Or. Admin. R. 101-015-0040

Current through Register Vol. 63, No. 6, June 1, 2024

Section 101-015-0040 - Policy Term Violations

(1) A PEBB-contracted insurance carrier may remove from coverage and/or deny the claims of a PEBB member due to policy term violations. Removal from coverage for policy term violations is at the discretion of the insurance carrier.

(a) If a policy term violation results in a termination from the plan or carrier that the violation was committed, it will not prevent the member from continuing enrollment in other PEBB types of coverages (e.g., medical, dental, vision, life, etc.), as long as they remain an employee and eligible for these benefits.

(b) If an eligible employee commits a policy term violation and loses coverage, PEBB will remove the entire family from the insurance plan since the benefits are extended to his or her dependents through the eligible employee. If the eligible employee chooses to, and it is offered, they can enroll in a different carrier plan (if applicable).

(c) If a dependent commits a policy term violation, PEBB will remove only the dependent from the insurance plan. If the eligible employee chooses to and it is offered, they can enroll in a different carrier plan (if applicable).

(d) The PEBB member who is removed from a PEBB sponsored insurance plan may appeal the decision through the carrier that terminated coverage.

(e) When a policy term violation has been discovered and investigated, the applicable insurance carrier will notify PEBB and the member with the outcome.

(2) The insurance carrier may do the following when a member has violated a provision of the policy the PEBB member has enrolled in, committed fraudulent activity or misrepresentation:

(a) The insurance carrier may retain the value of any expenditure it made related to the member who committed the fraudulent activity or misrepresentation.

(b) The insurance carrier may deny future enrollments of the individual in accordance with the carrier's policies.

Or. Admin. R. 101-015-0040

PEBB 3-2018, temporary adopt filed 02/23/2018, effective 02/23/2018 through 08/21/2018; PEBB 5-2018, adopt filed 08/15/2018, effective 8/15/2018

Statutory/Other Authority: ORS 243.125 & ORS 243.061-302, 659A.060-069, 743.600-602 and 743.707

Statutes/Other Implemented: ORS 243 & ORS 243.061-302, 292.501 and 2007 OL Chap. 99