Section 26-A511. READABILITY STANDARDS FOR POLICIES AND ENDORSEMENTS

 

511.1The provisions of this section specifying standards for format and language shall apply to all motor vehicle insurance policies issued or renewed on or after June 2, 1986, and endorsements required by the Act and this chapter.

 

511.2Each policy shall include a table of contents.

 

511.3Each section shall be self-contained and independent. However, general provisions applicable to more than one (1) section may be included in a common section.

 

511.4The policy or endorsements, except for declarations pages, schedules, and tables shall be printed in not less than ten (10) point type.

 

511.5The policy and endorsements shall be printed in a legible type style with adequate contrast between ink and paper. Captions, headings, and spacing shall be used to increase overall legibility.

 

511.6The policy or endorsement shall be written in everyday, conversational language, consistent with its standing as a contract. Short sentences and personal style shall be used wherever possible.

 

511.7Technical terms and words with special meaning shall be avoided wherever possible.

 

511.8The policy or endorsement text shall achieve a minimum score of forty (40) on the Flesch Reading Ease Test or an equivalent score o any other comparable test, or a lower score on either, if the Commissioner finds the policy or endorsement reasonable easy to read.

 

511.9For the purpose of this section, a Flesch Reading Ease Test shall be scored by the following method:

 

(a)For a policy or endorsement containing ten thousand (10,000) words or less of text, the entire policy or endorsement shall be analyzed. For a policy or endorsement containing more than ten thousand (10,000) words or the readability of two (2) one hundred (100) word samples per page may be analyzed instead. The samples shall be separated by at least 20 printed lines.

 

(b)The total number of words in the text or sample shall be divided by the total number of sentences. The figure obtained shall be multiplied by 1.015;

 

(c)The total number of syllables in the test or sample shall be divided by the total number of words. The figure obtained shall be multiplied by 84.6; and

 

(d)The sum of the figures computed under §§ 511.9(b) and 511.9(c) of this chapter subtracted from 206.835 equals the Flesch Reading Ease Test Score.

 

511.10For purposes of § 511.9 the following procedures shall be used:

 

(a)A contraction, hyphenated word, numbers and letters, when separated by spaces, shall be counted as one word;

 

(b)A unit of text ending with a period, semi-colon, or colon shall be counted as a sentence;

 

(c)A syllable means a unit of spoken language consisting of one (1) or more letters of a word as divided by an accepted dictionary. Where the dictionary shows two (2) or more equally acceptable pronunciations of a work, the pronunciation containing fewer syllables may be used; and

 

(d)At the option of the insurer, or rating bureau any form made a part of the policy may be scored separately or as a part of the policy.

 

511.11The term "text" as used in § 511.9 includes all printed matter except the following:

 

(a)The name and address of the insurer;

 

(b)The name, number, or title of the policy or form;

 

(c)The table of contents or index;

 

(d)Heading and captions;

 

(e)Defined Terms;

 

(f)Proper nouns;

 

(g)Declaration pages; and

 

(h)Schedules or tables.

 

APPENDIX 5-1

[To be used pursuant to the provisions of §506]

 

Policy Form Certification

 

The [Definitions and General Provisions] of this policy apply unless modified by the [endorsement].

 

SECTION 1.

 

Personal Injury Protection Coverage

 

We will pay Personal Injury Protection benefits in accordance with the District of Columbia Compulsory/No Fault Motor Vehicle Insurance Act of 1982, as amended (the Act). We will pay these benefits to or for a covered person who sustains bodily injury  in an accident arising out of the maintenance or use of a motor vehicle or vehicle.

 

These Personal Injury Protection benefits consist of:

 

(1)Medical expense benefits up to $100,000 for reasonable charges incurred for reasonably necessary products, services and accommodations for a covered person's:

 

(a)Care;

 

(b)Recovery; or

 

(c)Rehabilitation.

 

Only semi-private hospital room charges will be paid unless special or intensive care is required.

 

We will pay for a product, service or accommodation only if its provider is licensed or approved and complies with any applicable laws or regulations pertinent thereto.

 

(2)Funeral expense benefits up to $2,000 for actual costs incurred for a covered person's funeral or funeral-related expenses.

 

(3)Work loss benefits up to a maximum aggregate limit of $24,000. Work Loss Benefits consist of:

 

(1)Loss of Income. Subject to the maximum aggregate limit, 80% of the loss of gross income, but not to exceed $2,000 per month for work which a covered  person would have performed except for the bodily  injury.

 

We will pay a higher percentage to the extend that a covered person furnishes us with reasonable proof that his or her income tax is less than 20% of gross income.

