Okla. Admin. Code § 365:10-5-4

Current through Vol. 42, No. 7, December 16, 2024

Section 365:10-5-4 - Prohibited policy provisions

(a)Probationary or waiting period. Except as provided in 365:10-5-3(6), no policy shall contain provisions establishing a probationary or waiting period during which no coverage is provided under the policy, subject to the further exception that a policy may specify a probationary or waiting period not to exceed six (6) months for specified diseases or conditions and losses resulting therefrom, for hernia, disorder of reproduction organs, varicose veins, exception shall not be applicable where such specified diseases or conditions are treated on an emergency basis. Accident policies shall not contain probationary or waiting periods.

(b)Policy or rider for dividend. No policy or rider for additional coverage may be issued as a dividend unless an equivalent cash payment is offered to the policyholder as an alternative to such dividend policy or rider. No such dividend policy or rider shall be issued for an initial term of less than 6 months. The initial renewal subsequent to the issuance of any policy or rider as a dividend shall clearly disclose that the policyholder is renewing the coverage that was provided as a dividend for the previous term and that such renewal is optional with the policyholder.

(c)Pre-existing conditions. No policy shall exclude coverage for a loss due to a pre-existing condition or a period greater than 12 months following policy issue where the application for such insurance does not seek disclosure of prior illness, disease or physical condition or prior medical care and treatment and such pre-existing condition is not specifically excluded by the terms of the policy.

(d)Hospital confinement indemnity coverage. Policies providing hospital confinement indemnity coverage shall not contain provisions excluding coverage because of confinement in a hospital operated by the federal government.

(e)Policy limits or exclusions, Exceptions. No policy shall limit or exclude coverage by type of illness, accident, treatment or medical condition, except as follows:

(1) Pre-existing conditions or diseases, except for congenital anomalies of a covered dependent child. This paragraph shall apply to:

(A) policies of accident and health insurance, and

(B) limited benefit insurance policies;

(2) Mental or emotional disorders, alcoholism and drug addiction;

(3) Pregnancy, except for complications of pregnancy, other than for policies defined in 365:10-5-5(g);

(4) Illness, treatment or medical condition arising out of:

(A) war or act of war (whether declared or undeclared) while serving in the military or an auxiliary unit attached to the military or working in an area of war whether voluntarily or as required by an employer; participation in a felony, riot or insurrections, service in the armed forces or units auxiliary thereto;

(B) suicide (sane or insane), attempted suicide or intentionally self-inflicted injury;

(C) aviation;

(D) with respect to short-term non-renewable policies, interscholastic sports;

(5) cosmetic surgery, except that "cosmetic surgery" shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child which has resulted, if a functional defect;

(6) foot care in connection with corns, calluses, flat feet, fallen arches, weak fee, chronic foot strain, or symptomatic complaint of the feet;

(7) treatment provided in a government hospital; benefits provided under Medicare or other governmental program (except Medicaid), any state or federal workers' compensation, employers liability or occupational disease law, or any motor vehicle no-fault law; services rendered by employees of hospitals, laboratories or other institutions; services performed by a member of the covered person's immediate family and services for which no charge is normally made in the absence of insurance;

(8) dental care or treatment;

(9) eye glasses, hearing aids and examination for the prescription or fitting thereof;

(10) rest cures, custodial care, transportation and routine physical examinations;

(11) territorial limitations;

(12) cost containment:

(A) pre-admission certification;

(B) second surgical opinion and third surgical opinion if the first two conflict;

(C) one-hundred percent coverage for generic drugs while hospital confined, or on a physician's prescription;

(D) insured self audit of hospital bills.

(f)Use of waiver. Except with respect to Medicare Supplement Coverages as defined in 365:10-5-5(b), other provisions of this section shall not impair or limit the use of waivers to exclude, limit or reduce coverage or benefits for specifically named or described pre-existing diseases, physical condition or extra hazardous activity, where waivers are required as a condition or issuance, renewal or reinstatement, signed acceptance by the insured is required unless on initial issuance the full text of the waiver is contained either on the first page or specification page. Waivers to exclude, limit or reduce coverage or benefits for specifically named or described pre-existing diseases or physical conditions shall not be used in Medicare Supplement Coverages.

(g)Use of the terms "Medicare Supplement" and "Medigap". Except as otherwise provided in 365:10-5-6(a)(11) the terms "Medicare Supplement", "Medigap" and words of similar import shall not be used unless the policy is issued in compliance with 365:10-5-5(b).

(h)Policy provisions. Policy provisions precluded in this section shall not be constructed as a limitation on the authority of the Commissioner to disapprove other policy provisions which, in the opinion of the Commissioner, are unjust, unfair, or unfairly discriminatory to the policyholder, beneficiary, or any person insured under the policy, pursuant to the Oklahoma Insurance Code.

(i)Policy limitations. A policy issued as a "Medicare Supplement Coverage" pursuant to 365:10-5-5(b) shall not include, when issued, limitations or exclusions of the type enumerated in 365:10-5-4(e)(6), (7), (11) and (12) if such limitations or exclusions are more restrictive than those of medicare for any type of care covered under such policy.

Okla. Admin. Code § 365:10-5-4

Amended at 22 Ok Reg 1954, eff 7-14-05; Amended at 28 Ok Reg 1960, eff 7-14-11