Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 1 - MINIMUM STANDARDS AND BENEFITS FOR ACCIDENT AND HEALTH INSURANCE › Section 365:10-5-5 - Accident and sickness minimum standards for benefits

Current
				  through Vol. 41, No. 20, July 1, 2024
(a)
Minimum standards.
The
				  following minimum standards for benefits are prescribed for categories of
				  coverage noted in the following subsections. No individual policy or accident
				  and sickness insurance shall be delivered or issued for delivery in this site
				  which does not meet the required minimum standards for the specified categories
				  unless the Commissioner finds that such policies or contracts are approvable as
				  Limited Benefit Health insurance and the Outline of Coverage complied with the
				  appropriate outline in 365:10-5-5(j). Nothing in this section shall preclude
				  the issuance of any policy or contract combining two or more categories of
				  coverage.
(b)
General
				  rules.
(1) A "noncancellable",
				  "guaranteed renewable", or "noncancellable and guaranteed renewable" policy
				  shall not provide for termination of coverage of the spouse solely because of
				  the occurrence of an event specified for termination of coverage of the
				  insured, other than non-payment of premium. The policy shall provide that in
				  the event of the insured's death, the spouse of the insured, if covered under
				  the policy, shall become the insured.
(2) The terms "noncancellable", "guaranteed
				  renewable" or noncancellable and guaranteed renewable" shall not be used
				  without further explanatory language in accordance with the disclosure
				  requirements of
				  365:10-5-6(a)(1).
				  The terms "noncancellable" or "noncancellable and guaranteed renewable" may be
				  used only in a policy which the insured has the right to continue in force by
				  the timely payment of premiums set forth in the policy until the age of
				  sixty-five (65) or to eligibility for medicare, during which period the insurer
				  has no right to make unilaterally any change in a provision of the policy while
				  the policy is in force; provided, however, any accident and health or accident
				  and health only policy which provides for periodic payments, weekly or monthly,
				  for a specified period during the continuance of disability resulting from
				  accident or sickness, may provide that the insured has the right to continue
				  the policy only to age sixty (60) if, at age sixty (60), the insured has the
				  right to continue the policy in force at least to age sixty-five (65) while
				  actively or regularly employed. Except as provided above, the term "guaranteed
				  renewable" may be used only in a policy which the insured has the right to
				  continue in force by the timely payment of premiums until the age of sixty-five
				  (65) or to eligibility for medicare, during which period the insurer has no
				  right to make unilaterally any change in any provision of the policy while the
				  policy is in force, except that the insurer may make changes in premium rates
				  by classes. Provided however, any accident and health or accident only policy
				  which provides for periodic payments, weekly or monthly, for a specified period
				  during the continuance of disability resulting from accident or sickness may
				  provide that the insured has the right to continue the policy only to age sixty
				  (60) if, at age sixty (60), the insured has the right to continue the policy in
				  force at least to age sixty-five (65) while actively and regularly
				  employed.
(3) In a family policy
				  covering both husband and wife the age of the younger spouse must be used as
				  the basis for meeting the age and duration requirements of the definitions of
				  noncancellable "or guaranteed renewable". However, this requirement shall not
				  prevent termination of coverage of the older spouse upon attainment of the
				  stated age limit (e.g., age 65) so long as the policy may be continued in force
				  as to the younger spouse to the age or for the duration period as specified in
				  said definition.
(4) When accident
				  health and dismemberment coverage is part of the insurance coverage offered
				  under the contract, the insured shall have the option to include all insureds
				  under such coverage and not just the principal insured.
(5) If a policy contains a status type
				  military service exclusion or a provision which suspends coverage during
				  military service, the policy shall provide, upon receipt of written request,
				  for refund of premiums as applicable to such person on a pro rata
				  basis.
(6) In the event the insurer
				  cancels or refuses to renew, policies providing pregnancy benefits shall
				  provide for an extension of benefits as to pregnancy commencing while the
				  policy is in force and for which benefits would have been payable had the
				  policy remained in force.
(7)
				  Policies providing convalescent or extended care benefits following
				  hospitalization shall not condition such benefits upon admission to the
				  convalescent or extended care facility within a period of less than fourteen
				  (14) days after discharge from the hospital.
(8) Family coverage shall continue for any
				  dependent child who is incapable of self sustaining employment due to mental
				  retardation or physical handicap on the date that such child's coverage would
				  otherwise terminate under the policy due to the attainment of a specified age
				  limit for children, if the child is chiefly dependent on the insured for
				  support and maintenance. The policy may require that within 31 days of such
				  date the company receive due proof of such incapacity in order for the insured
				  to elect to continue the policy in force with respect to such child, or that a
				  separate converted policy be issued at the option of the insured or
				  policyholder.
(9) Any policy
				  providing coverage for the recipient in a transplant operation shall also
				  provide reimbursement of any medical expense of a live donor to the extent that
				  benefits remain and are available under the recipient's policy, after benefits
				  for the recipient's own expenses have been paid.
(10) A policy may contain a provision
				  relating to recurrent disabilities, provided however, that no such provision
				  shall specify that a recurrent disability be separated in a period greater than
				  six (6) months.
(11) Accidental
				  death and dismemberment benefits shall be payable if the loss occurs within
				  ninety (90) days from the date of the accident, irrespective of total
				  disability. Disability income benefits, if provided, shall not require the loss
				  to commence less than thirty (30) days after the date of accident, nor shall
				  any policy which the insurer cancels or refuses to renew require that it be in
				  force at the time disability commences if the accident occurred while the
				  policy was in force.
(12) Specific
				  dismemberment benefits shall not be in lieu of other benefits unless the
				  specific benefit equals or exceeds the other benefits.
(13) Any accident only policy providing
				  benefits which vary according to the type of accidental cause shall prominently
				  set forth in the outline of coverage the circumstances under which benefits are
				  payable which are less than the maximum amount payable under the
				  policy.
(14) Termination of the
				  policy shall be without prejudice to any continuous loss which commenced while
				  the policy was in force, but the extension of benefits beyond the period the
				  policy was in force may be predicated upon the continuous total disability of
				  the insured, limited to the duration of the policy benefit period, if any, of
				  payment of the maximum benefits.
(15) Any policy which does not meet the
				  prescribed minimum standards stated in this section which in the opinion of the
				  Department, is either experimental in nature or is demonstrated to be of a type
				  of coverage that will fulfill a reasonable need of the person or persons
				  insured, may be approved only as to categories prescribed by the
				  Department.
(16) Nothing in this
				  regulation shall preclude the issuance of any policy or outline of coverage
				  that combines two or more of the categories of coverage enumerated in (c)
				  through (i) of this paragraph.