Or. Admin. Code § 836-020-0305

Current through Register Vol. 63, No. 10, October 1, 2024

Section 836-020-0305 - Disclosure; Application for Coverage

(1) When an insurance producer or representative of an insurer accepts an application for individual health insurance coverage other than coverage described in section (2) of this rule, the insurance producer or representative shall provide the applicant the documents required under this section. In the case of direct response solicitations of such individual health insurance coverage, the documents required under this section must be provided in conjunction with any application form. The following are the documents required to be provided under this section:

(a) A completed disclosure statement in the form shown in Exhibit 1 to this rule;

(b) An outline of coverage in the form shown for the applicable coverage in Exhibit 2 to this rule. If the offered policy provides coverage other than a coverage described in an outline of coverage in Exhibit 2 to this rule, the insurance producer or representative or the direct response insurer must deliver an outline that has first been approved by the Director under section (6) of this rule.

(2) When an insurance producer or representative of an insurer accepts an application for individual accidental death and dismemberment insurance, accident only insurance or hospital indemnity insurance, the insurance producer or representative shall provide the applicant the documents required under this section. In the case of direct response solicitations of such insurance, the documents required under this section must be provided in conjunction with any application form. The following are the documents required to be provided under this section:

(a) A completed disclosure statement in the form shown in Exhibit 3 to this rule;

(b) An outline of coverage in the form shown for the applicable coverage in Exhibit 2 to this rule. If the offered policy provides coverage other than a coverage described in an outline of coverage in Exhibit 2 to this rule, the insurance producer, representative or insurer must deliver an outline that has first been approved by the Director under section (5) of this rule.

(3) When an insurance producer or representative of an insurer accepts an application for group health insurance coverage, including group accidental death and dismemberment insurance, accident only insurance or hospital indemnity insurance, the insurance producer or representative shall provide to the applicant an outline of coverage in the form shown for the applicable coverage in Exhibit 2 to this rule. In the case of direct response solicitations, the outline must be provided in conjunction with any application form. If the offered policy provides coverage other than a coverage described in an outline of coverage in Exhibit 2 to this rule, the outline must first be approved by the Director under section (5) of this rule.

(4) For purposes of sections (1) to (3) of this rule, the following forms shall be used for the following coverages:

(a)Exhibit 2, form A, shall be used for comprehensive major medical expense coverage;

(b)Exhibit 2, form B, shall be used for hospital confinement indemnity coverage;

(c)Exhibit 2, form C, shall be used for accidental death and dismemberment only coverage and for accident only coverage;

(d)Exhibit 2, form D, shall be used for specified illness or specified accident coverage;

(e)Exhibit 2, form E, shall be used for limited benefit health coverage;

(f)Exhibit 2, form F, shall be used for basic hospital and medical-surgical expense coverage.

(5) An insurance producer or representative of an insurer may use a form or material other than the statements set forth in Exhibits1 and 3 to this rule or the outlines set forth in Exhibit 2 to this rule only if the form or material is first approved by the Director for the purpose of disclosure under this rule. Forms and other material submitted under this section are subject to the standards for advertising under OAR 836-020-0220 and 836-020-0225.

(6) When an insurance producer or representative of an insurer provides an applicant the applicable information required under section (1), (2) or (3) of this rule, or a form or material approved under section (5) of this rule, the insurance producer or representative shall obtain from the applicant an acknowledgement that the applicable information required under this rule was provided. In the case of direct response solicitations, the insurer or its representative or agent shall maintain proof that the documents required under this rule have been mailed to the applicant.

(7) This rule applies to all solicitations for health insurance, whether for initial, replacement or added coverage, except for solicitations for the following:

(a) Renewal of a health insurance policy, unless the application is to be used for the purpose of underwriting the policyholder;

(b) Medicare supplement insurance policies;

(c) Long term care insurance policies;

(d) Disability income insurance policies, as exempted from these rules under ORS 743.013;

(e) Accidental death and dismemberment insurance coverage and accident only insurance coverage when sold as a rider to a life insurance policy;

(f) Any individual policy issued under a conversion privilege in an insurance policy or contract.

[[ED. NOTE: Exhibits referenced are available from the agency.]

Or. Admin. Code § 836-020-0305

ID 12-1990, f. 6-12-90, cert. ef. 9-1-90; ID 8-2005, f. 5-18-05, cert. ef. 8-1-05

Exhibits referenced are available from the agency.

Stat. Auth.: ORS 731, 742 & 743

Stats. Implemented: ORS 742.009, 743.010 & 743.013