Chapter 743 — Health
and Life Insurance
2011 EDITION
HEALTH AND LIFE INSURANCE
INSURANCE
GENERAL PROVISIONS
743.010 Health
insurance policy and health benefit plan forms; rules
743.013 Disclosure
of differences in replacement health insurance policies; nonduplication
for persons 65 and older; rules
743.015 Filing
and approval of credit life and credit health insurance forms; filing of rates
743.018 Filing
of rates for life and health insurance; rules
743.019 Public
comment on proposed rates for health insurance
743.020 Rate
filing to include statement of administrative expenses; rules
743.024 Personal
insurance, insurable interest and beneficiaries
743.027 Consent
of individual required for life and health insurance; exceptions
743.028 Uniform
health insurance claim forms
743.030 Life
insurance for benefit of charity
743.039 Alteration
of application for life or health insurance
743.041 Payment
discharges insurer
743.043 Assignment
of policies
743.046 Exemption
of proceeds of individual life insurance other than annuities
743.047 Exemption
of proceeds of group life insurance
743.049 Exemption
of proceeds of annuity policies; assignability of
rights
743.050 Exemption
of proceeds of health insurance
743.053 Prohibition
on requirement that death or dismemberment occur in less than 180 days after
accident
743.056 Insurer
may not refuse to defend or pay claim based on provider’s disclosure of adverse
event
743.061 Uniform
standards for health care financial and administrative transactions; rules
743.062 Stakeholder
work group to recommend uniform standards
743.064 Coordination
with Oregon Health Authority concerning uniform standards; Department of Human
Services to be subject to standards
743.082 Selling
and leasing of provider panels by contracting entity; definitions
743.083 Registration
of contracting entity
743.085 Third
party contracts for leasing of provider panels; requirements
743.086 Additional
requirements for third party contracts
POLICY LANGUAGE SIMPLIFICATION
743.100 Short
title
743.101 Purpose
743.103 Definitions
for ORS 743.100 to 743.109
743.104 Scope
of ORS 743.100 to 743.109
743.106 Reading
ease standards for life and health insurance policies
743.107 When
director may authorize lower standards
743.109 Approval
of certain policy forms containing specified provisions; conditions for
approval
INDIVIDUAL LIFE INSURANCE AND ANNUITIES
(Generally)
743.150 Scope
of ORS 743.150, 743.153 and 743.156
743.153 Statement
of benefits
743.154 Acceleration
of death benefits; rules
743.156 Statement
of premium
(Individual Life Insurance Policies)
743.159 Scope
of ORS 743.162 to 743.243
743.162 Payment
of premium
743.165 Grace
period
743.168 Incontestability
743.171 Incontestability
and limitation of liability after reinstatement
743.174 Entire
contract
743.177 Statements
of insured
743.180 Misstatement
of age
743.183 Dividends
743.186 Policy
loan
743.187 Maximum
interest rate on policy loan; adjustable interest rate
743.189 Reinstatement
743.192 Payment
of claim; payment of interest upon failure to pay proceeds
743.195 Installment
payments
743.198 Title
743.201 Beneficiary
of industrial policies
743.204 Standard
Nonforfeiture Law for Life Insurance; applicability
743.207 Required
provisions relating to nonforfeiture
743.210 Determination
of cash surrender values; applicability to certain policies
743.213 Determination
of paid-up nonforfeiture benefits
743.215 Calculation
of adjusted premiums
743.216 Adjusted
premiums; applicability
743.218 Requirements
for determination of future premium amounts or minimum values
743.219 Supplemental
rules for calculating nonforfeiture benefits
743.221 Cash
surrender values upon default in premium payment
743.222 Policy
benefits and premiums that shall be disregarded in calculating cash surrender
values and paid-up nonforfeiture benefits
743.225 Prohibited
provisions
743.228 Acts
of corporate insured or beneficiary with respect to policy
743.230 Variable
life policy provisions
743.231 “Profit-sharing
policy” defined
743.234 “Charter
policy” or “founders policy” defined
743.237 “Coupon
policy” defined
743.240 Profit-sharing,
charter or founders policies prohibited
743.243 Restrictions
on form of coupon policy
743.245 Variable
life insurance policy provisions
743.247 Notice
to variable life insurance policyholders
(Individual Annuity and Pure Endowment
Policies)
743.252 Scope
of ORS 743.255 to 743.273
743.255 Grace
period for annuities
743.258 Incontestability
743.261 Entire
contract
743.264 Misstatement
of age or sex
743.267 Dividends
743.268 Advancement
of policy loans
743.269 Periodic
payments for period certain
743.270 Reinstatement
743.271 Periodic
stipulated payments on variable annuities
743.272 Computing
benefits
743.273 Standard
provisions of reversionary annuities
743.275 Standard
Nonforfeiture Law for Individual Deferred Annuities;
application
743.278 Required
provisions in annuity policies; exception
743.284 Computation
of benefits
743.287 Commencement
of annuity payments at optional maturity dates; calculation of benefits
743.290 Notice
of nonpayment of certain benefits to be included in annuity policy
743.293 Minimum
forfeiture amounts for annuity policies; rules
743.295 Effect
of certain life insurance and disability benefits on minimum nonforfeiture amounts
GROUP LIFE INSURANCE
743.303 Requirements
for issuance of group life insurance policies
743.306 Required
provisions in group life insurance policies
743.309 Nonforfeiture provisions
743.312 Grace
period
743.315 Incontestability
743.318 Application;
representations by policyholders and insureds
743.321 Evidence
of insurability
743.324 Misstatement
of age
743.327 Payments
under policy; payment of interest upon failure to pay proceeds
743.330 Issuance
of certificates
743.333 Termination
of individual coverage
743.336 Termination
of policy or class of insured persons
743.339 Death
during period for conversion to individual policy
743.342 Statement
furnished to insured under credit life insurance policy
743.345 Assignability of group life policies
743.348 Certain
sales practices prohibited
743.351 Eligibility
of association to be group life policyholder; rules
743.354 Requirements
for certain group life policies issued to trustees of certain funds; rules
743.356 Continuing
coverage upon replacement of group life policy
743.358 Borrowing
by certificate holders under group life policy
743.360 Alternative
group life insurance coverage
CREDIT LIFE AND CREDIT HEALTH INSURANCE
743.371 Definitions
for credit life and credit health insurance provisions
743.372 Applicability
of credit life and credit health insurance provisions
743.373 Forms
of credit life and credit health insurance
743.374 Limits
on amount of credit life insurance
743.375 Limit
on amount of credit health insurance
743.376 Duration
of credit life and credit health insurance
743.377 Credit
