reglab/statecodes huggingface dataset:
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3921 | Fraternal Benefit Societies › Section 3921.25 | Standards of Valuation for Certificates.

Effective:
January 1, 1997
Latest Legislation:
House Bill 468 - 121st General Assembly
(A) The standards of valuation for certificates that are delivered or issued for delivery in this state on or after January 1, 1997, but prior to January 1, 1998, shall be those standards that would have applied under the laws in effect on December 31, 1996.
(B) The minimum standards of valuation for certificates of life insurance, annuity and pure endowment certificates, total and permanent disability benefit certificates, accidental death benefit certificates, and noncancelable accident and health benefit certificates, that are delivered or issued for delivery in this state on or after January 1, 1998, shall comply with the valuation methods and standards, including interest assumptions, that are applicable to life insurers that issue policies containing like benefits.
(C) The superintendent of insurance may, in the superintendent's discretion, accept other standards for valuation if the superintendent finds that the reserves produced by such standards will not be less in the aggregate than reserves computed in accordance with the minimum valuation standards prescribed in this section. The superintendent may, in the superintendent's discretion, vary the standards of mortality applicable to all benefit contracts on substandard lives or other extra hazardous lives by any society authorized to do business in this state.
(D) Any society, with the consent of the supervising insurance official of its state of domicile and under any conditions that the superintendent may impose, may establish and maintain reserves on its certificates in excess of the reserves required, provided that the contractual rights of any benefit member are not affected by such action.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3921 | Fraternal Benefit Societies › Section 3921.26 | Annual Financial Statement - Valuation of Certificates.

Effective:
January 1, 1997
Latest Legislation:
House Bill 468 - 121st General Assembly
(A) Each fraternal benefit society transacting business in this state shall annually file with the superintendent of insurance a true statement of its financial condition, transactions, and affairs for the preceding calendar year. The statement shall be filed on or before the first day of March. The statement shall be in general form and content as approved by the national association of insurance commissioners for fraternal benefit societies, and as supplemented by additional information required by the superintendent.
(B) As part of the annual statement required under division (A) of this section, each society shall, on or before the first day of March, file with the superintendent a valuation of its certificates in force on the immediately preceding thirty-first day of December. The superintendent may, in the superintendent's discretion for cause shown, extend the deadline for filing the valuation for a period of not more than two calendar months. The valuation shall be prepared in accordance with the standards set forth in section 3921.25 of the Revised Code. The valuation and underlying data shall be certified by a qualified actuary or verified, at the expense of the society, by an actuary employed or appointed by the insurance regulatory authority of the society's state of domicile.
(C) If a society fails to comply with division (A) or (B) of this section, the superintendent shall impose a fine of one hundred dollars for each day the noncompliance continues. In addition, the superintendent shall issue an order requiring the society to cease doing business in this state until the society complies with this section. Notice of the order shall be mailed by regular mail, immediately after its issuance by the superintendent, to the society subject to the order.
(D) Any fine collected pursuant to division (C) of this section shall be paid into the state treasury to the credit of the department of insurance operating fund created under section 3901.021 of the Revised Code.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3921 | Fraternal Benefit Societies › Section 3921.27 | Renewal of License - Fee.

Effective:
January 1, 1997
Latest Legislation:
House Bill 468 - 121st General Assembly
Fraternal benefit societies that are authorized to transact business in this state on December 31, 1996, may continue such business until April 1, 1997. The authority of those societies and all societies licensed on or after January 1, 1997, may be renewed annually, but in all cases shall terminate on the first day of the succeeding April. However, a license so issued shall continue in full force and effect until a renewal of the license has been specifically refused. For each license or renewal the society shall pay the superintendent of insurance a fee of twenty-five dollars. A duly certified copy or duplicate of such license is prima facie evidence that the licensee is a fraternal benefit society within the meaning of this chapter.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3921 | Fraternal Benefit Societies › Section 3921.28 | Examination of Domestic and Foreign Societies.