 

(b)Replacement Services. Subject to the maximum aggregate limit, expenses not to exceed $50 per day which are reasonably incurred to obtain ordinary and necessary services to replace those the covered person  would have performed for personal or family benefit except for the bodily injury. The services must be performed within 3 years after the date of the accident. The services cannot be obtained to produce income for the covered person.

 

Work loss benefits do not continue after a covered person dies.

 

The amounts stated above are the most we will pay to or for a covered person as the result of any one accident regardless of the number of:

 

(1)Claims made;

 

(2)Your covered autos;

 

(3)Motor Vehicles or vehicles involved in the accident; or

 

(4)Insurers providing Personal Injury Protection benefits.

 

Deductible

 

Any amount payable to or for a covered person shall be reduced by the amount of the deductible you elect as shown in the [schedule or declarations]. The deductible applies only to you and to any family member. However, the deductible does not apply to benefits payable for emergency medical services furnished during the first 72 hours after the accident.

 

Note:Deductible provision may be deleted at company's option.

 

Exclusions

 

We will not pay Personal Injury Protection benefits for bodily injury:

 

(1)Sustained by any person injured While intentionally causing or attempting to cause injury to himself, herself or any other person.

 

(2)Sustained by a person using a motor vehicle or vehicle he or she has taken unlawfully, unless that person reasonably believed, at the time he or she first used the motor vehicle or vehicle, that he or she was entitled to take and use the motor vehicle or vehicle.

 

(3)Sustained by the owner of a motor vehicle involved in the accident for. which the coverage required by the Act is not in effect.

 

(4)Sustained by a non-resident of the District While operating or occupying a motor vehicle, other than your covered auto, if that motor vehicle is not registered in the District.

 

(5)Sustained by the owner or operator of a vehicle involved in the accident if no motor vehicle is involved in the accident. This exclusion does not apply if any vehicle involved in the accident is your covered auto.*

 

*Note:The second sentence of Exclusion (5) is not to be used with policies covering motor vehicles only.

 

(6)Sustained by any person injured as a result of conduct within the course of the business of repairing, servicing or otherwise maintaining motor vehicles or vehicles. This exclusion does not apply if the conduct is as follows:

 

(a)Off the business premises; or

 

(b)In the course of loading or unloading a motor vehicles or vehicles.

 

(7)Sustained by any person while occupying a motor vehicle or vehicle located for use as a residence or premises.

 

(8)Caused by or as a consequence of the following:

 

(a)Discharge of a nuclear weapon (even if accidental);

 

(b)War (declared or undeclared);

 

(c)Civil war;

 

(d)Insurrection; or

 

(e)Rebellion or revolution.

 

(9)From or as a consequence of the following, whether controlled or uncontrolled or however caused;

 

(a)Nuclear reaction;

 

(b)Radiation; or

 

(c)Radioactive contamination.]

 

Definitions

 

Under this coverage the definitions are as follows:

 

(1)"you" and "your" means the [Named Insured] shown in [the Declarations.]

 

(2)"we" "us" and our means [the company providing this coverage].

 

(3)"bodily injury" means bodily harm sustained in an accident including any illness, disease or death resulting from that bodily harm.

 

(4)["covered person"] means:

 

(A)You and any family member;

 

(B)Any person while occupying your covered auto;

 

(C)Any other person sustaining bodily injury in an accident within the District of Columbia in which your  covered auto is involved.

 

(5)["family member"] means your spouse or any person related to you by blood, marriage or adoption who is a resident of your household. This includes any other resident of your household under age 18 who is in your custody or your relative's custody.

 

(6)"motor vehicle" means any device propelled by an internal combustion engine, electricity or steam. However, "motor vehicle" does not mean a motorcycle, a traction engine used exclusively for drawing vehicles in fields, a road roller or a vehicle propelled only upon rails and tracks.

 

(7)"occupying" means in, upon, getting in, on, out or off.

 

(8)"vehicle" means:

 

(a)A trailer as defined in the Act; or

 

(b)An appliance moved or designed to be moved over a publicly maintained way on wheels or traction tread which is:

 

i.Operated by power other than muscular power; or

 

ii.Drawn by a draft animal or beast of burden.

 

*9.[ your covered auto"] means a motor vehicle:

 

(a)For which you are required to maintain security under the Act; and

 

(b)To which liability coverage under this policy applies.

 

**9.["your covered auto"] means a motorcycle:

 

(a)For which a premium for the coverage is charged, and

 

(b)To which liability coverage under this policy applies.

 

***9 ["your covered  auto"] means:

 

(a)A motor vehicle:

 

(i)For which you are required to maintain security under the Act, and

 

(ii)To which liability coverage under this policy applies; and

 

(b)A motorcycle:

 

(i)For which a premium for this coverage is charged; and

 

(ii)To which liability coverage under this policy applies.

 

Note:*For use with policies covering motor vehicles only.