life and credit health insurance policy or group certificate; contents;
delivery of policy, certificate or copy of application
743.378 Charges
and refunds to debtor
743.379 Status
of remuneration to creditor
743.380 Claim
report and payment
HEALTH INSURANCE
(Individual)
743.402 Exceptions
to individual health insurance policy requirements
743.405 General
requirements
743.408 Mandatory
provisions
743.411 Entire
contract; changes
743.414 Time
limit on certain defenses; incontestability
743.417 Grace
period
743.420 Reinstatement
743.423 Notice
of claim
743.426 Claim
forms
743.429 Proofs
of loss
743.432 Time
of payment of claims
743.435 Payment
of claims
743.438 Physical
examinations and autopsy
743.441 Legal
actions
743.444 Change
of beneficiary
743.447 Optional
provisions
743.450 Change
of occupation
743.453 Misstatement
of age
743.456 Other
insurance in same insurer
743.459 Insurance
with other insurers; expense incurred benefits
743.462 Insurance
with other insurers; other than expense incurred benefits
743.465 Relation
of earnings to insurance
743.468 Unpaid
premium
743.471 Cancellation
743.472 Permissible
reasons for cancellation or refusal to renew
743.474 Conformity
with state statutes
743.477 Illegal
occupation
743.483 Arrangement
of provisions
743.486 Scope
of term “insured” in statutory policy provisions
743.489 Extension
of coverage beyond policy period; effect of misstatement of age
743.492 Policy
return and premium refund provision
743.495 Use
of terms “noncancelable” or “guaranteed renewable”;
synonymous terms
743.498 Statement
in policy of cancelability or renewability
743.499 Notice
to policyholder required for cancellation or nonrenewal of health benefit plan;
effect of failure to give notice
(Group and Blanket)
743.522 “Group
health insurance” described
743.523 Certain
sales practices prohibited
743.524 Eligibility
of association to be group health policyholder; rules
743.526 Determination
of whether trustees are policyholders; consequences; rules
743.527 When
group health insurance policies to continue in effect upon payment of premium
by insured individual
743.528 Required
provisions in group health insurance policies
743.529 Continuation
of benefits after termination of group health insurance policy; rules
743.530 Continuation
of benefits after injury or illness covered by workers’ compensation
743.531 Direct
payment of hospital and medical services; rate limitations
743.533 Leased
workers; offering group health insurance
743.534 “Blanket
health insurance” defined
743.537 Required
provisions for blanket health insurance policies
743.540 Application
and certificates not required for blanket health insurance policies
743.543 Payment
of benefits under blanket health insurance policies
743.546 Exemption
of policy form approval for blanket health insurance policies
743.549 Restriction
on reduction of benefits provisions in group and blanket health insurance policies
743.550 Student
health insurance
743.552 Guidelines
for application of ORS 743.549; rules
743.560 Minimum
grace period; notice upon termination of policy; effect of failure to notify
743.562 Applicability
of ORS 743.560
743.565 Separate
notice to policyholder required before cancellation of individual or group
health insurance policy for nonpayment of premium
743.566 Rules
for certain notice requirements
(Continuation)
743.600 Availability
of continued coverage under group policy for surviving, divorced or separated
spouse 55 or older
743.601 Procedure
for obtaining continuation of coverage under ORS 743.600
743.602 Premium
for continuation of coverage under ORS 743.600; termination of right to
continuation
743.610 Continuation
of coverage under group policy upon termination of membership in group health
insurance policy; applicability of waiting period to rehired employee
(Long Term Care)
743.650 Long
Term Care Insurance Act; purpose; application
743.652 Definitions
for ORS 743.650 to 743.665
743.653 Prohibition
on certain policies
743.655 Rules;
disclosure; contents of policy
743.656 Eligibility
for benefits; providers required to be covered
743.662 Rescission
of policy and denial of claims
743.664 Offer
of nonforfeiture benefit; rules
743.665 Prompt
pay requirements; rules
(Medicare Supplement)
743.680 Definitions
for ORS 743.680 to 743.689
743.682 Application
of ORS 743.680 to 743.689
743.683 Policy
contents; standards for benefit and claims payments; rules
743.684 Filing
of policy; loss ratio standards; insurance producer compensation
743.685 Outline
of coverage; information brochure; rules
743.686 Right
to return of policy; premium refund
743.687 Advertising
743.688 Rules
743.689 Director’s
authority upon violation of ORS 743.680 to 743.689
(Small Employer, Group, Individual and Portability
Health Insurance, Generally)
743.730 Definitions
for ORS 743.730 to 743.773
743.731 Purposes
743.733 Issuance
of group health benefit plan to affiliated group of employers; determination of
number of employees for purpose of determining eligibility as small employer
743.734 Group
health benefit plans subject to provisions of specified laws; exemptions
743.736 Requirement
to offer basic health benefit plans to small employers; approval of plans and
forms; offering of plan by carriers; exceptions
743.737 Requirements
for small employer health benefit plans
743.745 Requirements
for basic health benefit plans; director’s authority to regulate portability,
small group and individual plans; standard health statement for late enrollees;
allowable preexisting condition exclusions
743.748 Submission
of information by carriers offering health benefit plans
743.749 Certifications
and disclosure of coverage
743.751 Use
of health statements in group health benefit plans
743.752 Coverage
in group health benefit plans; consideration of prospective enrollee health
status restricted; effect of discontinuing offer of plans; exceptions; coverage
by multiple employer welfare arrangements
743.754 Requirements
for group health benefit plans
743.757 Health
benefit coverage for guaranteed association
743.758 Implementation
of federal laws; rules
743.760 Approval
of portability plans; offering of plans by carriers; required provisions;
actuarial certification
743.761 Satisfaction
of requirements of ORS 743.760 by carrier offering individual health benefit
plans; rules
743.764 Preventive
health services; coverage; cost sharing
743.766 Use
of health statements in individual health benefit plans; preexisting condition
exclusions; eligibility to apply for Oregon Medical Insurance Pool; renewal;
discontinuation of coverage
743.767 Premium
rates for individual health benefit plans
743.769 Carrier
marketing of individual health benefit plans; rules; duties of carrier
regarding applications; effect of discontinuing offer of plans
743.773 Rules
for ORS 743.766 to 743.769
743.775 Submission