Effective:
October 3, 2023
Latest Legislation:
House Bill 33 - 135th General Assembly
(A)(1) Each domestic fraternal benefit society and each applicant for a certificate of incorporation as a domestic fraternal benefit society shall be subject to examination by the superintendent of insurance in accordance with section 3901.07 of the Revised Code. Section 3901.07 of the Revised Code shall govern every aspect of the examination, including the circumstances under and frequency with which it is conducted, and the authority of the superintendent and any examiner or other person appointed by the superintendent.
(2)(a) A domestic fraternal benefit society shall be liable for the payment of any additional expense of an examination resulting from unreasonable delays by the society in fulfilling a request for documents or information by the examiner conducting the examination. A delay is deemed unreasonable if the examiner has made two separate unfulfilled requests for the same documents or information. A request for records or information from an examiner shall allow the fraternal benefit society a minimum of ten business days to fulfill the request.
(b) In the event of an unreasonable delay, the examiner shall notify the superintendent, who shall set a hearing, under Chapter 119. of the Revised Code, to determine if there has been an unreasonable delay because of the fraternal benefit society's response to a request for documents or information and to calculate the additional expense incurred by the superintendent as a result of the unreasonable delay.
(3) A summary of the examination of the superintendent and any recommendations or statements of the superintendent that accompany the report, shall be read at the first meeting of the board of directors or corresponding body of the society following the receipt thereof, and if directed so to do by the superintendent, shall also be read at the first meeting of the supreme legislative or governing body of the society following the receipt thereof. A copy of the report, recommendations, and statements of the superintendent shall be furnished by the society to each member of the board of directors or other governing body.
(B) Each foreign or alien fraternal benefit society transacting or applying for admission to transact business in this state shall be subject to examination by the superintendent in accordance with section 3901.07 of the Revised Code. Section 3901.07 of the Revised Code shall govern every aspect of the examination, including the circumstances under and frequency with which it is conducted, the authority of the superintendent and any examiner or other person appointed by the superintendent, the liability for the assessment of expenses incurred in conducting the examination, and the remittance of the assessment to the department of insurance operating fund.
Last updated October 3, 2023 at 12:25 PM
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3921 | Fraternal Benefit Societies › Section 3921.29 | Foreign or Alien Benefit Society License.

Effective:
January 1, 2013
Latest Legislation:
House Bill 341 - 129th General Assembly
No foreign or alien fraternal benefit society shall transact business in this state without a license issued by the superintendent of insurance. Any such society may be licensed to transact business in this state upon filing all of the following with the superintendent:
(A) A duly certified copy of its articles of incorporation;
(B) A copy of its bylaws certified by its secretary or corresponding officer;
(C) A written appointment of an agent as prescribed in section 3921.35 of the Revised Code;
(D) A statement of its business made under oath of its president and secretary or corresponding officers in a form prescribed by the superintendent and duly verified by an examination made by the supervising insurance official of its state of domicile or of any other state, district, territory, province, or country, which examination is satisfactory to the superintendent;
(E) Certification from the proper official of its state, district, territory, province, or country of domicile that the society is legally incorporated and licensed to transact business in that state, district, territory, province, or country;
(F) Copies of its certificate forms;
(G) A description of its investments that shows that its assets are invested in accordance with this chapter;
(H) Any other information the superintendent considers necessary.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3921 | Fraternal Benefit Societies › Section 3921.30 | Notice of Deficiency.

Effective:
January 1, 2013
Latest Legislation:
House Bill 341 - 129th General Assembly
If the superintendent of insurance finds, upon investigation, that a domestic fraternal benefit society has exceeded its powers, has failed to comply with any provision of this chapter, is not fulfilling its contracts in good faith, has a membership of less than four hundred after an existence of one year or more, or is conducting business fraudulently or in a manner hazardous to its members, creditors, the public, or the business, the superintendent shall issue a written notice to the society that sets forth the deficiency and the reasons for the superintendent's dissatisfaction, and that requires the society to correct the deficiency within thirty days after receipt of the notice. If the society fails to correct the deficiency within that thirty-day period, the superintendent shall commence an action against the society under sections 3903.01 to 3903.59 of the Revised Code.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3921 | Fraternal Benefit Societies › Section 3921.31 | Notice and Correction of Deficiency of Society.

Effective:
January 1, 2013
Latest Legislation:
House Bill 341 - 129th General Assembly
If the superintendent of insurance finds, upon investigation, that a foreign or alien fraternal benefit society transacting or applying to transact business in this state has exceeded its powers, has failed to comply with any provision of this chapter, is not fulfilling its contracts in good faith, or is conducting its business fraudulently or in a manner hazardous to its members or creditors or the public, the superintendent shall issue a written notice to the society that sets forth the deficiency and the reasons for the superintendent's dissatisfaction, and that requires the society to correct the deficiency within thirty days after receipt of the notice. If the society fails to correct the deficiency within that thirty-day period, the superintendent shall commence an action against the society under section 3903.71 of the Revised Code.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3921 | Fraternal Benefit Societies › Section 3921.32 | Liquidation.

