{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3540.1.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3540.1.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3540.1.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3540.1.html"}],"law_id":58127,"edition_id":1,"section_id":58127,"structure_id":13628,"section_number":"38.2-3540.1","catch_line":"Claims experience","history":"1992, c. 800; 1999, c. 116; 2003, c. 654; 2004, c. 772.","full_text":"A\n\nEach group accident and sickness insurance policy and health care plan shall contain a provision which provides that the insurer, upon request, shall provide a policyholder that employed an average of at least 100 individuals who were insureds, subscribers, or enrollees on business days during the preceding 12-month period with a complete record of the policyholder’s medical claims experience or medical costs incurred under the group policy, contract or plan. This record shall include all claims incurred for the lesser of (i) the period of time since the policy, contract or plan was issued or issued for delivery or (ii) the period of time since the policy, contract, or plan was last renewed, reissued or extended, if already issued. This record shall be made available promptly to the policyholder upon request made not less than 30 days prior to the date upon which the premiums or contractual terms of the policy, contract or plan may be amended. Nothing in this section shall require the disclosure of personal or privileged information about an individual that is protected from disclosure under Chapter 6 (§ 38.2-600 et seq.) of this title, or under any other applicable federal or state law or regulation. No policyholder shall be required to pay for information requested pursuant to this section.B\n\nA policyholder that employed an average of at least 100 individuals who were insureds, subscribers or enrollees on business days during the preceding 12-month period shall receive from its insurer, upon request, at the time that the insurer provides a record of medical claims experience or medical costs under subsection A of this section (i) a summary of medical claims charges or medical costs incurred and the amount paid with respect to those claims for the most recently available 24-month period; (ii) a listing of the number of insured, subscribers or enrollees for whom combined medical claims payments or medical costs exceed $100,000 for the most recently available 12-month period, and for the preceding 12 months if not previously provided, with information as to whether these enrollees from the most recently available 12-month period remain enrolled under the policy, and provided that a policyholder and insurer may agree by contract to provide the listing for amounts less than $100,000; and (iii) total enrollment in each membership type as of the end of the most recently available 12-month period. This record shall be made available to the policyholder within 20 business days upon written request made not less than 45 days prior to the date upon which the premiums or contractual terms of the policy may be amended. Nothing in this section shall require the disclosure of personal or privileged information about an individual that is protected from disclosure under Chapter 6 (§ 38.2-600 et seq.) of this title, or under any other applicable federal or state law or regulation. No policyholder shall be required to pay for information requested pursuant to this section.C\n\nWith respect to group accident and sickness insurance policies, the requirements of this section shall apply to all policies, contracts, and plans delivered, issued for delivery, reissued or extended on and after July 1, 2003, or at any time after the effective date hereof when any term of any such policy, contract or plan is changed or any premium adjustment is made. With respect to health care plans, the requirements of this section shall apply to all contracts delivered, issued for delivery, reissued or extended on and after January 1, 2005, or at any time after the effective date hereof when any term of any such contract or plan is changed or any premium adjustment is made.","order_by":null,"text":{"0":{"id":212966,"text":"Each group accident and sickness insurance policy and health care plan shall contain a provision which provides that the insurer, upon request, shall provide a policyholder that employed an average of at least 100 individuals who were insureds, subscribers, or enrollees on business days during the preceding 12-month period with a complete record of the policyholder’s medical claims experience or medical costs incurred under the group policy, contract or plan. This record shall include all claims incurred for the lesser of (i) the period of time since the policy, contract or plan was issued or issued for delivery or (ii) the period of time since the policy, contract, or plan was last renewed, reissued or extended, if already issued. This record shall be made available promptly to the policyholder upon request made not less than 30 days prior to the date upon which the premiums or contractual terms of the policy, contract or plan may be amended. Nothing in this section shall require the disclosure of personal or privileged information about an individual that is protected from disclosure under Chapter 6 (§ 38.2-600 et seq.) of this title, or under any other applicable federal or state law or regulation. No policyholder shall be required to pay for information requested pursuant to this section.