of information by carriers offering individual health benefit plans
743.777 Electronic
administration; discounted rates; requirements
743.787 Definitions
for ORS 743.788
743.788 Prescription
drug identification card
743.790 Rules
for prescription drug identification cards
MISCELLANEOUS
743.801 Definitions
743.803 Medical
services contract provisions; nonprovider party
prohibitions; future contracts
743.804 Required
notices to applicants and enrollees; grievances, internal appeals and external
reviews
743.806 Utilization
review requirements for medical services contracts to which insurer not party
743.807 Utilization
review requirements for insurers offering health benefit plan
743.808 Requirements
for insurers that require designation of participating primary care physician;
exceptions
743.811 Applicability
743.814 Requirements
for insurers offering managed health insurance; quality assessment; rules
743.817 Requirements
for insurers offering managed health or preferred provider organization
insurance; rules; opportunity to participate
743.818 Data
reporting
743.819 Reporting
requirements; rules
743.821 Required
managed health insurance contract provision; enrollee liability
743.822 Requirement
to offer bronze and silver plans; rules
743.823 Enforcement
of Newborns’ and Mothers’ Health Protection Act of 1996
743.824 Cash
dividends for healthy behaviors
743.826 Requirements
for catastrophic plans
743.827 Health
Care Consumer Protection Advisory Committee
743.829 Decisions
regarding health care facility length of stay, level of care and follow-up care
743.831 Consortium
established; managed health care performance
743.834 Insurer
prohibited practices; patient communication and referral
743.837 Prior
authorization requirements
743.839 Disclosure
of information
743.842 Emergency
eye care services without referral from primary care provider
RIGHTS OF ENROLLEES
743.845 Designation
of women’s health care provider as primary care provider; direct access to
women’s health care provider
743.847 Medicaid
not considered in coverage eligibility determination; claims for services paid
for by medical assistance; prohibited ground for denial of enrollment of child;
insurer duties
743.854 Continuity
of care
743.856 Referrals
to specialists
743.857 External
review; rules
743.858 Director
to contract with independent review organizations to provide external review;
rules
743.859 Notice
to enrollee of right to sue if insurer does not follow decision of independent
review organization
743.861 Enrollee
application for external review; when enrollee deemed to have exhausted
internal appeal
743.862 Duties
of independent review organizations; expedited reviews
743.863 Civil
penalty for failure to comply by insurer that agreed to be bound by decision
743.864 Private
right of action
743.871 Definitions
for ORS 743.871 to 743.893
743.874 Estimate
of costs for in-network procedure or service
743.876 Estimate
of costs for out-of-network procedure or service
743.878 Submission
of methodology used to determine insurer’s allowable charges
743.883 Alternative
mechanism for disclosure of costs and charges
743.893 Rules
743.894 Rescinding
coverage; permissible bases; notice; rules
PAYMENT OF CLAIMS
743.911 Payment
or denial of health benefit plan claims; rules
743.912 Refund
of paid claims
743.913 Interest
on unpaid claims
743.917 Underpayment
of claims
743.918 Claims
submitted during credentialing period
ASSESSMENT ON CLAIMS ADMINISTERED BY
PUBLIC EMPLOYEES’ BENEFIT BOARD
743.951 Payment
procedures; right to hearing
ASSESSMENT ON PREMIUMS
743.960 Definitions
for ORS 743.960 and 743.961
743.961 Payment
procedures
743.965 Incorrect
payments; right to hearing
743.990 Penalties
743.003 [1967
c.359 §335; renumbered 742.001 in 1989]
743.006
[Formerly 736.300; renumbered 742.003 in 1989]
743.009 [1967
c.359 §337; 1969 c.336 §11; 1973 c.608 §1; renumbered 742.005 in 1989]
GENERAL PROVISIONS
743.010 Health insurance policy and health
benefit plan forms; rules. In addition to all other powers
of the Director of the Department of Consumer and Business Services with
respect thereto, the director may issue rules with respect to policy forms and
health benefit plan forms described in ORS 742.005 (6)(a) and (b):
(1)
Establishing minimum benefit standards;
(2)
Requiring the ratio of benefits to premiums to be not less than a specified
percentage in order to be considered reasonable, and requiring the periodic
filing of data that will demonstrate the insurer’s compliance; and
(3)
Establishing requirements intended to discourage duplication or overlapping of
coverage and replacement, without regard to the advantage to policyholders, of
existing policies by new policies. [1979 c.857 §2; 1997 c.96 §1; 1999 c.987 §4a]
743.011 [1985
c.827 §2; repealed by 1989 c.255 §15]
743.012 [1967
c.359 §338; 1989 c.700 §13; renumbered 742.007 in 1989]
743.013 Disclosure of differences in
replacement health insurance policies; nonduplication
for persons 65 and older; rules. (1) The
Director of the Department of Consumer and Business Services shall adopt by
rule requirements for disclosure by group and individual health insurers to individual
and group health insurance policyholders the difference between coverage under
the existing policy and coverage being offered to replace that coverage.
(2)
The provisions of this section do not apply to disability income insurance.
(3)
The director shall adopt by rule requirements for nonduplication
and replacement of major medical, Medicare supplement, long term care and
special illness policies for applicants 65 years of age and older. The
insurance producer shall offer to compare for any applicants 65 years of age
and older the applicant’s existing policy or policies and coverage being
offered to replace or supplement the applicant’s existing coverage. [1989 c.474
§2; 2003 c.364 §106]
743.015 Filing and approval of credit life
and credit health insurance forms; filing of rates.
(1) All credit life and credit health insurance policies subject to ORS 743.371
to 743.380, and all certificates of insurance, notices of proposed insurance,
applications for insurance, indorsements and riders
used in connection with such kinds of policies, delivered or issued for
delivery in this state and the schedules of premium rates pertaining thereto
shall be filed with the Director of the Department of Consumer and Business
Services. Such forms are subject to approval, disapproval or withdrawal of
approval by the director as provided in ORS 742.003, 742.005 and 742.007.
(2)
An insurer may revise the schedules of premium rates from time to time and
shall file the revised schedules with the director. An insurer may not issue
any credit life or credit health insurance policy for which the premium rate
exceeds that determined by the schedules of the insurer as then on file with
the director.