Effective:
April 6, 2023
Latest Legislation:
House Bill 575 - 134th General Assembly
(A) Liquidation proceedings for a domestic fraternal benefit society shall be conducted consistent with the purposes of section 3903.02 of the Revised Code in a manner designed to conserve assets, limit liquidation expenses, and avoid any assessment of shares of a deficiency.
(B)(1) The liquidator shall attempt to transfer policies or certificates of the liquidating fraternal benefit society by way of assignment, assumption, or other means to another fraternal benefit society, whether domestic or foreign, or, if no fraternal benefit society will accept such a transfer, to another insurer. No fraternal benefit society shall be obligated to accept a transfer from a liquidating society.
(2) Upon the effective date of a transfer to an insurer that is not a fraternal benefit society and in consideration for the transfer, each member of the society and owner of a policy or certificate shall be deemed to agree to both of the following:
(a) That any terms of an insurance policy or certificate providing for the maintenance of the society's solvency or subjecting the policy or certificate to the bylaws of the society are null and void;
(b) Such other changes determined by the liquidator to be necessary to effectuate the transfer.
The assuming insurer shall endorse the policy or certificate accordingly.
(3) Any transfer shall constitute a novation of the liquidating fraternal benefit society's certificates effective upon the date of transfer.
Last updated January 31, 2023 at 5:41 PM
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3921 | Fraternal Benefit Societies › Section 3921.33 | Licensing of Agents - Exceptions.

Effective:
January 1, 2013
Latest Legislation:
House Bill 341 - 129th General Assembly
(A) Agents of fraternal benefit societies shall be licensed in the manner provided for agents of insurance companies in Chapter 3905. of the Revised Code, and shall be required to complete continuing education as set forth in section 3905.481 of the Revised Code starting with the twenty-four-month period commencing on the first day of January of 1999. However, no written or other examination shall be required of any person whose application for the original issuance of a license to represent a fraternal benefit society as its agent was filed with the superintendent of insurance prior to January 1, 1997.
(B) The following persons shall not be required to be licensed in accordance with division (A) of this section:
(1) Any regularly salaried officer, employee, or member of a licensed society who devotes substantially all of the person's services to activities other than the solicitation of fraternal insurance contracts from the public, and who receives for the solicitation of any such contracts no commission or other compensation directly dependent upon the amount of business obtained.
The officers, employees, and members described in division (B)(1) of this section also are not subject to examination by the superintendent under Chapter 3905. of the Revised Code.
(2) Any agent or representative of a society who devotes, or intends to devote, less than fifty per cent of the person's time to the solicitation and procurement of insurance contracts for the society. For purposes of division (B)(2) of this section, any person who, in the preceding calendar year, has received a commission or other compensation for soliciting and procuring any of the following contracts on behalf of an individual society is presumed to have devoted, or to have intended to devote, fifty per cent of the person's time to the solicitation and procurement of insurance contracts:
(a) Life insurance contracts that, in the aggregate, exceeded two hundred thousand dollars of coverage for all lives insured for the preceding calendar year;
(b) A permanent life insurance contract offering more than ten thousand dollars of coverage on an individual life;
(c) A term life insurance contract offering more than fifty thousand dollars of coverage on an individual life;
(d) Any insurance contracts other than life that the society may write and that insure the individual lives of more than twenty-five individuals;
(e) Any contract issued on a variable basis, as authorized by division (C) of section 3921.22 of the Revised Code.
(C) Notwithstanding division (B) of this section, any person selling an annuity contract under the authority of division (A)(3) of section 3921.16 of the Revised Code shall be licensed pursuant to Chapter 3905. of the Revised Code.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3921 | Fraternal Benefit Societies › Section 3921.331 | Effect of Child Support Default on License.

Effective:
March 22, 2001
Latest Legislation:
Senate Bill 180 - 123rd General Assembly
On receipt of a notice pursuant to section 3123.43 of the Revised Code, the superintendent of insurance shall comply with sections 3123.41 to 3123.50 of the Revised Code and any applicable rules adopted under section 3123.63 of the Revised Code with respect to a license issued pursuant to this chapter.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3921 | Fraternal Benefit Societies › Section 3921.34 | Application of Deceptive Act or Practice Prohibitions.

