justicedao/ipfs_state_laws huggingface dataset:
836-080-0039 Duties of Insurers with Respect to Direct Response Solicitations (1) In the case of an application that is initiated as a result of a direct response solicitation, the insurer shall require, with or as part of each completed application for a policy or contract, a statement asking whether the applicant, by applying for the proposed policy or contract, intends to replace, discontinue or change an existing policy or contract. If the applicant indicates a replacement or change is not intended or if the applicant fails to respond to the statement, the insurer shall send the applicant, with the policy or contract, a notice regarding replacement in Appendix B to this rule, or other substantially similar form approved by the Director. (2) If the insurer has proposed the replacement or if the applicant indicates a replacement is intended and the insurer continues with the replacement, the insurer shall: (a) Provide to the applicant or prospective applicant with the policy or contract a notice, as described in Appendix C to this rule, or other substantially similar form approved by the Director. In these instances the insurer may delete the references to the insurance producer, including the insurance producer’s signature, and references not applicable to the product being sold or replaced, without having to obtain approval of the form from the Director. The insurer's obligation to obtain the applicant's signature shall be satisfied if it can demonstrate that it has made a diligent effort to secure a signed copy of the notice referred to in this subsection. The requirement to make a diligent effort shall be deemed satisfied if the insurer includes in the mailing a self-addressed postage prepaid envelope with instructions for the return of the signed notice referred to in this section; and (b) Comply with the requirements of OAR 836-080-0029(1)(b), if the applicant furnishes the names of the existing insurers, and the requirements of OAR 836-080-0029(1)(c) and (d), and (2). [ED. NOTE: Appendices referenced are available from the agency.] Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 746.085 & 746.240 History: ID 8-2005, f. 5-18-05, cert. ef. 8-1-05 ID 5-2001, f. 4-16-01, cert. ef. 11-1-01
836-080-0043 Violations and Penalties (1) Any failure to comply with OAR 836-080-0001 to 836-080-0043 shall be considered an unfair trade practice for purposes of ORS 746.240. Examples of violations include: (a) Any deceptive or misleading information set forth in sales material; (b) Failing to ask the applicant in completing the application the pertinent questions regarding the possibility of financing or replacement; (c) The intentional incorrect recording of an answer; (d) Advising an applicant to respond negatively to any question regarding replacement in order to prevent notice to the existing insurer; or (e) Advising a policyholder or contract owner to write directly to the insurer in such a way as to attempt to obscure the identity of the replacing insurance producer or insurer. (2) Policyholders and contract owners have the right to replace existing life insurance policies or annuity contracts after indicating in or as a part of applications for new coverage that replacement is not their intention; however, patterns of such action by policyholders or contract owners of the same insurance producer shall be deemed prima facie evidence of the insurance producer’s knowledge that replacement was intended in connection with the identified transactions, and these patterns of action shall be deemed prima facie evidence of the insurance producer’s intent to violate OAR 836-080-0001 to 836-080-0043. (3) When it is determined that the requirements of OAR 836-080-0001 to 836-080-0043 have not been met, the replacing insurer shall provide to the policyholder or contract owner an in force illustration if available or policy summary for the replacement policy or available disclosure document for the replacement contract and the appropriate notice regarding replacements in Appendix A or C to this rule. [ED. NOTE: Appendices referenced are available from the agency.] Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 746.085 & 746.240 History: ID 8-2005, f. 5-18-05, cert. ef. 8-1-05 ID 5-2001, f. 4-16-01, cert. ef. 11-1-01
836-080-0050 Authority; Purpose and Scope OAR 836-080-0055 is issued under ORS 743.731 and the general rulemaking authority of the Director of the Department of Consumer and Business Services set forth in ORS 731.244(2). The purpose of OAR 836-080-0055 is to identify particular insurance practices involving distinctions based on sexual orientation and distinctions between men and women or between married and unmarried individuals that constitute unfair discrimination in violation of ORS 746.015. Statutory/Other Authority: ORS 731 Statutes/Other Implemented: ORS 746.015(1) History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 IC 61, f. 12-2-74, ef. 1-1-75
