Okla. Admin. Code § 365:10-5-6

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

Section 365:10-5-6 - Required disclosure provisions

(a)General rules.

(1) Each individual policy of accident and sickness insurance shall include a renewal, continuation, or non-renewal provision. The language or specification of such provision must be consistent with the type of contract to be issued. Such provision shall be appropriately captioned, shall appear on the first page of the policy, and shall clearly state the duration where limited, of renewability and the duration of the term of coverage for which the policy is issued and for which it may be renewed.

(2) Except for riders or endorsements by which the insurer effectuates a request made in writing by the policyholder or exercises a specifically reserved right under the policy, all riders or endorsements added to a policy after date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require signed acceptance by the policyholder. After date of policy issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy terms must be agreed to in writing signed by the insured, except if the increased benefits or coverage is required by law.

(3) Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, such premium charge shall be set forth in the policy.

(4) A policy which provides for the payment of benefits based on standards described as "usual and customary", "reasonable and customary" or words of similar import, shall include a definition of such terms and an explanation of such terms in its accompanying outline of coverage.

(5) If a policy contains any limitations with respect to pre-existing conditions, such limitations must appear as a separate paragraph of the policy and be labeled as "Pre-existing Condition Limitations."

(6) All "accident only" policies shall contain a prominent statement on the first page of the policy or attached thereto, in either contrasting color or in boldface type at least equal to the size of type used for policy captions, a prominent statement as follows: "This is an accident only policy and it does not pay benefits for loss from sickness"

(7) All policies, except single premium nonrenewable policies and as otherwise provided in this paragraph, shall have a notice prominently printed on the first page of the policy or attached thereto, stating in substance that the policyholder shall have the right to return the policy within ten (10) days of its delivery and to have the premium refunded if, after examination of the policy, the policyholder is not satisfied for any reason. If the insurer does not return any premiums or moneys paid therefor within thirty (30) days from the date of cancellation, the insurer shall pay interest on the proceeds which shall be the same rate of interest as the average United States Treasury Bill rate of the preceding calendar year as certified to the State Insurance Commissioner by the State Treasurer on the first regular business day in January of each year, plus two percentage points which shall accrue from the date of cancellation until the premiums or moneys are returned. In such event, the policy shall be deemed to have been cancelled on the date the policy was placed in the United States mails in a properly addressed post paid envelope; or, if not so posted, on the date of delivery of such policy to the insurer. With respect to policies issued pursuant to a direct response solicitation to persons eligible for Medicare the policy shall have a notice prominently printed on the first page of the policy or attached thereto, stating in substance that the policyholder shall have the right to return the policy within thirty (30) days of its delivery and to have the premium refunded if after examination of the policy the policyholder is not satisfied for any reason. If the insurer does not return any premiums or moneys paid therefor within thirty (30) days from the date of cancellation, the insurer shall pay interest on the proceeds which shall be the same rate of interest as the average United States Treasury Bill rate of the preceding calendar year as certified to the State Insurance Commissioner by the State Treasurer on the first regular business day in January of each year, plus two percentage points which shall accrue from the date of cancellation until the premiums or moneys are returned. In such event, the policy shall be deemed to have been cancelled on the date the policy was placed in the United States mails in a properly addressed post paid envelope; or, if not so posted, on the date of delivery of such policy to the insurer.

(8) If age is to be used as a determining factor for reducing the maximum aggregate benefits made available in the policy as originally issued, such fact must be prominently set forth in the outline of coverage.

(9) If a policy contains a conversion privilege, it shall comply, in substance with the following: the caption of the provision shall be "Conversion Privilege", or words of similar import. The provision shall indicate the persons eligible for conversion, the circumstances applicable to the conversion privilege, including any limitations on the conversion, and the person by whom the conversion privilege may be exercised. The provision shall specify the benefits to be provided on conversion or may state that the converted coverage will be as provided on a policy form then being used by the insurer for that purpose.

(10) Insurers issuing policies which provide hospital or medical expense coverage on an expense incurred or indemnity basis other than incidentally, to a person's eligible for Medicare by reason of age, shall provide to the policyholder, a Medicare supplement buyer's guide in a form prescribed by the Commissioner. Delivery of the buyer's guide shall be made whether or not the policy qualified as a "Medicare Supplement Coverage" in accordance with this Chapter. Except in the case of direct response insurers, delivery of the buyer's guide shall be made at the time of application and acknowledgment of receipt of certificate of delivery of the buyer's guide shall be provided to the insurer. Direct response insurers shall deliver the buyer's guide upon request but not later than at the time the policy is delivered.

