of service (Minn. Stat. 62Q.75, subds. 2-3). A clean claim has no defect, missing documentation or special circumstance preventing timely payment (subd. 1(b)).
9.5 Change of Beneficiary and the Optional Provisions (Outline: Change of Beneficiary; Misstatement of Age and Gender; Change of Occupation; Illegal Occupation; Relation of Earnings)
Change of beneficiary. Unless the insured makes an irrevocable designation, the insured may change beneficiary, and the beneficiary's consent is not needed for surrender, assignment or any other policy change. The irrevocable-designation clause may be omitted at the insurer's option (Minn. Stat. 62A.04, subd. 2(12)).
The optional provisions may appear only in statutory words:
| Optional provision | What it does | Where |
|---|---|---|
| Change of occupation | Moving to a more hazardous class cuts benefits to what the premium would buy at that class's rates; moving to a less hazardous class lowers the premium and returns the unearned excess pro rata | subd. 3(1) |
| Misstatement of age | All amounts payable are what the premium paid would have bought at the correct age | subd. 3(2) |
| Other insurance (same insurer; other insurers) | Excess in the same insurer is void with premium returned; undisclosed other valid coverage prorates benefits | subd. 3(3)-(5) |
| Relation of earnings to insurance | If total monthly loss-of-time benefits exceed the greater of earnings at disability or average earnings in the prior two years, benefits are prorated; total cannot fall below the lesser of $200 a month or the sum of the monthly benefits | subd. 3(6) |
| Unpaid premium | Premium due may be deducted from a claim payment | subd. 3(7) |
| Cancellation | Insurer may cancel on at least five days' written notice; insured may cancel after the original term; pro rata earned premium unless monthly or less | subd. 3(8) |
| Conformity with state statutes | A provision in conflict with the insured's state law is amended to the statute's minimum | subd. 3(9) |
| Illegal occupation | No liability for loss to which a contributing cause was committing or attempting a felony or an illegal occupation | subd. 3(10) |
| Narcotics | No liability for loss from being under the influence of a narcotic not administered on a physician's advice | subd. 3(11) |
The earnings clause may appear only in a policy the insured can continue to at least age 50 (or, if issued after 44, for at least five years) (subd. 3(6)).
In Minnesota
- Age, not gender. The outline says "misstatement of age and gender." Section 62A.04, subdivision 3(2), speaks only of age. Minnesota separately bars gender as a premium or underwriting factor for individual health plans and all health plans (Minn. Stat. 62A.65, subd. 4; 62A.306).
- Age limits. If a policy sets an age after which coverage ends and the insurer accepts premium for a period beyond it, coverage continues to the end of that period. If the age was misstated and the insured would not have been issued the policy at the correct age, the insurer may, within 90 days of discovering the misstatement, limit its liability to a refund of all premiums; in other cases it may adjust premium, or adjust benefits to the actual age and premium (Minn. Stat. 62A.08).
- Applicant other than insured. A person with a proper insurable interest may apply for, own and receive benefits under a policy covering the insured (Minn. Stat. 62A.04, subd. 6).