(3)
If a group policy of credit life or credit health insurance has been or is
delivered in another state, the insurer shall file only the group certificate,
the individual application and the notice of proposed insurance delivered or
issued for delivery in this state as specified in ORS 743.377 (2) and (4). The
director shall approve the group certificate, the individual application and
the notice of proposed insurance if the forms conform with the requirements
specified in ORS 743.377 (2) and (4) and the schedules of premium rates
applicable to the insurance evidenced by the certificate or notice are not in
excess of the insurer’s schedules of premium rates filed with the director. [Formerly
739.595; 1969 c.336 §12; 1971 c.231 §20; 2005 c.185 §3]
743.018 Filing of rates for life and
health insurance; rules. (1) Except for group life and
health insurance, and except as provided in ORS 743.015, every insurer shall
file with the Director of the Department of Consumer and Business Services all
schedules and tables of premium rates for life and health insurance to be used
on risks in this state, and shall file any amendments to or corrections of such
schedules and tables. Premium rates are subject to approval, disapproval or
withdrawal of approval by the director as provided in ORS 742.003, 742.005 and
742.007.
(2)
Except as provided in ORS 743.737 and 743.760 and subsection (3) of this
section, a rate filing by a carrier for any of the following health benefit
plans subject to ORS 743.730 to 743.773 shall be available for public
inspection immediately upon submission of the filing to the director:
(a)
Health benefit plans for small employers.
(b)
Portability health benefit plans.
(c)
Individual health benefit plans.
(3)
The director may by rule:
(a)
Specify all information a carrier must submit as part of a rate filing under
this section; and
(b)
Identify the information submitted that will be exempt from disclosure under
this section because the information constitutes a trade secret and would, if
disclosed, harm competition.
(4)
The director, after conducting an actuarial review of the rate filing, may
approve a proposed premium rate for a health benefit plan for small employers
or for an individual health benefit plan if, in the director’s discretion, the
proposed rates are:
(a)
Actuarially sound;
(b)
Reasonable and not excessive, inadequate or unfairly discriminatory; and
(c)
Based upon reasonable administrative expenses.
(5)
In order to determine whether the proposed premium rates for a health benefit
plan for small employers or for an individual health benefit plan are reasonable
and not excessive, inadequate or unfairly discriminatory, the director may
consider:
(a)
The insurer’s financial position, including but not limited to profitability,
surplus, reserves and investment savings.
(b)
Historical and projected administrative costs and medical and hospital
expenses.
(c)
Historical and projected loss ratio between the amounts spent on medical
services and earned premiums.
(d)
Any anticipated change in the number of enrollees if the proposed premium rate
is approved.
(e)
Changes to covered benefits or health benefit plan design.
(f)
Changes in the insurer’s health care cost containment and quality improvement
efforts since the insurer’s last rate filing for the same category of health
benefit plan.
(g)
Whether the proposed change in the premium rate is necessary to maintain the
insurer’s solvency or to maintain rate stability and prevent excessive rate
increases in the future.
(h)
Any public comments received under ORS 743.019 pertaining to the standards set
forth in subsection (4) of this section and this subsection.
(6)
With the written consent of the insurer, the director may modify a schedule or
table of premium rates filed in accordance with subsection (1) of this section.
(7)
The requirements of this section do not supersede other provisions of law that
require insurers, health care service contractors or multiple employer welfare
arrangements providing health insurance to file schedules or tables of premium
rates or proposed premium rates with the director or to seek the director’s
approval of rates or changes to rates. [1967 c.359 §340; 2007 c.391 §1; 2009
c.595 §31]
Note:
Additions by chapter 322, Oregon Laws 2011, to the series 743.730 to 743.773,
which become operative January 2, 2014, expand the series to 743.730 to
743.773, 743.822 and 743.826. See sections 1, 2 [743.822 (2)], 3 [743.822 (1)],
4 [743.826] and 6, chapter 322, Oregon Laws 2011. See Preface to Oregon Revised
Statutes for further explanation.
743.019 Public comment on proposed rates
for health insurance. (1) When an insurer files a
schedule or table of premium rates for individual, portability or small
employer health insurance under ORS 743.018, the Director of the Department of
Consumer and Business Services shall open a 30-day public comment period on the
rate filing that begins on the date the insurer files the schedule or table of
premium rates. The director shall post all comments to the website of the
Department of Consumer and Business Services without delay.
(2)
The director shall give written notice to an insurer approving or disapproving
a rate filing or, with the written consent of the insurer, modifying a rate
filing submitted under ORS 743.018 no later than 10 business days after the
close of the public comment period. The notice shall comply with the
requirements of ORS 183.415. [2009 c.595 §28]
Note:
743.019 and 743.020 were added to and made a part of ORS chapter 743 by
legislative action but were not added to any smaller series therein. See
Preface to Oregon Revised Statutes for further explanation.
743.020 Rate filing to include statement
of administrative expenses; rules. An insurer
licensed by the Department of Consumer and Business Services shall include in
any rate filing under ORS 743.018 with respect to individual and small employer
health insurance policies a statement of administrative expenses in the form
and manner prescribed by the department by rule. The statement must include,
but is not limited to:
(1)
A statement of administrative expenses on a per member per month basis; and
(2)
An explanation of the basis for any proposed premium rate increases or
decreases. [2009 c.595 §29]
Note: See
note under 743.019.
743.021 [1967
c.359 §341; 1971 c.231 §21; 1973 c.525 §1; renumbered 742.009 in 1989]
743.024 Personal insurance, insurable interest
and beneficiaries. (1) Any individual of competent
legal capacity may procure or effect an insurance policy on the individual’s
own life or body for the benefit of any person. However, except as provided in
ORS 743.030, no person shall procure or cause to be procured any insurance
policy upon the life or body of another unless the benefits under such policy
are payable to the individual insured or the personal representatives of the
individual, or to a person having, at the time such policy was entered into, an
insurable interest in the individual insured.
(2)
If the beneficiary, assignee or other payee under any policy made in violation
of this section receives from the insurer any benefits thereunder
accruing upon the death, disablement or injury of the individual insured, the
individual insured or the individual’s executor or administrator, as the case
may be, may maintain an action to recover such benefits from the person so
receiving them.
(3)
An insurer shall be entitled to rely upon all statements, declarations and
representations made by an applicant for insurance relative to the matter of
insurable interest. No insurer shall incur legal liability, except as set forth
in the policy, by virtue of any untrue statements, declarations or
representations so relied upon in good faith by the insurer.
(4)
This section does not apply to annuity policies. [1967 c.359 §342]
743.027 Consent of individual required for
life and health insurance; exceptions. A life or
health insurance policy upon an individual, except a policy of group life
insurance or of group or blanket health insurance, may not be made or
effectuated unless at the time of the making of the policy the individual
insured, being of competent legal capacity to contract, applies therefor or has consented thereto in writing, except in the
following cases:
(1)
A spouse may effectuate such insurance upon the other spouse.