Effective:
January 1, 1997
Latest Legislation:
House Bill 468 - 121st General Assembly
Sections 3901.19 to 3901.26 of the Revised Code, and any other provision of Title XXXIX of the Revised Code that prohibits life or sickness and accident insurers from engaging in any unfair and deceptive act or practice in the business of insurance, continue on and after January 1, 1997, to apply to every fraternal benefit society authorized to do business in this state. However, nothing in any of those sections or provisions shall be construed as applying to or otherwise affecting either the right of any society to determine its eligibility requirements for membership or the offering of benefits exclusively to members or persons eligible for membership in the society by a subsidiary corporation or affiliated organization of the society.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3921 | Fraternal Benefit Societies › Section 3921.36 | False or Misleading Statements.

Effective:
January 1, 1997
Latest Legislation:
House Bill 468 - 121st General Assembly
(A) No person shall cause or permit to be made, issued, or circulated in any form any of the following:
(1) Any misrepresentation or false or misleading statement concerning the terms, benefits, or advantages of any fraternal insurance contract now issued or to be issued in this state, or the financial condition of any fraternal benefit society;
(2) Any false or misleading estimate or statement concerning the dividends or shares of surplus paid or to be paid by any society on any insurance contract;
(3) Any incomplete comparison of an insurance contract of one society with an insurance contract of another society or insurer for the purpose of inducing the lapse, forfeiture, or surrender of any insurance contract. A comparison of insurance contracts is incomplete if either of the following applies:
(a) The comparison does not compare in detail the gross rates, the gross rates less any dividend or other reduction allowed at the date of the comparison, any increase in cash values, and all the benefits provided by each contract for the possible duration of the contract as determined by the life expectancy of the insured;
(b) The comparison omits from consideration any benefit or value provided in the contract, any differences as to amount or period of rates, or any differences in limitations or conditions or other provisions that directly or indirectly affect the benefits.
In any determination of the incompleteness or misleading character of any comparison or statement, it is presumed that the insured has no knowledge of any of the contents of the contract involved.
(B) No person shall solicit membership for, or in any manner assist in procuring membership in, any society not licensed to do business in this state.
(C) No person shall purposely violate, or neglect or refuse to comply with, any provision of this chapter for which a penalty is not otherwise prescribed.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3921 | Fraternal Benefit Societies › Section 3921.37 | Exceptions to Chapter.

Effective:
January 1, 1997
Latest Legislation:
House Bill 468 - 121st General Assembly
(A) Nothing in this chapter shall be construed as applying to or otherwise affecting any of the following:
(1) Grand or subordinate lodges of societies, orders, or associations doing business in this state that provide benefits exclusively through local or subordinate lodges;
(2) Orders, societies, or associations that admit to membership only persons engaged in one or more crafts or hazardous occupations, in the same or similar lines of business, insuring only their own members, their families and descendants of members, and the ladies' societies or ladies' auxiliaries to such orders, societies, or associations;
(3) Domestic societies that limit their membership to employees of a particular city or town, designated firm, business house, or corporation that provide for a death benefit of not more than four hundred dollars or disability benefits of not more than three hundred fifty dollars to any person in any one year, or both;
(4) Domestic societies or associations of a purely religious, charitable, or benevolent description, that provide for a death benefit of not more than four hundred dollars or for disability benefits of not more than three hundred fifty dollars to any one person in any one year, or both.
(B) No society that, pursuant to division (A) of this section, is exempt from the requirements of this chapter, except any society described in division (A)(2) of this section, shall give or allow, or promise to give or allow, to any person any compensation for procuring new members.
(C) Every society that provides for benefits in case of death or disability resulting solely from accident, and that does not obligate itself to pay natural death or sick benefits, shall have all of the privileges and be subject to all the applicable provisions of this chapter, except for the provisions and rules relating to medical examination, valuations of benefit certificates, and incontestability.
(D) The superintendent of insurance may require from any society or association, by examination or otherwise, such information as will enable the superintendent to determine whether the society or association is exempt from the requirements of this chapter.
(E) Societies that, pursuant to division (A) of this section, are exempt from the requirements of this chapter shall also be exempt from all other provisions of the insurance laws of this state.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3921 | Fraternal Benefit Societies › Section 3921.38 | Review of Superintendent's Decisions and Findings.

Effective:
January 1, 1997
Latest Legislation:
House Bill 468 - 121st General Assembly
All decisions and findings of the superintendent of insurance made under the provisions of this chapter are subject to review by the proper proceedings in any court of competent jurisdiction in this state.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3921 | Fraternal Benefit Societies › Section 3921.99 | Penalty.