836-080-0055 Unfair Discrimination Identified Distinctions based on sex, sexual orientation or marital status made in the following matters constitute unfair discrimination: (1) The availability of a particular insurance policy. (2) The availability of a particular amount of insurance or set of coverage delimiting factors. (3) The availability of a particular policy coverage or type of benefit, except for those relating to physical characteristics unique to one sex. (4) The premium for a particular insurance policy other than an individual or small group health benefit plan, unless the distinction is demonstrably based on reasonable supporting data. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 746.015(1) History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 IC 61, f. 12-2-74, ef. 1-1-75
836-080-0080 Definition, Claims Handling Services; Claims Procedures and Information (1) As used in ORS 743.911 and 743.913: (a) "Clean claim" means a claim under a health benefit plan that has no defect, impropriety, lack of any required substantiating documentation or particular circumstance requiring special treatment that prevents timely payment. (b) “Clean claim does not mean a claim pended under 45 CFR 156.270(d)(1). (2) For purposes of ORS 743.911 and 743.913, an insurer is considered to have received a claim when the claim is received by the insurer itself or when the claim is received by a representative of the insurer that performs claims handling on the sole behalf of the insurer, whichever receipt date is earlier. A representative may include but is not limited to a third party administrator, a claims service or a pricing service. (3) For the purpose of communicating the information necessary for claim form completion as required by ORS 743.911(3), an insurer must include any specific description of standard supporting documentation, information and data routinely required to be submitted with a claim form. Compliance with the standard transaction requirements established under the federal Health Insurance Portability and Accountability Act at 45 CFR parts 160 and 162 or OAR 836-100-0105 and 836-100-0110 constitutes compliance with this section. Statutory/Other Authority: ORS 731.244 & 743.911 Statutes/Other Implemented: ORS 743.911 & 743.913 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 1-2002, f. & cert. ef. 1-15-02
836-080-0085 Annual Report; Sampling (1) Each insurer shall report to the Director annually on its compliance with Section 2, Chapter 747, Oregon Laws 2001 (Enrolled Senate Bill 894), governing claims received by an insurer from a provider on behalf of an enrollee, according to the requirements of this rule. (2) Not later than March 1 of each year, each insurer shall submit the following to the Director: (a) A count of all claims for which final disposition has been made by the insurer during the immediately preceding calendar year. (b) A count of all claims included in the count in subsection (a) of this section that were each finally disposed of later than the 30th day after the date on which the insurer received the claim. (c) A data file that includes a population list with respect to the claims described in subsection (b) of this section, in the form and manner specified by the Director. (3) The Director shall select a number of sample files from each insurer’s data file submitted under section (2) of this rule, using a methodology determined by the Director to provide a representative and statistically valid sampling of the insurer’s insured population and shall deliver to the insurer the file numbers and the format in which the information required under section (4) of this rule shall be captured and submitted to the Director. (4) Each insurer shall examine each sample selected under section (3) of this rule against its records to determine information requested by the Director. The information shall include but not be limited to the following: (a) The date on which the claim was received; (b) The date on which the insurer requested additional information on the claim; (c) The date on which the insurer received the additional information; (d) The date on which the insurer paid or denied the claim. (e) Whether interest was owed or paid on the claim under section 3, chapter 747, Oregon Laws 2001, or whether the insurer was not required to pay interest as provided in Section 3(2), Chapter 747, Oregon Laws 2001. (f) Whether the claim was paid or denied. For the purpose of this subsection, a claim that is paid in part and denied in part shall be treated as a paid claim. (5) Not later than the 60th day after the date on which an insurer receives the selection of sample files from the Director under section (3) of this rule, the insurer shall submit to the Director a report of its data determined under section (4) of this rule in the format prescribed by the Director. (6) For the purpose of the annual report that is due for calendar year 2002, an insurer shall sample and count only those claims that were submitted to an insurer on or after January 1, 2002 and on or before December 31, 2002. Statutory/Other Authority: ORS 731.244 & Sec. 2 & 3, Ch. 747 & OL 2001 Statutes/Other Implemented: Sec. 2 & 3, Ch. 747 & OL 2001 History: ID 1-2002, f. & cert. ef. 1-15-02