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":212967,"text":"A policyholder that employed an average of at least 100 individuals who were insureds, subscribers or enrollees on business days during the preceding 12-month period shall receive from its insurer, upon request, at the time that the insurer provides a record of medical claims experience or medical costs under subsection A of this section (i) a summary of medical claims charges or medical costs incurred and the amount paid with respect to those claims for the most recently available 24-month period; (ii) a listing of the number of insured, subscribers or enrollees for whom combined medical claims payments or medical costs exceed $100,000 for the most recently available 12-month period, and for the preceding 12 months if not previously provided, with information as to whether these enrollees from the most recently available 12-month period remain enrolled under the policy, and provided that a policyholder and insurer may agree by contract to provide the listing for amounts less than $100,000; and (iii) total enrollment in each membership type as of the end of the most recently available 12-month period. This record shall be made available to the policyholder within 20 business days upon written request made not less than 45 days prior to the date upon which the premiums or contractual terms of the policy may be amended. Nothing in this section shall require the disclosure of personal or privileged information about an individual that is protected from disclosure under Chapter 6 (§ 38.2-600 et seq.) of this title, or under any other applicable federal or state law or regulation. No policyholder shall be required to pay for information requested pursuant to this section.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":212968,"text":"With respect to group accident and sickness insurance policies, the requirements of this section shall apply to all policies, contracts, and plans delivered, issued for delivery, reissued or extended on and after July 1, 2003, or at any time after the effective date hereof when any term of any such policy, contract or plan is changed or any premium adjustment is made. With respect to health care plans, the requirements of this section shall apply to all contracts delivered, issued for delivery, reissued or extended on and after January 1, 2005, or at any time after the effective date hereof when any term of any such contract or plan is changed or any premium adjustment is made.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B"}},"ancestry":[{"id":13628,"edition_id":1,"name":"Group Accident and Sickness Insurance Policies","identifier":"3","label":"article","depth":3,"order_by":1,"parent_id":13348,"metadata":{},"date_created":"2026-06-26 03:45:25","date_modified":"2026-06-26 03:45:25","permalink":{"id":215739,"object_type":"structure","relational_id":13628,"identifier":"3","token":"38.2\/35\/3","url":"\/38.2\/35\/3\/","edition_id":1,"permalink":0,"preferred":1}},{"id":13348,"edition_id":1,"name":"Accident and Sickness Insurance Policies","identifier":"35","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:44:41","date_modified":"2026-06-26 03:44:41","permalink":{"id":215641,"object_type":"structure","relational_id":13348,"identifier":"35","token":"38.2\/35","url":"\/38.2\/35\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12698,"edition_id":1,"name":"Insurance","identifier":"38.2","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:49","date_modified":"2026-06-26 03:43:49","permalink":{"id":210661,"object_type":"structure","relational_id":12698,"identifier":"38.2","token":"38.2","url":"\/38.2\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":82746,"structure_id":13628,"section_number":"38.2-3521","catch_line":"Repealed","url":"\/38.2-3521\/","token":"38.2\/35\/3\/38.2-3521","metadata":false},{"id":83222,"structure_id":13628,"section_number":"38.2-3521.1","catch_line":"Group accident and sickness insurance definitions","url":"\/38.2-3521.1\/","token":"38.2\/35\/3\/38.2-3521.1","metadata":false},{"id":62206,"structure_id":13628,"section_number":"38.2-3521.2","catch_line":"Blanket accident and sickness insurance","url":"\/38.2-3521.2\/","token":"38.2\/35\/3\/38.2-3521.2","metadata":false},{"id":61357,"structure_id":13628,"section_number":"38.2-3522","catch_line":"Repealed","url":"\/38.2-3522\/","token":"38.2\/35\/3\/38.2-3522","metadata":false},{"id":67462,"structure_id":13628,"section_number":"38.2-3522.1","catch_line":"Limits of group accident and sickness insurance","url":"\/38.2-3522.1\/","token":"38.2\/35\/3\/38.2-3522.1","metadata":false},{"id":57697,"structure_id":13628,"section_number":"38.2-3523","catch_line":"Repealed","url":"\/38.2-3523\/","token":"38.2\/35\/3\/38.2-3523","metadata":false},{"id":71976,"structure_id":13628,"section_number":"38.2-3523.1","catch_line":"Review