Effective:
January 1, 1997
Latest Legislation:
House Bill 468 - 121st General Assembly
(A) Whoever violates division (A) of section 3921.36 of the Revised Code or knowingly receives any compensation or commission by or in consequence of such violation, is guilty of a misdemeanor of the first degree, and shall in addition be liable for a civil penalty in the amount of three times the sum received by the violator as compensation or commission, which penalty may be sued for and recovered by any person or society aggrieved for the person's or society's own use and benefit in accordance with the provisions of civil practice.
(B) Whoever violates division (B) of section 3921.36 of the Revised Code shall be fined not less than fifty nor more than two hundred dollars.
(C) Whoever violates division (C) of section 3921.36 of the Revised Code shall be fined not more than two hundred dollars.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3922 | External Review › Section 3922.02 | Request for Review of Adverse Benefit Determination.

Effective:
September 6, 2012
Latest Legislation:
House Bill 341 - 129th General Assembly
(A) A covered person may make a request for an external review of an adverse benefit determination.
(B) All requests for external review shall be made in writing, including by electronic means, by the covered person to the health plan issuer within one hundred eighty days of the date of the final adverse benefit determination. However, in the case of an expedited external review under section 3922.09 of the Revised Code, the review may be requested orally.
(C) An adverse benefit determination shall be eligible for internal appeal or external review, regardless of the cost of the requested health care service related to the adverse benefit determination.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3922 | External Review › Section 3922.03 | Internal Appeal Processes; Review of Final Determination.

Effective:
September 6, 2012
Latest Legislation:
House Bill 341 - 129th General Assembly
(A) All health plan issuers shall implement an internal appeal process under which a covered person may appeal an adverse benefit determination. This process must be in compliance with the "Patient Protection and Affordable Care Act of 2010," Pub. L. 111-148, 124 Stat. 119, as amended, and the associated regulations, as well as any other applicable state laws or rules or federal regulations.
(B) Review of a final adverse benefit determination shall be through an external review under section 3922.08, 3922.09, or 3922.10 of the Revised Code.
(C) All health plan issuers shall provide notice to covered persons, pursuant to and in accordance with federal regulations, of all internal appeal processes, external review processes, the availability of any applicable office of health insurance assistance, ombudsman program, or other similar program in this state to assist consumers.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3922 | External Review › Section 3922.06 | Reconsideration by Issuer.

Effective:
September 6, 2012
Latest Legislation:
House Bill 341 - 129th General Assembly
Except for when an expedited request is made under section 3922.09 or 3922.10 of the Revised Code, an independent review organization shall forward upon receipt a copy of any information received from a covered person pursuant to division (D)(1) of section 3922.05 of the Revised Code, as well as any other information received from the covered person, to the health plan issuer.
Upon receipt of that information or the information described in division (K) of section 3922.10 of the Revised Code, a health plan issuer may reconsider its adverse benefit determination and provide coverage for the health service in question.
Reconsideration of an adverse benefit determination by a health plan issuer based upon receipt of information under this section shall not delay or terminate an external review.
If a health plan issuer reverses an adverse benefit determination under this section, the health plan issuer shall notify, in writing and within one business day of making such a decision, the covered person, the assigned independent review organization, and the superintendent of insurance.
Upon receipt of such a notification, the assigned independent review organization shall terminate the associated external review.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3922 | External Review › Section 3922.07 | Information Considered for Review.

Effective:
December 26, 2011
Latest Legislation:
House Bill 218 - 129th General Assembly
In addition to the information provided under division (D)(1)(b) of section 3922.05, division (B) of section 3922.08, division (C) of section 3922.09, and division (D) of section 3922.10 of the Revised Code, an assigned independent review organization, to the extent that such documents are available and appropriate, shall consider all of the following when conducting its review:
(A) The covered person's medical records;
(B) The attending health care professional's recommendation;
(C) Consulting reports from appropriate health care professionals and other documents submitted by the health plan issuer, covered person, or covered person's treating provider;
(D) The terms of coverage under the covered person's health benefit plan to ensure that the independent review organization's decision is not contrary to the terms of the plan;
(E) The most appropriate practice guidelines, including evidence-based standards, and practice guidelines developed by the federal government, and national or professional medical societies, boards, and associations;
(F) Any applicable clinical review criteria developed and used by the health plan issuer or its designated utilization review organization;
(G) The opinion of the independent review organization's clinical reviewer or reviewers after considering the other sources described in this section.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3922 | External Review › Section 3922.08 | Provisions Applicable to Standard Reviews; Timing;.