836-080-0090 Suitability in the Sale of Life Insurance A person may not recommend to a consumer the purchase, sale or replacement of a life insurance policy, or any rider, endorsement or amendment to the policy, without reasonable grounds to believe that the recommendation or transaction is not unsuitable for the consumer based upon reasonable inquiry concerning the consumer's insurance objectives, financial situation and needs, age and other relevant information known by the person. For the purpose of this rule, when a person recommends a group life insurance policy, "consumer" refers to the intended group policyholder. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 746.100, 746.110 & 746.240 History: ID 2-2011, f. & cert. ef. 2-4-11 ID 6-2004, f. 8-26-04, cert. ef. 1-1-05
836-080-0105 Statutory Authority; Purpose; Effective Date (1) OAR 836-080-0105 to 836-080-0155 are adopted pursuant to the general rulemaking authority of the Commissioner in ORS 731.244 to aid in the effectuation of ORS Chapter 746, especially the enforcement of 746.015, 746.075, 746.160(3), and 746.240, as well as the effectuation and enforcement of 737.205 to 737.348, 742.003, 742.005, 742.009 and other related provisions of the Oregon Insurance Code. (2) The purpose of OAR 836-080-0105 to 836-080-0155 is to regulate the content and use of participation provisions in commercial lines of property and casualty insurance policies so as to prevent misrepresentations and other unfair practices relating to future dividends, to prevent unfair and coercive practices in the allocation and payment of dividends, and to effectuate the statutes governing ratemaking, classification of risks, and approval of policy forms, with respect to commercial lines of property and casualty insurance issued on the participating basis. [Publications: Publications referenced are available from the agency.] Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 746, 746.015, 746.075, 746.160 & 746.240 History: ID 15-1996, f. & cert. ef. 11-12-96 IC 69, f. & ef. 7-20-76
836-080-0110 Applicability OAR 836-080-0105 to 836-080-0155: (1) Apply to all authorized insurers, whether stock, mutual, or reciprocal, and to the State Accident Insurance Fund. (2) Apply to those forms of property and casualty insurance known by custom as “commercial lines”; and do not apply to other lines or forms of insurance. Statutory/Other Authority: ORS 731 & 746 Statutes/Other Implemented: ORS 746.015(1), 746.075, 746.160(3) & 746.240 History: IC 69, f. & ef. 7-20-76
836-080-0115 Definitions As used in OAR 836-080-0105 to 836-080-0155, unless the context requires otherwise: (1) “Dividend statement” has the meaning given the term by OAR 836-080-0130. (2) “Insurer” has the meaning given the term by ORS 731.106 and includes the State Accident Insurance Fund. (3) “Issue” when referring to an insurance policy includes “renew” and “endorse.” (4) “Participating policy” means a policy that grants participation rights to the policyholder. (5) “Participation” means the right of a policyholder to share in the distribution of profits or other assets of the insurer, whether or not the right is conditional or limited by other provisions. (6) “Policy” has the meaning given the term by ORS 731.122, and the term includes endorsements and the agreements between the State Accident Insurance Fund and individual contributing employers by which the Fund provides workmen’s compensation coverage. (7) “Policyholder” means a person who owns or has an interest in a policy and the term includes a prospective policyholder. (8) “Prospective policyholder” includes a policyholder who is considering the renewal or discontinuance of an existing policy. Statutory/Other Authority: ORS 731 & 746 Statutes/Other Implemented: ORS 746.015(1), 746.075, 746.160(3) & 746.240 History: IC 69, f. & ef. 7-20-76
