Wyoming Health Study Guide

Wyoming’s accident and health provisions look like the NAIC uniform provisions until you check two numbers. Notice of claim is 60 days, not 20. The time limit on certain defenses is three years, not two. A candidate running on national material will answer both wrong and have no reason to suspect it.

Twelve sections, not one lettered list

Most states enact the uniform accident and sickness provisions as lettered or numbered items inside a single statute. Wyoming enacts each as its own section. W.S. 26-18-104(a) requires policies to contain the provisions in “W.S. 26-18-105 through 26-18-116” in the words in which they appear, subject to the commissioner approving substituted wording at least as favourable to the insured.

The practical consequence is worth noticing: a question asking for “the fourth uniform provision” has no clean Wyoming answer, and every pinpoint cite is to a section rather than a subsection.

The claim timeline

Notice of claim — 60 days. W.S. 26-18-109, verbatim: “Written notice of claim shall be given to the insurer within sixty (60) days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible.”

Claim forms — 15 days, and then deemed compliance. On receiving notice the insurer furnishes proof-of-loss forms; if it does not do so within 15 days, the claimant is deemed to have complied by submitting written proof of the occurrence, character and extent of the loss (W.S. 26-18-110).

Proofs of loss — 90 days, running from termination of the period for which the insurer is liable on a periodic-payment claim, or from the date of loss otherwise. Late proof does not invalidate the claim if it was not reasonably possible to give it in time — but, “except in the absence of legal capacity,” no later than one year from when proof was required (W.S. 26-18-111).

Time of payment — immediately upon receipt of written proof for anything other than periodic payments; accrued periodic indemnities at intervals not less frequently than monthly (W.S. 26-18-112).

Legal actions — no suit before 60 days after proof of loss is furnished, and none after three years from when proof was required (W.S. 26-18-115).

Defenses, preexisting conditions and reinstatement

Time limit on certain defenses — three years. After three years from date of issue, no misstatements except fraudulent ones may void the policy or deny a claim. The alternative “incontestable” wording is available for policies the insured may continue to at least age 50, and it excludes any period during which the insured is disabled (W.S. 26-18-106).

Preexisting conditions get their own limits in the same section: an exclusion may not extend beyond 12 months after the effective date, and reaches only conditions for which medical advice, diagnosis, care or treatment was recommended or received in the 6 months immediately preceding.

Reinstatement (W.S. 26-18-108) turns on whether an application is required. Acceptance of a renewal premium without requiring an application reinstates the policy outright. Where an application is required and a conditional receipt issued, the policy reinstates on approval — or, failing approval, on the 45th day after the conditional receipt unless the insurer has already given written disapproval. The reinstated policy covers accidental injury sustained after that date and sickness beginning more than 10 days after it.

Continuation of group coverage — and the number that is not Wyoming’s

W.S. 26-19-113 gives a continuation right on a “non-COBRA” group policy — one not subject to federal COBRA continuation rights.

Read what the Wyoming statute does not contain: any employer-size number at all. The familiar twenty-employee line is the federal COBRA boundary, and it is what makes a plan non-COBRA in the first place. Saying “Wyoming’s continuation applies to employers with fewer than 20 employees” states a federal number as though Wyoming had written it.

Wyoming’s own figures are these. Continuation runs to the earlier of listed events, with an outside limit of 12 months. The continuee pays not more than 102% of the group rate. Election is in writing within the 31-day period following termination of coverage, with the first contribution accompanying it. And eligibility requires having been continuously covered during the entire three-month period ending with the loss of eligibility. It reaches hospital, surgical or major medical expense insurance — not specified-disease or accident-only policies.

External review

W.S. 26-40-201 gives a claimant 120 days from the insurer’s written explanation to request external review in writing. The insurer assigns it to an independent review organization approved by the commissioner and staffed by professionals with no association with the insurer. The IRO determines documentation completeness within 5 days, decides within 45 days, and if it finds the claim should be allowed the insurer must approve and notify within 5 days.

That process has teeth from an unexpected direction: failing to comply with it is itself an unfair claims settlement practice under W.S. 26-13-124(a)(xvi), as is failing to pay after an external review organization has declared the claim covered, at (a)(xvii).