Effective:
December 26, 2011
Latest Legislation:
House Bill 218 - 129th General Assembly
(A) The provisions of this section apply only to standard reviews, which are not expedited and do not involve an experimental or investigational treatment.
(B) Within five days after the receipt of a request for an external review that is complete and valid, the health plan issuer shall provide to the assigned independent review organization all documents and information considered in making the adverse benefit determination.
(C) An external review shall not be delayed due to failure on the part of the health plan issuer to provide the information required under division (B) of this section.
(D)(1) An independent review organization may reverse an adverse benefit determination if the information required under division (B) of this section is not provided in the allotted time. The independent review organization may also grant a request from the health plan issuer for more time to provide the required information.
(2) If an adverse benefit determination is reversed under division (D)(1) of this section, the independent review organization shall notify, within one business day of making the decision, the covered person, the health plan issuer, and the superintendent of insurance.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3922 | External Review › Section 3922.11 | Review by Superintendent of Insurance.

Effective:
January 1, 2021
Latest Legislation:
House Bill 339 - 133rd General Assembly
(A) The superintendent of insurance shall establish and maintain a system for receiving and reviewing requests for external review for adverse benefit determinations where the determination by the health plan issuer was based on a contractual issue and did not involve a medical judgment or a determination based on any medical information, except for emergency services, as specified in division (C) of section 3922.05 of the Revised Code.
(B) A health plan issuer shall submit a request for external review pursuant to division (B) or (C) of section 3922.05 of the Revised Code to the superintendent, in accordance with any associated rules, policies, or procedures adopted by the superintendent of insurance.
(C) On receipt of a request from a health plan issuer, the superintendent shall consider whether the health care service is a service covered under the terms of the covered person's policy, contract, certificate, or agreement, except that the superintendent shall not conduct a review under this section unless the covered person has exhausted the health plan issuer's internal appeal process, pursuant to sections 3922.03 and 3922.04 of the Revised Code. The health plan issuer and covered person shall provide the superintendent with any information required by the superintendent that is in their possession and is germane to the review.
(D) Unless the superintendent is not able to do so because making the determination requires a medical judgment or a determination based on medical information, the superintendent shall determine whether the health care service at issue is a service covered under the terms of the covered person's contract, policy, certificate, or agreement. The superintendent shall notify the covered person and the health plan issuer of the superintendent's determination.
(E) If the superintendent notifies the health plan issuer that making the determination requires a medical judgment or a determination based on medical information, the health plan issuer shall initiate an external review under this chapter.
(F) If the superintendent determines that the health service is a covered service, the health plan issuer shall cover the service.
(G) If the superintendent determines that the health care service is not a covered service, the health plan issuer is not required to cover the service or afford the covered person an external review by an independent review organization.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3922 | External Review › Section 3922.12 | Effect of Decision.

Effective:
December 26, 2011
Latest Legislation:
House Bill 218 - 129th General Assembly
(A) An external review decision is binding on the health plan issuer except to the extent the health plan issuer has other remedies available under applicable state law, or unless the superintendent of insurance determines that, due to the facts and circumstances of an external review, a second external review is required.
(B) An external review decision is binding on the covered person except to the extent the covered person has other remedies available under applicable federal or state law, or unless the superintendent determines that, due to the facts and circumstances of an external review, a second external review is required.
(C) A covered person may not file a subsequent request for external review involving the same adverse benefit determination for which the covered person has already received an external review decision pursuant to this chapter, except in the event that new medical or scientific evidence is submitted to the health plan issuer.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3922 | External Review › Section 3922.13 | Accreditation of Independent Review Organizations.