836-080-0120 Statement as to Participation Required Upon Request Before Delivery of Policy; Provision Required in Participating Policy; Contents of Provision (1) Upon the request of a policy-holder to an insurer, the policyholder is entitled to receive a written statement, before the policy is delivered, specifying whether the policy is or is not a participating policy. (2) If the insurer intends the policy to grant participation rights to policyholders, the policy shall contain a provision designated “Participation Provision.” The participation provision shall include the following wording or substantially equivalent wording approved by the Commissioner: “It is unlawful in Oregon for an insurer to promise to pay policyholder dividends for any unexpired portion of the policy term or to misrepresent the conditions for dividend payment. Dividends will be due and payable only for a policy period that has expired, and only if declared by and under conditions prescribed by the Board of Directors of the Insurer.” [ED. NOTE: Effective as follows: Sec. (1), 7-20-76; Sec. (2), 1-1-77 Statutory/Other Authority: ORS 731 & 746 Statutes/Other Implemented: ORS 746.015(1), 746.075, 746.160(3) & 746.240 History: IC 69-1976, f. 7-20-76, ef. 7-20-76
836-080-0125 Prohibited Representations Regarding Participation Rights Prior to the declaration of a dividend, an insurer shall not represent, orally or in writing, that the insurer agrees or will agree: (1) To pay a specified amount as a dividend; or (2) To a formula that fixes, or to factors that fix or can be used to fix: (a) The amount of a dividend; (b) The percentage of premium that will be paid as a dividend; or (c) The amount or percentage of premium to be retained by the insurer after payment of dividends. Statutory/Other Authority: ORS 731 & 746 Statutes/Other Implemented: ORS 746.015(1), 746.075, 746.160(3) & 746.240 History: IC 69, f. & ef. 7-20-76
836-080-0130 Dividend Statement Permitted; Required to Be Written; Prohibited and Permitted Advice (1) An insurer may advise a policy holder of the kinds of information the insurer expects to take into consideration in determining whether to declare a dividend and the amount thereof. Any such advice is considered a “dividend statement” as the term is used in this section. A dividend statement shall not, however, be of such a nature as to make it possible to determine, directly or indirectly: (a) The amount of a dividend; (b) The percentage of premium that will be paid as a dividend; or (c) The amount or percentage of premium to be retained by the insurer after payment of dividends. (2) A dividend statement shall be in writing. It shall include a statement that is identical to the wording of the participation provision that OAR 836-080-0120 requires to be included in the policy. Such statement shall appear ahead of and have at least equal prominence with the advice regarding dividends permitted under section (1) of this rule. A dividend statement also shall contain with equal prominence the following wording or substantially equivalent wording approved by the Commissioner: “Furthermore, it is an unlawful rebate and a violation of the Oregon Insurance Code for an insured or a representative of an insured knowingly to accept a dividend pursuant to a promise to pay policyholder dividends if the promise is made before the policy is issued or if the promise is made for any unexpired portion of a policy period.” (3) A dividend statement may describe the rates or amounts of dividends previously declared or paid on similar policies, or the scales or schedules previously used to determine the rates or amounts of dividends. However, such a description shall also set forth the period covered by the policies on which such dividends were paid and state that past dividend performance is not a guarantee of future dividend performance. (4) A dividend statement may set forth a time schedule according to which the insurer intends to declare or pay a dividend, if any. [Publications: Publications referenced are available from the agency.] Statutory/Other Authority: ORS 731 & 746 Statutes/Other Implemented: ORS 746.015(1), 746.075, 746.160(3) & 746.240 History: IC 69, f. 7-20-76, ef. 1-1-77
836-080-0135 Dividend Rights Accrue Upon Declaration of Dividends; Contents of Dividend Declaration Resolution (1) The right of a policyholder to a dividend, or to a determination of whether any dividend will be paid to the policyholder or the amount of a dividend that will be paid to the policyholder, shall not accrue unless the board of directors or other governing body of the insurer: (a) Determines that the insurer has a surplus from which the dividend may lawfully be paid; and (b) Declares the dividend by resolution adopted after the expiration of the policy period for which the dividend was earned. (2) The resolution declaring a policyholder dividend for a group of policies shall: (a) Identify by policy inception or expiration dates the policies to which the declaration is applicable; (b) Specify the policy period for which the dividend is payable; and (c) Specify the dividend plans, scales, tables, formulas, schedules, and factors applied, or to be applied, to determine whether any dividends will be paid and the amounts of dividends to be allocated to individual policies. Statutory/Other Authority: ORS 731 & 746 Statutes/Other Implemented: ORS 746.015(1), 746.075, 746.160(3) & 746.240 History: IC 69, f. & ef. 7-20-76