(11) Outlines of coverage delivered in connection with policies defined as Hospital Confinement Indemnity in 365:10-5-6(i), Specified Disease in 365:10-5-6(i), or Limited Benefit Health Insurance Coverage in 365:10-5-6(k) to persons eligible for Medicare by reason of age shall contain in addition to the requirements of 365:10-5-6(f), (j) and (k), the following language which shall be printed on or attached to the first page of the outline coverage: This policy IS NOT A MEDICARE SUPPLEMENT policy. If you are eligible for Medicare review the Medicare Supplement Buyer's Guide available from the company.

(b)Outline of coverage requirements for individual coverages.

(1) No individual or family accident and health insurance policy, shall be delivered, or issued for delivery, in this state unless:

(A) Accompanied by an appropriate outline of coverage in plain and simple language, in no less than 10 point type and provided further, that in case of limited or substandard policies, as described herein, the outline of coverage shall state, in no less than 11 point type that said policy is of limited nature or other appropriate information, as prescribed by the State Insurance Commissioner.

(B) Or, an appropriate outline of coverage is compiled and delivered to the applicant at the same time application is made, and an acknowledgment of receipt or certificate of delivery of such outline is provided to the insurer with the application.

(2) In the case of a direct response, such as a written application to the insurance company from an application the outline of coverage shall accompany the policy when issued.

(3) Such outline of coverage shall contain:

(A) A statement identifying the applicable category of coverage afforded by the policy as based on the minimum basic standards set forth in these regulations.

(B) A brief description of the principal benefits and coverage provided in the policy.

(C) A summary statement of the principal exclusions and limitations or reductions contained in the policy, including, but not limited to, pre-existing conditions, probationary periods, elimination periods, and any age limitations or reductions.

(D) A summary statement of the renewal provision, including any reservation of the insurer of a right to change premiums.

(E) A statement that the outline contains a summary only of the details of the policy as issued or of the policy as applied for and that the issued policy should be referred to for the actual contractual governing provisions.

(c)Basic hospital expense coverage. An outline of coverage, in the form prescribed, shall be issued in connection with policies meeting the standards of 365:10-5-5(c). The items included in the outline of coverage must appear in the sequence prescribed.

(d)Basic medical surgical expense coverage. An outline of coverage, in the form prescribed, shall be issued in connection with policies meeting the standards of 365:10-5-5(d). The items included in the outline of coverage must appear in the sequence prescribed.

(e)Basic hospital and medical surgical expense coverage. An outline of coverage, in the form prescribed, shall be issued in connection with policies meeting the standards of 365:10-5-5(c) and (d). The items included in the outline of coverage must appear in the sequence prescribed.

(f)Hospital confinement indemnity coverage. An outline of coverage, in the form prescribed, shall be issued in connection with policies meeting the standards of 365:10-5-5(e). The items included in the outline of coverage must appear in the sequence prescribed.

(g)Major medical expense coverage. An outline of coverage, in the form prescribed, shall be issued in connection with policies meeting the standards of 365:10-5-5(f). The items included in the outline coverage must appear in the sequence prescribed.

(h)Disability income protection coverage. An outline of coverage, in the form prescribed, shall be issued in connection with policies meeting the standards of 365:10-5-5(g). The items include in the outline of coverage must appear in the sequence prescribed.

(i)Accident only coverage. An outline of coverage, in the form prescribed, shall be issued in connection with policies meeting the standards of 365:10-5-5(h). The items included in the outline of coverage must appear in the sequence prescribed.

(j)Specified disease or specified accident coverage. An outline of coverage, in the form prescribed, shall be issued in connection with policies meeting the standards of 365:10-5-5(i). The coverage shall be identified by the appropriate bracketed title. The items included in the outline of coverage must appear in the sequence prescribed.

(k)Medicare supplement coverage. An outline of coverage, in the form prescribed, shall be issued in connection with policies that meet the standards of 365:10-5-5(b). The items included in the outline of coverage must appear in the sequence prescribed.

(l)Limited benefit health coverage. An outline of coverage, in the form prescribed, shall be issued in connection with policies which do not meet the minimum standards of 365:10-5-5(c), (d), (e), (f), (g), (h), (i) and (j). The items included in the outline of coverage must appear in the sequence prescribed.

Okla. Admin. Code § 365:10-5-6

Amended at 11 Ok Reg 1839, eff 5-15-94