Effective:
December 26, 2011
Latest Legislation:
House Bill 218 - 129th General Assembly
The superintendent shall accredit independent review organizations as prescribed by this section.
(A) The superintendent shall develop an application form to accredit and renew accreditation of an independent review organization.
(B) An independent review organization seeking to be accredited by the superintendent, or to renew its accreditation, shall submit the application form and include with the form all documentation and information necessary for the superintendent to determine if the independent review organization satisfies the minimum qualifications established under section 3922.14 of the Revised Code.
(C)(1) Except as provided in division (C)(2) of this section, an independent review organization is eligible for accreditation by the superintendent under this section only if it is accredited by a nationally recognized private accrediting entity that the superintendent has determined has accreditation standards that are equivalent to or exceed the minimum qualifications for independent review organizations under section 3922.14 of the Revised Code.
(2) The superintendent may approve independent review organizations that are not accredited by a nationally recognized private accrediting entity, if there are no acceptable nationally recognized private accrediting entities providing independent review organization accreditation.
(D) An independent review organization shall apply to renew its accreditation on an annual basis.
(E) If the superintendent determines that an independent review organization has lost its accreditation by a nationally recognized private accrediting entity or no longer satisfies the minimum requirements established under section 3922.14 of the Revised Code, the superintendent shall revoke the independent review organization's accreditation and shall remove the independent review organization from the list of independent review organizations approved to conduct external reviews.
(F) The superintendent shall maintain and periodically update a list of accredited independent review organizations.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3922 | External Review › Section 3922.15 | Qualifications for Clinical Reviewers.

Effective:
September 6, 2012
Latest Legislation:
House Bill 341 - 129th General Assembly
All clinical reviewers assigned by an independent review organization to conduct external reviews shall have the same license as the health care provider of the service in question, and shall be physicians or other appropriate health care providers who meet all of the following minimum qualifications:
(A) Be an expert in the treatment of the medical condition that is the subject of the external review;
(B) Be knowledgeable about the requested health care service through clinical experience, within the last three years, treating patients with the same, or a similar, medical condition, and, in the case of an external review of an experimental or investigational health care service, be an expert, through clinical experience in the last three years, in the treatment of the covered person's condition and have knowledge of the requested health care service;
(C) Hold a nonrestricted license in a state of the United States and, for physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the external review;
(D) Have no history of disciplinary actions or sanctions, including loss of staff privileges or participation restrictions, that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body that raise a question as to the clinical reviewer's physical, mental, or professional competence or moral character.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3922 | External Review › Section 3922.16 | Construction of Chapter; Limitations on Liability.

Effective:
September 6, 2012
Latest Legislation:
House Bill 341 - 129th General Assembly
(A) Nothing in this chapter shall be construed to create a cause of action against any of the following:
(1) An employer that provides health care benefits to employees through a health plan issuer;
(2) A clinical reviewer or independent review organization that participates in an external review under this chapter;
(3) A health plan issuer that provides coverage for benefits pursuant to this chapter.
(B) An independent review organization and any clinical reviewer an independent review organization uses in conducting an external review under this chapter is not liable in damages in a civil action for injury, death, or loss to person or property and is not subject to professional disciplinary action for making, in good faith, any finding, conclusion, or determination required to complete the external review.
(C) This section does not grant immunity from civil liability or professional disciplinary action to an independent review organization or clinical reviewer for an action that is outside the scope of authority granted under this chapter.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3922 | External Review › Section 3922.17 | Maintenance of Records; Reports.

Effective:
December 26, 2011
Latest Legislation:
House Bill 218 - 129th General Assembly
(A)(1) An independent review organization assigned pursuant to sections 3922.08, 3922.09, or 3922.10 of the Revised Code to conduct an external review shall maintain written records in accordance with the associated rules established by the superintendent, in the aggregate by state, and by the health plan issuer, on all external reviews requested and conducted during a calendar year.
Each independent review organization shall submit this information to the superintendent, upon request, in a report in the format specified by the superintendent that shall include, in the aggregate by state and for each health plan issuer, all of the following:
(a) The total number of requests for external review;
(b) The number of requests for external review resolved and, of those resolved, the number upholding and the number reversing an adverse benefit determination;
(c) The average length of time for a resolution;
(d) A summary of the types of requested health care services or cases for which an external review was sought;
(e) The number of external reviews that were terminated as the result of a reconsideration by the health plan issuer of an adverse benefit determination after the receipt of additional information from the covered person under section 3922.05 of the Revised Code;
(f) The costs associated with external reviews, including the amounts charged by the independent review organization to conduct the reviews;
(g) The medical specialty, or the type, of clinical reviewer used to conduct each external review, as related to the specific medical condition of the covered person;
(h) Any other information the superintendent may request or require.
(2) The independent review organization shall retain the written records required under division (A)(1) of this section for at least three years.
(B) A health plan issuer shall maintain written records on all requests made for an external review under this chapter and shall provide all such information as required by any associated rules, policies, or procedures adopted by the superintendent of insurance. A health plan issuer shall maintain written records on all requests for external review for at least three years.
(C) The superintendent shall compile and annually publish the information collected under this section and report the information to the governor, the speaker and minority leader of the house of representatives, the president and minority leader of the senate, and the chairs and ranking minority members of the house and senate committees with jurisdiction over health and insurance issues.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3922 | External Review › Section 3922.18 | Payment of Costs.