 

**For use with policies covering motorcycles only.

 

***For use with policies covering both motor vehicles and motorcycles.

 

Coordination and Non-Duplication

 

(1)Personal Injury protection benefits are excess over but shall not duplicate amounts paid, payable or required to be provided under:

 

(a)Social security (except medicaid benefits);

 

(b)Workers' compensation;

 

(c)Temporary nonoccupational disability insurance that is required by a state or the District of Columbia government; or

 

(d)Any government program (except the proceeds of government life insurance).

 

This does not apply if the law authorizing these benefits makes them secondary to or duplicative of the benefits provided under the Act.

 

(2)No person may recover duplicate Personal Injury Protection benefits for the same element of loss.

 

(3)If a covered person is entitled to Personal Injury Protection benefits under more than one policy, the maximum recovery under all policies will not exceed the amount payable under the policy with the highest dollar limits of benefits.

 

Priorities of Policies

 

We will pay Personal Injury Protection benefits in accordance with the order of priorities set forth by the Act. We will not pay if there is another insurer at a higher level of priority. The priority or is:

 

First - The insurer of the employer, if the covered person is:

 

(a)An employee or relative of an employee; and

 

(b)Occupying a motor vehicle provided or made available by the employer in the course of employment.

 

Second - The insurer of the owner or operator of a motor vehicle in the business of transporting passengers for hire, if the covered person is a passenger. This priority does not apply to the insurer of a school bus or bus operating under a government sponsored program.

 

Third - The insurer providing benefits to the covered person  as a named insured. It two or more policies apply under this priority and one specifically insures the motor vehicle or motorcycle involved in the accident, it shall be the policy under which benefits are payable.

 

Fourth - The insurer providing benefits to the covered person  as a family member who is not a named insured under another policy providing coverage under the Act. If two or more policies apply under this priority and one specifically insures the motor vehicle or motorcycle involved in the accident, it shall be the policy under Which benefits are payable.

 

Fifth - The insurer of the motor vehicle or motorcycle occupied by the covered person.

 

Sixth - The insurer providing Personal Injury Protection coverage on any motor vehicle or motorcycle involved in the accident if the covered person is not provided coverage under any other policy.

 

If two or more policies have equal priority, the insurer against which the claim is first made shall process and pay the claim as if wholly responsible, subject to subsequent contribution pro rata.

 

For the purposes of determining priorities, an unoccupied parked motor vehicle or motorcycle is not a motor vehicle or motorcycle involved in an accident unless it was parked in a manner as to create an unreasonable risk of injury.

 

Duties After an Accident of Loss

 

We must be notified promptly of how, when, and where the accident happened. Notice should also include the names and addresses of any injured persons and of any witnesses.

 

A person seeking coverage shall do the following:

 

(a)Cooperate with us in the investigation or settlement of any claim.

 

(b)Submit as often as we reasonably require to physical examinations by physicians we select. We will pay for these exams.

 

(c)Authorize us to obtain the following:

 

(1)Medical reports;

 

(2)Statements of earnings; and

 

(3)Other pertinent records.

 

(d)Submit a written proof of claim when required by us.

 

(e)Promptly send us copies of the legal papers if a suit is brought.

 

(f)If we request, furnish us a sworn statement of earnings or lack of earnings:

 

(1)For a reasonable time prior to the accident; and

 

(2)Since the accident.

 

General Provisions

 

Policy Period and Territory

 

This coverage applies only to accidents which occur during the policy period as shown in [the Declarations] and within the policy territory. The policy territory is the United States of America, its Territories or Possessions, or Canada.

 

Legal Action Against Us

 

No legal action may be brought against us until there has been full compliance with all the terms of this policy.

 

Our Right to Recover Payment

 

Subject to any applicable limitations stated in the Act and applicable Regulations:

 

(1)If we make a payment under this coverage and the person to or for whom payment was made has a right to recover damages for another, we shall be subrogated to that right. That person shall do:

 

(a)Whatever is necessary to enable us to exercise our rights; and

 

(b)Nothing after loss to prejudice them.

 

(2)If we make a payment under this coverage and the person to or from whom payment is made recovers damages from another, that person shall:

 

(a)Hold in trust for us the proceeds of the recovery; and

 

(b)Reimburse us to the extent of our payment.

 

Assignment of Claims to Future Benefits

 

A covered person, may not assign his or her right to any Personal Injury Protection benefits payable in the future.

 

SECTION 2.

 

Premiums Recomputation

 

Section 6 of the Act places limitations on a person's right to sue for damages. The premium for the policy reflects these limitations. If a court declares any of these limitations unenforceable we have the right to recompute the premium.

 

Note:Companies may substitute the appropriate terms, reference or language for matter in brackets.

 

source

Final Rulemaking published at 35 DCR 7649 (October 21, 1988).