836-080-0140 Unfair Discrimination in Allocation of Dividends Prohibited; Criteria for Allocation; Prima Facie Evidence of Unfair Discrimination (1) An insurer shall not unfairly discriminate in the allocation of dividends. (2) The dividend plans, scales, tables, formulas, schedules and factors specified in the dividend declaration may provide for allocation of dividends at a fixed percentage of premiums, or may provide for variations in the percentage of premium paid as dividends or other variations in determining the amounts of dividends. The variations may be based on loss or expense factors, or on any other reasonable considerations, such as risk size, risk location, or industry or trade hazard classification, which have a probable effect on losses or expenses. (3) Failure to apply in a consistent manner the plans, scales, tables, formulas, schedules, and factors adopted and specified in a dividend declaration is prima facie evidence of unfair discrimination. However, a variation from procedures set forth in a dividend statement that was provided to a policyholder prior to inception of the policy will not of itself be considered unfairly discriminatory. Statutory/Other Authority: ORS 731 & 746 Statutes/Other Implemented: ORS 746.015(1), 746.075, 746.160(3) & 746.240 History: IC 69, f. & ef. 7-20-76
836-080-0145 Unfair Forfeiture of Dividend for Failure to Renew Prohibited An insurer shall not reduce or deny a policyholder dividend because of the policy-holder’s refusal to accept renewal of the policy or another policy from the same insurer. A reasonable change in the time schedule for computing or paying a policyholder dividend will not of itself be considered a reduction or denial of the dividend, or unfairly discriminatory, if: (1) The change is applied uniformly to the policyholders in like circumstances; and (2) The nature of the change is set forth in a dividend statement that was provided to the policyholder before the inception of the policy for which the change is made. Statutory/Other Authority: ORS 731 & 746 Statutes/Other Implemented: ORS 746.015(1), 746.075, 746.160(3) & 746.240 History: IC 69, f. & ef. 7-20-76
836-080-0150 Policyholder Dividend Rights of Group Members and Dividend Group Policyholders; Reduction or Denial Without Prior Advice Prohibited; “Dividend Group” Defined; Standards for Dividend Groups (1) When used in this section: (a) “Group” means a collection of insurance buyers who are members of a common organization and who are treated collectively by an insurer for determining insurance dividends; and (b) “Laws of the group” means the articles of incorporation, bylaws, agreements of association, rules, or regulations of the organization to which members of a group belong. (2) An insurer shall not issue a policy to a group or to any members of a group, unless: (a) The grouping has been approved by the Commissioner in accordance with ORS 746.145 or 746.150, whichever section applies; and (b) The laws of the group comply with section (3) of this rule. (3) The laws of the group shall provide that a distribution of funds derived from a policyholder dividend will not be reduced or denied to any member of the group: (a) Except for reasons stated in the laws of the group; and (b) Unless the insurer has given a copy of the stated reasons to the member or the policyholder before issuance of the policy for which the reduction or denial is made. (4) The Commissioner will approve dividend groups of persons or risks covered by an insurer for insurance other than workers’ compensation insurance only if: (a) The grouping is made up of homogeneous risks; (b) The grouping is made under the auspices of an organization which has existed for at least two years and was formed for purposes other than obtaining insurance; (c) The grouping is likely to bring about substantial improvement in loss prevention or claims handling; and (d) Information is filed with the Commissioner about eligibility for participation in the grouping and the system for allocating dividends among the participants. (5) Within 60 days of receiving a group dividend proposal, the Commissioner shall notify the insurer whether the proposal has been approved or disapproved, stating the basis for such action. Statutory/Other Authority: ORS 731.244 & 746.145 Statutes/Other Implemented: ORS 746.015(1), 746.075, 746.160(3) & 746.240 History: ID 5-1991, f. & cert. ef. 4-25-91 Reverted to IC 1-1984, f. 1-18-84, ef. 2-1-84 ID 16-1990(Temp), f. & cert. ef. 7-3-90 IC 1-1984, f. 1-18-84, ef. 2-1-84 IC 69, f. 7-20-76, ef. 1-1-77