(2)
Any person having an insurable interest in the life of a minor, or any person
upon whom a minor is dependent for support and maintenance, may effectuate
insurance upon the life of or pertaining to such minor.
(3)
Family policies may be issued insuring any two or more members of a family on
an application signed by either parent, a stepparent, or by a husband or wife.
(4)
A person may effectuate insurance that provides for the funeral expenses of an
adult who is dependent upon the person for support and maintenance.
(5)
A person may effectuate insurance that provides for the funeral expenses of an
adult if the person:
(a)
Is closely related to the adult by blood or by law or has a substantial
interest in the adult engendered by love and affection; and
(b)
Has a lawful and substantial interest in having the life, health and bodily
safety of the adult continue. [1967 c.359 §342a; 1991 c.182 §2; 2009 c.331 §1]
743.028 Uniform health insurance claim
forms. The Director of the Department of
Consumer and Business Services shall prescribe uniform health insurance claim
forms which shall be used by all insurers transacting health insurance in this
state and by all state agencies that require health insurance claim forms for
their records. [1973 c.109 §2]
743.030 Life insurance for benefit of
charity. (1) Life insurance policies may be
effected although the person paying the consideration has no insurable interest
in the life of the person insured if a charitable, benevolent, educational or
religious institution is designated irrevocably as the beneficiary.
(2)
In making such policies the person paying the premium shall make and sign the
application therefor as owner. The application also
must be signed by the person whose life is to be insured. Such a policy shall
be valid and binding between and among all of the parties thereto.
(3)
The person paying the consideration for such insurance shall have all rights
conferred by the policy to loan value at any time during the premium-paying
period, but not at maturity, notwithstanding such person has no insurable
interest in the life of the person insured. [Formerly 739.420]
743.033 [1967
c.359 §344; renumbered 742.011 in 1989]
743.036
[Formerly 736.330; 1973 c.823 §149; repealed by 1973 c.827 §83]
743.037 [1973
c.521 §2; renumbered 743.721 in 1989]
743.039 Alteration of application for life
or health insurance. (1) An application for a life
insurance policy may not provide for alterations by any person other than the
applicant in either the application or the policy to be issued thereon with
respect to the amount of insurance, classification of risk, plan of insurance
or the benefits unless the application contains a statement that no such
changes are effective until approved in writing by the applicant.
(2)
No alteration of any written application for any health insurance policy shall
be made by any person other than the applicant without the written consent of
the applicant, except that insertions may be made by the insurer, for
administrative purposes only, in such manner as to indicate clearly that such
insertions are not to be ascribed to the applicant. [1967 c.359 §346]
743.041 Payment discharges insurer.
Whenever the proceeds of or payments under a life or health insurance policy
become payable in accordance with the terms of such policy, or the exercise of
any right or privilege under such policy, and the insurer makes payment in
accordance with the terms of the policy or in accordance with any written
assignment of the policy, the person so designated as being entitled to the
proceeds or payments shall be entitled to receive them and to give full acquittance therefor, and such
payments shall fully discharge the insurer from all claims under the policy
unless, before payment is made, the insurer has received at its home office
written notice by or on behalf of some other person that such other person
claims to be entitled to such proceeds or payments or some interest in the
policy. [Formerly 743.084]
743.042 [1967
c.359 §347; 1985 c.465 §1; renumbered 742.013 in 1989]
743.043 Assignment of policies.
A policy may be assignable or not assignable, as provided by its terms. Subject
to its terms relating to assignability, any life or
health insurance policy, under the terms of which the beneficiary may be
changed upon the sole request of the insured or owner, may be assigned either
by pledge or transfer of title, by an assignment executed by the insured or
owner alone and delivered to the insurer, whether or not the pledgee or assignee is the insurer. Any such assignment
shall entitle the insurer to deal with the assignee as the owner or pledgee of the policy in accordance with the terms of the
assignment, until the insurer has received at its home office written notice of
termination of the assignment or pledge, or written notice by or on behalf of
some other person claiming some interest in the policy in conflict with the
assignment. [Formerly 743.087]
743.045
[Formerly 736.305; 1971 c.231 §22; 1985 c.465 §2; renumbered 742.016 in 1989]
743.046 Exemption of proceeds of
individual life insurance other than annuities.
(1) When a policy of insurance is effected by any person on any person’s own
life or on another life in favor of some person other than that person having
an insurable interest in the life insured, the lawful beneficiary thereof,
other than that person or that person’s legal representative, is entitled to
its proceeds against the creditors or representatives of the person effecting
the policy.
(2)
The person to whom a policy of life insurance is made payable may maintain an
action thereon in the person’s own name.
(3)
A policy of life insurance payable to a beneficiary other than the estate of
the insured, having by its terms a cash surrender value available to the
insured, is exempt from execution issued from any court in this state and in
the event of bankruptcy of such insured is exempt from all demands in legal
proceeding under such bankruptcy.
(4)
Subject to the statute of limitations, the amount of any premiums paid in fraud
of creditors for such insurance, with interest thereon, shall inure to their
benefit from the proceeds of the policy. The insurer issuing the policy shall
be discharged of all liability thereon by payment of its proceeds in accordance
with its terms unless, before such payment, the insurer has received at its
home office written notice by or in behalf of some creditor, with
specifications of the amount claimed, claiming to recover for certain premiums
paid in fraud of creditors.
(5)
The insured under any policy within this section shall not be denied the right
to change the beneficiary when such right is expressly reserved in the policy.
(6)
This section does not apply to annuity policies. [Formerly 739.405 and then
743.099]
743.047 Exemption of proceeds of group
life insurance. (1) A policy of group life
insurance or the proceeds thereof payable to a person or persons other than the
individual insured or the individual’s estate shall be exempt from debts and
claims of creditors or representatives of the individual insured and, in the
event of bankruptcy of the individual insured, from all demands in legal
proceedings under such bankruptcy.
(2)
The provisions of subsection (1) of this section do not apply to group life
insurance issued to a creditor covering the creditor’s debtors to the extent
that such proceeds are applied to payment of the obligation for the purpose of
which the insurance was so issued. [Formerly 743.102]
743.048
[Formerly 736.315; renumbered 742.018]
743.049 Exemption of proceeds of annuity
policies; assignability of rights.