of records","url":"\/38.2-3523.1\/","token":"38.2\/35\/3\/38.2-3523.1","metadata":false},{"id":61669,"structure_id":13628,"section_number":"38.2-3523.2","catch_line":"Policies issued outside of the Commonwealth of Virginia","url":"\/38.2-3523.2\/","token":"38.2\/35\/3\/38.2-3523.2","metadata":false},{"id":59982,"structure_id":13628,"section_number":"38.2-3523.3","catch_line":"Requirements for those marketing group accident and sickness insurance","url":"\/38.2-3523.3\/","token":"38.2\/35\/3\/38.2-3523.3","metadata":false},{"id":84584,"structure_id":13628,"section_number":"38.2-3523.4","catch_line":"Minimum number of persons covered","url":"\/38.2-3523.4\/","token":"38.2\/35\/3\/38.2-3523.4","metadata":false},{"id":54597,"structure_id":13628,"section_number":"38.2-3524","catch_line":"Repealed","url":"\/38.2-3524\/","token":"38.2\/35\/3\/38.2-3524","metadata":false},{"id":78059,"structure_id":13628,"section_number":"38.2-3525","catch_line":"Group accident and sickness insurance coverages of spouses, dependent children or other persons","url":"\/38.2-3525\/","token":"38.2\/35\/3\/38.2-3525","metadata":false},{"id":70591,"structure_id":13628,"section_number":"38.2-3526","catch_line":"Standard provisions required; exceptions","url":"\/38.2-3526\/","token":"38.2\/35\/3\/38.2-3526","metadata":false},{"id":66611,"structure_id":13628,"section_number":"38.2-3527","catch_line":"Grace period","url":"\/38.2-3527\/","token":"38.2\/35\/3\/38.2-3527","metadata":false},{"id":71054,"structure_id":13628,"section_number":"38.2-3528","catch_line":"Incontestability","url":"\/38.2-3528\/","token":"38.2\/35\/3\/38.2-3528","metadata":false},{"id":80053,"structure_id":13628,"section_number":"38.2-3529","catch_line":"Entire contract; statements deemed representations","url":"\/38.2-3529\/","token":"38.2\/35\/3\/38.2-3529","metadata":false},{"id":59015,"structure_id":13628,"section_number":"38.2-3530","catch_line":"Evidence of individual insurability","url":"\/38.2-3530\/","token":"38.2\/35\/3\/38.2-3530","metadata":false},{"id":57577,"structure_id":13628,"section_number":"38.2-3531","catch_line":"Additional exclusions and limitations","url":"\/38.2-3531\/","token":"38.2\/35\/3\/38.2-3531","metadata":false},{"id":66450,"structure_id":13628,"section_number":"38.2-3532","catch_line":"Misstatement of age","url":"\/38.2-3532\/","token":"38.2\/35\/3\/38.2-3532","metadata":false},{"id":85603,"structure_id":13628,"section_number":"38.2-3533","catch_line":"Individual certificates","url":"\/38.2-3533\/","token":"38.2\/35\/3\/38.2-3533","metadata":false},{"id":72638,"structure_id":13628,"section_number":"38.2-3534","catch_line":"Notice of claim","url":"\/38.2-3534\/","token":"38.2\/35\/3\/38.2-3534","metadata":false},{"id":65149,"structure_id":13628,"section_number":"38.2-3535","catch_line":"Claim forms","url":"\/38.2-3535\/","token":"38.2\/35\/3\/38.2-3535","metadata":false},{"id":79101,"structure_id":13628,"section_number":"38.2-3536","catch_line":"Proofs of loss","url":"\/38.2-3536\/","token":"38.2\/35\/3\/38.2-3536","metadata":false},{"id":72065,"structure_id":13628,"section_number":"38.2-3537","catch_line":"Time of payment of claims","url":"\/38.2-3537\/","token":"38.2\/35\/3\/38.2-3537","metadata":false},{"id":65230,"structure_id":13628,"section_number":"38.2-3538","catch_line":"Payment of benefits","url":"\/38.2-3538\/","token":"38.2\/35\/3\/38.2-3538","metadata":false},{"id":69184,"structure_id":13628,"section_number":"38.2-3539","catch_line":"Physical examinations and autopsy","url":"\/38.2-3539\/","token":"38.2\/35\/3\/38.2-3539","metadata":false},{"id":77451,"structure_id":13628,"section_number":"38.2-3540","catch_line":"Legal actions","url":"\/38.2-3540\/","token":"38.2\/35\/3\/38.2-3540","metadata":false},{"id":58127,"structure_id":13628,"section_number":"38.2-3540.1","catch_line":"Claims experience","url":"\/38.2-3540.1\/","token":"38.2\/35\/3\/38.2-3540.1","metadata":false},{"id":82316,"structure_id":13628,"section_number":"38.2-3540.2","catch_line":"Employee wellness program","url":"\/38.2-3540.2\/","token":"38.2\/35\/3\/38.2-3540.2","metadata":false},{"id":55325,"structure_id":13628,"section_number":"38.2-3541","catch_line":"Continuation on termination of eligibility","url":"\/38.2-3541\/","token":"38.2\/35\/3\/38.2-3541","metadata":false},{"id":61422,"structure_id":13628,"section_number":"38.2-3541.1","catch_line":"Repealed","url":"\/38.2-3541.1\/","token":"38.2\/35\/3\/38.2-3541.1","metadata":false},{"id":63267,"structure_id":13628,"section_number":"38.2-3541.2","catch_line":"Enrollment following change in eligibility status under assistance programs","url":"\/38.2-3541.2\/","token":"38.2\/35\/3\/38.2-3541.2","metadata":false},{"id":75709,"structure_id":13628,"section_number":"38.2-3542","catch_line":"Notice to employees upon termination of coverage; penalty for failure to remit funds","url":"\/38.2-3542\/","token":"38.2\/35\/3\/38.2-3542","metadata":false},{"id":81170,"structure_id":13628,"section_number":"38.2-3543","catch_line":"Provisions