Effective:
December 26, 2011
Latest Legislation:
House Bill 218 - 129th General Assembly
The health plan issuer against which a request for a standard external review or an expedited external review is filed shall pay the cost of the external review, including the cost of any external review that is required at the direction of the superintendent.
If the superintendent determines that, due to the facts and circumstances of an external review, a second external review is required, the health plan issuer shall pay the costs of the second review.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3922 | External Review › Section 3922.20 | Admissibility of Written Decision or Medicare Reimbursement Standards.

Effective:
December 26, 2011
Latest Legislation:
House Bill 218 - 129th General Assembly
Consistent with the Rules of Evidence, a written decision or opinion prepared by an independent review organization under this chapter shall be admissible in any civil action related to the coverage decision that was the subject of the decision or opinion. The independent review organization's decision or opinion shall be presumed to be a scientifically valid and accurate description of the state of medical knowledge at the time it was written.
Consistent with the Rules of Evidence, any party to a civil action related to a plan's decision involving an investigational or experimental drug, device, or treatment may introduce into evidence any applicable medicare reimbursement standards established under Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3922 | External Review › Section 3922.21 | Confidentiality.

Effective:
December 26, 2011
Latest Legislation:
House Bill 218 - 129th General Assembly
(A) When a record containing information pertaining to the medical history, diagnosis, prognosis, or medical condition of a covered person is provided to the superintendent of insurance for any reason under this chapter or sections 1751.77 to 1751.87 of the Revised Code, regardless of the source, the superintendent shall maintain the confidentiality of the record. The record in the superintendent's possession is not a public record under section 149.43 of the Revised Code, except to the extent that information from the record is used in preparing reports under section 3922.17 of the Revised Code.
(B) Notwithstanding division (A) of this section, the superintendent may share a record that is the subject of this section in connection with the investigation or prosecution of any illegal or criminal activity with the chief deputy rehabilitator, the chief deputy liquidator, other deputy rehabilitators and liquidators, and any other person employed by, or acting on behalf of, the superintendent pursuant to Chapter 3901. or 3903. of the Revised Code, with other local, state, federal, and international regulatory and law enforcement agencies, with local, state, and federal prosecutors, and with the national association of insurance commissioners and its affiliates and subsidiaries, provided that the recipient agrees to maintain the confidential or privileged status of the confidential or privileged record and has authority to do so.
(C) Nothing in this section shall prohibit the superintendent from receiving records in accordance with section 3901.045 of the Revised Code.
(D) The superintendent may enter into agreements governing the sharing and use of records consistent with the requirements of this section.
(E) No waiver of any applicable privilege or claim of confidentiality in the records that are the subject of this section shall occur as a result of sharing or receiving records as authorized in divisions (B) and (C) of this section.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3922 | External Review › Section 3922.22 | Adoption of Rules.

Effective:
December 26, 2011
Latest Legislation:
House Bill 218 - 129th General Assembly
The superintendent may adopt rules under Chapter 119. of the Revised Code to carry out the purposes of this chapter and shall prescribe forms relating to notices, appeals, and requests for external review under this chapter.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3923 | Sickness and Accident Insurance › Section 3923.01 | Policy of Sickness and Accident Insurance Defined.

Effective:
November 24, 1995
Latest Legislation:
Senate Bill 150 - 121st General Assembly
As used in this chapter, "policy of sickness and accident insurance" includes any policy, contract, or certificate of insurance against loss or expense resulting from the sickness of the insured, or from the bodily injury or death of the insured by accident, or both, that is delivered, issued for delivery, renewed, or used in this state on or after the date occurring six months after the effective date of this amendment.
2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3923 | Sickness and Accident Insurance › Section 3923.011 | Sickness and Accident Insurance Definitions.

Effective:
January 9, 1961
Latest Legislation:
House Bill 1 - 104th General Assembly
As used in any policy of sickness and accident insurance delivered, issued for delivery, or used in this state, unless otherwise provided in the policy or in an indorsement thereon or in a rider attached thereto:
(A) "Total disability" means inability to perform the duties of any gainful occupation for which the insured is reasonably fitted by training, experience, and accomplishment.
(B) "Confinement to house" includes the activities of a convalescent not able to be gainfully employed.
(C) "Accidental death" means death by accident exclusively and independently of all other causes.