(1) The benefits, rights, privileges and options which are due or prospectively
due an annuitant under any annuity policy issued before, on or after June 8,
1967, shall not be subject to execution, nor shall the annuitant be compelled
to exercise any such rights, powers or options, nor shall creditors be allowed to
interfere with or terminate the policy, except:
(a)
As to amounts paid for or as premium on any such annuity with intent to defraud
creditors, with interest thereon, and of which the creditor has given the
insurer written notice at its home office prior to the making of the payments
to the annuitant out of which the creditor seeks to recover. Any such notice
shall specify the amount claimed or such facts as will enable the insurer to
ascertain such amount, and shall set forth such facts as will enable the
insurer to ascertain the annuity policy, the annuitant and the payments sought
to be avoided on the ground of fraud.
(b)
The total exemption of benefits presently due and payable to any annuitant
periodically or at stated times under all annuity policies under which the
person is an annuitant shall not at any time exceed $500 per month for the
length of time represented by such installments. Such periodic payments in
excess of $500 per month shall be subject to garnishee execution to the same
extent as are wages and salaries.
(c)
If the total benefits presently due and payable to any annuitant under all
annuity policies under which the person is an annuitant shall at any time
exceed payment at the rate of $500 per month, the court may order such annuitant
to pay to a judgment creditor or apply on the judgment, in installments, the
portion of such excess benefits as to the court may appear just and proper,
after due regard for the reasonable requirements of the judgment debtor and
family, if dependent upon the judgment debtor, as well as any payments required
to be made by the annuitant to other creditors under prior court orders.
(2)
If the policy so provides, the benefits, rights, privileges or options accruing
under the policy to a beneficiary or assignee shall not be transferable nor
subject to commutation, and if the benefits are payable periodically or at
stated times, the same exemptions and exceptions contained in this section for
the annuitant shall apply with respect to such beneficiary or assignee. [Formerly
743.105; 1991 c.182 §3]
743.050 Exemption of proceeds of health
insurance. Except as may otherwise be expressly
provided by the policy, the proceeds or avails of all health insurance policies
and of provisions providing benefits on account of the insured’s disability
which are supplemental to life insurance policies, issued before, on or after
June 8, 1967, shall be exempt from all liability for any debt of the insured,
and from any debt of the beneficiary existing at the time the proceeds are made
available for the use of the beneficiary. [Formerly 743.108]
743.051 [1967
c.359 §350; renumbered 742.021 in 1989]
743.052 [1971
c.372 §2; renumbered 743.719 in 1989]
743.053 Prohibition on requirement that
death or dismemberment occur in less than 180 days after accident.
A life insurance policy or health insurance policy, whether group or
individual, that contains provisions providing benefits in case of death or
dismemberment by accident shall not require that the death or dismemberment occur
less than 180 days after the date of the accident in order for benefits to be
paid under the policy. [1991 c.182 §8]
743.054 [1967
c.359 §351; renumbered 742.023 in 1989]
743.055 [1991
c.875 §2; repealed by 1995 c.506 §11]
743.056 Insurer may not refuse to defend
or pay claim based on provider’s disclosure of adverse event.
(1) As used in this section:
(a)
“Adverse event” means a negative consequence of patient care that is
unanticipated, is usually preventable and results in or presents a significant
risk of patient injury.
(b)
“Claim” means a written demand for restitution for an injury alleged to have
been caused by the medical negligence of a health practitioner or licensed
health care facility.
(c)
“Health practitioner” means a person described in ORS 31.740 (1).
(d)
“Patient’s family” includes:
(A)
A parent, sibling or child by marriage, blood, adoption or domestic
partnership.
(B)
A foster parent or foster child.
(2)
An insurer may not decline or refuse to defend or indemnify a health practitioner
or a health care facility with respect to a claim, for any reason that is based
on the disclosure to the patient or the patient’s family by the health
practitioner or facility of an adverse event or information relating to the
cause of an adverse event.
(3)
A policy or contract of insurance or indemnity may not include a provision or
term excluding or limiting coverage based on the disclosure to a patient or the
patient’s family by a health practitioner or facility of an adverse event or
information relating to the cause of an adverse event. [2011 c.30 §2]
Note:
743.056 was added to and made a part of the Insurance Code by legislative
action but was not added to ORS chapter 743 or any series therein. See Preface
to Oregon Revised Statutes for further explanation.
743.057 [1967
c.359 §352; renumbered 742.026 in 1989]
743.060 [1967
c.359 §353; renumbered 742.028 in 1989]
743.061 Uniform standards for health care
financial and administrative transactions; rules.
(1) The Department of Consumer and Business Services may adopt by rule uniform
standards applicable to persons listed in subsection (2) of this section for
health care financial and administrative transactions, including uniform
standards for:
(a)
Eligibility inquiry and response;
(b)
Claim submission;
(c)
Payment remittance advice;
(d)
Claims payment or electronic funds transfer;
(e)
Claims status inquiry and response;
(f)
Claims attachments;
(g)
Prior authorization;
(h)
Provider credentialing; or
(i) Health care financial and administrative transactions
identified by the stakeholder work group described in ORS 743.062.
(2)
Any uniform standards adopted under subsection (1) of this section apply to:
(a)
Health insurers.
(b)
Prepaid managed care health services organizations as defined in ORS 414.736.
(c)
Third party administrators.
(d)
Any person or public body that either individually or jointly establishes a
self-insurance plan, program or contract, including but not limited to persons
and public bodies that are otherwise exempt from the Insurance Code under ORS
731.036.
(e)
Health care clearinghouses or other entities that process or facilitate the
processing of health care financial and administrative transactions from a
nonstandard format to a standard format.
(f)
Any other person identified by the department that processes health care
financial and administrative transactions between a health care provider and an
entity described in this subsection.
(3)
In developing or updating any uniform standards adopted under subsection (1) of
this section, the department shall consider recommendations from the Oregon
Health Authority under ORS 743.062. [2011 c.130 §2]
Note:
743.061 was added to and made a part of the Insurance Code by legislative
action but was not added to ORS chapter 743 or any series therein. See Preface
to Oregon Revised Statutes for further explanation.
743.062 Stakeholder work group to recommend
uniform standards. (1) The Oregon Health Authority
shall convene a stakeholder work group to recommend uniform standards for
health care financial and administrative transactions, including, to the extent
allowed by law, standards applicable to commercial health insurance plans,
self-funded plans and state governmental health plans and programs.