required by other jurisdictions","url":"\/38.2-3543\/","token":"38.2\/35\/3\/38.2-3543","metadata":false},{"id":83285,"structure_id":13628,"section_number":"38.2-3543.1","catch_line":"Regulations","url":"\/38.2-3543.1\/","token":"38.2\/35\/3\/38.2-3543.1","metadata":false},{"id":65251,"structure_id":13628,"section_number":"38.2-3543.2","catch_line":"Applicability of laws","url":"\/38.2-3543.2\/","token":"38.2\/35\/3\/38.2-3543.2","metadata":false}],"previous_section":{"id":77451,"structure_id":13628,"section_number":"38.2-3540","catch_line":"Legal actions","url":"\/38.2-3540\/","token":"38.2\/35\/3\/38.2-3540","metadata":false},"next_section":{"id":82316,"structure_id":13628,"section_number":"38.2-3540.2","catch_line":"Employee wellness program","url":"\/38.2-3540.2\/","token":"38.2\/35\/3\/38.2-3540.2","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3540.1\/","history_text":"

This law was first created in 1992. The record of its establishment is cataloged in chapter 800 of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year. Unfortunately, the 1992 \u201cActs\u201d aren\u2019t available online. It has been modified 3 times. Those modifications are cataloged by \u201cThe Acts of Assembly,\u201d a state publication, by year and chapter. Those modifications that can be read on the General Assembly\u2019s website will be linked accordingly. Those modifications are as follows: in 1999, chapter 116<\/a>; in 2003, chapter 654<\/a>; in 2004, chapter 772<\/a>.<\/p>","references":[{"id":55347,"section_number":"38.2-4214","catch_line":"Application of certain provisions of law","order_by":null,"url":"\/38.2-4214\/"},{"id":67952,"section_number":"38.2-4319","catch_line":"Statutory construction and relationship to other laws","order_by":null,"url":"\/38.2-4319\/"}],"refers_to":[{"id":64742,"section_number":"38.2-600","catch_line":"Purposes","order_by":null,"url":"\/38.2-600\/"}],"permalink":{"id":215849,"object_type":"law","relational_id":58127,"identifier":"38.2-3540.1","token":"38.2\/35\/3\/38.2-3540.1","url":"\/38.2-3540.1\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3540.1\/","token":"38.2\/35\/3\/38.2-3540.1","dublin_core":{"Title":"Claims experience","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3540.1","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> Each group accident and sickness insurance<\/span> policy and health care plan shall contain a provision which provides that the insurer<\/span>, upon request, shall provide a policyholder that employed an average of at least 100 individuals who were insureds, subscribers, or enrollees on business days during the preceding 12-month period with a complete record of the policyholder’s medical claims experience or medical costs incurred under the group policy, contract<\/span> or plan. This record shall include all claims incurred for the lesser of (i) the period of time since the policy, contract<\/span> or plan was issued or issued for delivery or (ii) the period of time since the policy, contract<\/span>, or plan was last renewed, reissued or extended, if already issued. This record shall be made available promptly to the policyholder upon request made not less than 30 days prior to the date upon which the premiums or contractual terms of the policy, contract<\/span> or plan may be amended. Nothing in this section shall require the disclosure of personal or privileged information about an individual that is protected from disclosure under Chapter 6 (§ 38.2-600<\/a> et seq.) of this title, or under any other applicable federal or state<\/span> law<\/span> or regulation. No policyholder shall be required to pay for information requested pursuant to this section. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> A policyholder that employed an average of at least 100 individuals who were insureds, subscribers or enrollees on business days during the preceding 12-month period shall receive from its insurer<\/span>, upon request, at the time that the insurer<\/span> provides a record of medical claims experience or medical costs under subsection A of this section (i) a summary of medical claims charges or medical costs incurred and the amount paid with respect to those claims for the most recently available 24-month period; (ii) a listing of the number of insured, subscribers or enrollees for whom combined medical claims payments or medical costs exceed $100,000 for the most recently available 12-month period, and for the preceding 12 months if not previously provided, with information as to whether these enrollees from the most recently available 12-month period remain enrolled under the policy, and provided that a policyholder and insurer<\/span> may agree by contract<\/span> to provide the listing for amounts less than $100,000; and (iii) total enrollment in each membership type as of the end of the most recently available 12-month period. This record shall be made available to the policyholder within 20 business days upon written request made not less than 45 days prior to the date upon which the premiums or contractual terms of the policy may be amended. Nothing in this section shall require the disclosure of personal or privileged information about an individual that is protected from disclosure under Chapter 6 (§ 38.2-600<\/a> et seq.) of this title, or under any other applicable federal or state<\/span> law<\/span> or regulation. No policyholder shall be required to pay for information requested pursuant to this section. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> With respect to group accident and sickness insurance policies<\/span>, the requirements of this section shall apply to all policies, contracts<\/span>, and plans delivered, issued for delivery, reissued or extended on and after July 1, 2003, or at any time after the effective date hereof when any term of any such policy, contract<\/span> or plan is changed or any premium adjustment is made. With respect to health care plans, the requirements of this section shall apply to all contracts<\/span> delivered, issued for delivery, reissued or extended on and after January 1, 2005, or at any time after the effective date hereof when any term of any such contract<\/span> or plan is changed or any premium adjustment is made. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nCLAIMS EXPERIENCE (\u00a7 38.2-3540.1)\n\nA. Each group accident and sickness insurance policy and health care plan shall\ncontain a provision which provides that the insurer, upon request, shall provide\na policyholder that employed an average of at least 100 individuals who were\ninsureds, subscribers, or enrollees on business days during the preceding\n12-month period with a complete record of the policyholder’s medical\nclaims experience or medical costs incurred under the group policy, contract or\nplan. This record shall include all claims incurred for the lesser of (i) the\nperiod of time since the policy, contract or plan was issued or issued for\ndelivery or (ii) the period of time since the policy, contract, or plan was last\nrenewed, reissued or extended, if already issued. This record shall be made\navailable promptly to the policyholder upon request made not less than 30 days\nprior to the date upon which the premiums or contractual terms of the policy,\ncontract or plan may be amended. Nothing in this section shall require the\ndisclosure of personal or privileged information about an individual that is\nprotected from disclosure under Chapter 6 (§ 38.2-600 et seq.) of this\ntitle, or under any other applicable federal or state law or regulation. No\npolicyholder shall be required to pay for information requested pursuant to this\nsection.\n\nB. A policyholder that employed an average of at least 100 individuals who were\ninsureds, subscribers or enrollees on business days during the preceding\n12-month period shall receive from its insurer, upon request, at the time that\nthe insurer provides a record of medical claims experience or medical costs\nunder subsection A of this section (i) a summary of medical claims charges or\nmedical costs incurred and the amount paid with respect to those claims for the\nmost recently available 24-month period; (ii) a listing of the number of\ninsured, subscribers or enrollees for whom combined medical claims payments or\nmedical costs exceed $100,000 for the most recently available 12-month period,\nand for the preceding 12 months if not previously provided, with information as\nto whether these enrollees from the most recently available 12-month period\nremain enrolled under the policy, and provided that a policyholder and insurer\nmay agree by contract to provide the listing for amounts less than $100,000; and\n(iii) total enrollment in each membership type as of the end of the most\nrecently available 12-month period. This record shall be made available to the\npolicyholder within 20 business days upon written request made not less than 45\ndays prior to the date upon which the premiums or contractual terms of the\npolicy may be amended. Nothing in this section shall require the disclosure of\npersonal or privileged information about an individual that is protected from\ndisclosure under Chapter 6 (§ 38.2-600 et seq.) of this title, or under any\nother applicable federal or state law or regulation. No policyholder shall be\nrequired to pay for information requested pursuant to this section.\n\nC. With respect to group accident and sickness insurance policies, the\nrequirements of this section shall apply to all policies, contracts, and plans\ndelivered, issued for delivery, reissued or extended on and after July 1, 2003,\nor at any time after the effective date hereof when any term of any such policy,\ncontract or plan is changed or any premium adjustment is made. With respect to\nhealth care plans, the requirements of this section shall apply to all contracts\ndelivered, issued for delivery, reissued or extended on and after January 1,\n2005, or at any time after the effective date hereof when any term of any such\ncontract or plan is changed or any premium adjustment is made.\n\nHISTORY: 1992, c. 800; 1999, c. 116; 2003, c. 654; 2004, c. 772.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}