(2)
The authority shall report uniform standards recommended under subsection (1)
of this section to the Department of Consumer and Business Services for
consideration in the adoption of uniform standards by the department under ORS
743.061.
(3)
The stakeholder work group, in recommending uniform standards under subsection
(1) of this section, shall consider or incorporate any applicable national
standards for administrative simplification and timelines for implementation of
national standards for administrative simplification that are established
pursuant to federal law. [2011 c.130 §3]
Note:
743.062 and 743.064 were enacted into law by the Legislative Assembly but were
not added to or made a part of ORS chapter 743 or any series therein by
legislative action. See Preface to Oregon Revised Statutes for further
explanation.
743.063 [1967
c.359 §354; renumbered 742.033 in 1989]
743.064 Coordination with Oregon Health
Authority concerning uniform standards; Department of Human Services to be
subject to standards. (1) The Department of Consumer
and Business Services and the Oregon Health Authority shall confer before the
department finalizes rules implementing uniform standards under ORS 743.061,
for the purpose of reconciling any differences between the department’s and the
authority’s requirements for health care financial and administrative
transactions described in ORS 743.061. If the Department of Consumer and
Business Services proposes to amend any rule concerning uniform standards for
health care financial and administrative transactions under ORS 743.061 or the
authority proposes to amend any rule in a manner that would be inconsistent
with the uniform standards, the agency proposing to amend the rules shall
notify the other agency. The agencies shall confer before a final rule is
adopted to ensure that the standards remain uniform and consistent to the
extent practicable.
(2)
The Department of Human Services shall be subject to the uniform standards
adopted by the Department of Consumer and Business Services and the authority
under ORS 743.061 that are applicable to the operations of the Department of
Human Services. [2011 c.130 §5]
Note: See
note under 743.062.
743.066 [1967
c.359 §355; 1971 c.231 §23; renumbered 742.036 in 1989]
743.069 [1967
c.359 §356; renumbered 742.038 in 1989]
743.072
[Formerly 736.310; 1971 c.231 §24; 1973 c.149 §1; renumbered 742.041 in 1989]
743.075 [1967
c.359 §358; 1975 c.391 §1; 1977 c.742 §8; renumbered 742.043 in 1989]
743.078 [1967
c.359 §359; renumbered 742.046 in 1989]
743.080 [1971
c.231 §5; 1983 c.249 §1; renumbered 742.048 in 1989]
743.081 [1967
c.359 §360; renumbered 742.051 in 1989]
743.082 Selling and leasing of provider
panels by contracting entity; definitions. As
used in this section and ORS 743.083 to 743.086:
(1)(a)
“Contracting entity” means any person that contracts directly with a provider
for the delivery of health care services or contracts with a third party for
the purpose of selling or making available to the third party the provider’s
health care services or discounted rates or the services or rates of a provider
panel under a provider network contract.
(b)
“Contracting entity” includes a person under common ownership and control of a
contracting entity.
(c)
“Contracting entity” does not include:
(A)
A managed care organization that is certified under ORS 656.260;
(B)
A discount medical plan organization as defined in ORS 742.420;
(C)
The state medical assistance program;
(D)
An independent practice association; or
(E)
A self-funded, employer-sponsored health insurance plan regulated under the
Employee Retirement Income Security Act of 1974, as codified and amended at 29
U.S.C. 1001, et seq., or any person that provides only administrative services
to the self-funded employer-sponsored health insurance plan.
(2)
“Health care services” means the treatment of humans for bodily injury,
disablement or death by accidental means or as a result of sickness or
childbirth, or in prevention of sickness, but does not include treatment for
bodily injury, disablement or occupational diseases incurred as a result of
employment.
(3)
“Independent practice association” has the meaning given that term in ORS
743.801.
(4)
“Person” has the meaning given that term in ORS 731.116.
(5)(a)
“Provider” includes:
(A)
A physician as defined in ORS 677.010.
(B)
A physician group, independent practice association, physician-controlled
organization, hospital organization or other provider organization that
contracts with a provider for the purpose of facilitating the provider’s
participation in a provider network contract.
(C)
A person licensed, certified or otherwise authorized or permitted by the laws
of this state to administer medical services or mental health services in the
ordinary course of business or practice of a profession.
(b)
“Provider” does not include a contracting entity.
(6)
“Provider network contract” means a contract between a provider and a
contracting entity for the provision of health care services to patients other
than Medicare enrollees or medical assistance recipients.
(7)(a)
“Third party” means a person that enters into a contract with a contracting
entity or with another party, other than a provider, for the right to exercise
the rights of the contracting entity under a provider network contract.
(b)
“Third party” includes any of the following:
(A)
A payer that directly reimburses the cost of the delivery of health care
services;
(B)
A third party administrator or other entity that administers or processes
claims on behalf of a payer;
(C)
A preferred provider organization or network;
(D)
A physician-controlled organization or a hospital organization; or
(E)
An entity that is engaged in the electronic transmission of claims between a
contracting entity and a payer and does not provide to another party access to
the health care services and discounted rates of a provider.
(c)
“Third party” does not include:
(A)
Entities offering health care services under the same brand pursuant to a brand
licensing agreement with the same licenser; or
(B)
A self-funded, employer-sponsored health insurance plan regulated under the
Employee Retirement Income Security Act of 1974, as codified and amended at 29
U.S.C. 1001, et seq., or any person that provides only administrative services
to the self-funded employer-sponsored health insurance plan. [2011 c.561 §1]
Note:
743.082, 743.085 and 743.086 were enacted into law by the Legislative Assembly
but were not added to or made a part of ORS chapter 743 or any series therein
by legislative action. See Preface to Oregon Revised Statutes for further
explanation.
743.083 Registration of contracting
entity. (1) A contracting entity that does not
have a certificate of authority shall register with the Department of Consumer
and Business Services as a contracting entity by submitting the following
information to the department in written or electronic form as prescribed by
the department along with any fee prescribed by the department:
(a)
The official name of the entity and any secondary, alternative or substitute
designations.
(b)
The mailing address and telephone number of the headquarters of the entity.
(c)
The name and telephone number of a representative of the entity who shall serve
as the primary contact for the department.
(2)
The requirements of this section do not apply to a contracting entity that is
under common ownership and control of a contracting entity that is licensed by
or has a certificate of authority from the department. [2011 c.561 §3]
Note:
743.083 was added to and made a part of the Insurance Code by legislative
action but was not added to ORS chapter 743 or any series therein. See Preface
to Oregon Revised Statutes for further explanation.
743.084 [1967
c.359 §361; renumbered 743.041 in 1989]
743.085 Third party contracts for leasing
of provider panels; requirements. (1) A
contracting entity or a third party may not contract with another third party
to provide access to the health care services and discounted rates of a
provider under a provider network contract unless:
(a)
The third party contract is specifically authorized by the provider network
contract; and
(b)
The third party contract obligates the third party to comply with all
applicable terms, limitations and conditions of the provider network contract.
(2)
A contracting entity that provides access to the health care services and
discounted rates of a provider under a provider network contract shall:
(a)
Give to the provider in writing or electronically, at the time a provider
network contract is entered into, a list of all third parties known by the
contracting entity at the time to which the contracting entity has or will
provide access to the health care services and discounted rates of a provider
under the provider network contract;
(b)
Maintain an Internet website, toll-free telephone number or other readily
available mechanism through which a provider may obtain a list, updated at
least every 90 days, of all third parties that have access to the provider’s
health care services and discounted rates under the provider network contract;
(c)
Provide each third party listed under paragraph (a) or (b) of this subsection
with information necessary to enable the third party to comply with all
relevant terms, limitations and conditions of the provider network contract;
(d)
Require a third party to identify on each remittance or explanation of payment
sent to a provider the source of any contractual discount in rates taken by the
third party under the provider network contract; and
(e)(A)
Notify each third party listed under paragraph (a) or (b) of this subsection of
the termination of the provider network contract no later than 30 days prior to
the effective date of the termination; and
(B)
Require third parties to cease claiming entitlement to discounted rates or
other rights under a provider network contract after the termination of the
contract.
(3)
The notice required under subsection (2)(e)(A) of this section can be provided
by any reasonable means, including but not limited to written notice,
electronic communication or an update to an electronic database.
(4)
Subject to any applicable continuity of care requirements, agreements or
contractual provisions:
(a)
A third party’s right to access a provider’s health care services and
discounted rates under a provider network contract shall terminate on the date
the provider network contract is terminated;
(b)
Claims for health care services performed after the termination date of the
provider network contract are not eligible for processing and payment in
accordance with the provider network contract; and
(c)
Claims for health care services performed before the termination date of the
provider network contract, but processed after the termination date, are
eligible for processing and payment in accordance with the provider network
contract.
(5)(a)
All information made available to a provider in accordance with the
requirements of this section and ORS 743.086 shall be confidential and may not
be disclosed to any person not involved in the provider’s practice or the
administration thereof without the prior written consent of the contracting
entity.
(b)
This section and ORS 743.086 may not be construed to prohibit a contracting
entity from requiring a provider to execute a reasonable confidentiality
agreement to ensure that confidential or proprietary information disclosed by
the contracting entity is not used for any purpose other than the provider’s
direct practice management or billing activities. [2011 c.561 §4]
Note: See
note under 743.082.
743.086 Additional requirements for third
party contracts. (1) A contract between a third
party and a contracting entity or between two third parties with respect to a
provider network contract must comply with this section and ORS 743.085.
(2)(a)
A third party shall inform the contracting entity and providers under a
contracting entity’s provider network contract of a website, toll-free number
or other readily available mechanism to identify the names of all third parties
to which the third party provides access to the health care services and
discounted rates of a provider under the provider network contract.
(b)
The third party shall update the website described in paragraph (a) of this
subsection at least every 90 days to reflect all third parties currently
provided access. Upon request, the third party shall make the information
available to a provider via telephone or through direct notification.
(3)
A provider may refuse to accept as payment in full a discounted payment made by
a third party under the terms of a provider network contract if there is no
valid contractual basis for the discount or the discount is taken in violation
of this section or ORS 743.085. [2011 c.561 §5]
Note: See
note under 743.082.
743.087 [1967
c.359 §362; renumbered 743.043 in 1989]
743.090 [Formerly
736.335; repealed by 1973 c.827 §83]
743.093 [1967
c.359 §364; renumbered 742.053 in 1989]
743.096 [1967
c.359 §365; renumbered 742.056 in 1989]
743.099
[Formerly 739.405; renumbered 743.046 in 1989]
POLICY LANGUAGE SIMPLIFICATION
743.100 Short title.
ORS 743.100 to 743.109 may be cited as the Life and Health Insurance Policy
Language Simplification Act. [Formerly 743.350]
743.101 Purpose.
(1) The purpose of the Life and Health Insurance Policy Language Simplification
Act is to establish minimum standards for language used in policies and
certificates of life insurance and health insurance delivered or issued for
delivery in this state in order to facilitate ease of reading.
(2)
ORS 743.100 to 743.109 is not intended to increase the risk assumed by insurers
or to supersede their obligation to comply with the substance of other
Insurance Code provisions applicable to insurance policies. ORS 743.100 to
743.109 is not intended to impede flexibility and innovation in the development
of policy forms or content or to lead to the standardization of policy forms or
content. [Formerly 743.353]
743.102 [1967
c.359 §367; renumbered 743.047 in 1989]
743.103 Definitions for ORS 743.100 to
743.109. As used in ORS 743.100 to 743.109, “policy”
has the meaning given in ORS 731.122 and, in addition, includes a certificate
issued pursuant to a group insurance policy delivered or issued for delivery in
this state. [Formerly 743.357]
743.104 Scope of ORS 743.100 to 743.109.
(1) ORS 743.100 to 743.109 apply to all policies delivered or issued for
delivery in this state, except:
(a)
Any policy that is a security subject to federal jurisdiction.
(b)
Any group policy covering a group of 1,000 or more lives at date of issue,
other than a group credit life insurance policy or a group credit health
insurance policy. However, this paragraph shall not exempt any certificate
issued pursuant to a group policy.
(c)
Any group annuity contract that serves as a funding vehicle for a pension,
profit-sharing or deferred compensation plan.
(d)
Any form used in connection with, as a conversion from, as an addition to, or,
pursuant to a contractual provision, in exchange for, a policy delivered or
issued for delivery on a form approved or permitted to be issued prior to the
date the form must be approved under section 9, chapter 708, Oregon Laws 1979.
(e)
The renewal of a policy delivered or issued for delivery prior to the date the
policy form must be approved under section 9, chapter 708, Oregon Laws 1979.
(f)
Any certificate issued pursuant to a group policy not delivered or issued for
delivery in this state.
(2)
A non-English language policy will be deemed to comply with ORS 743.106 if the
insurer certifies that the policy is translated from an English language policy
that complies with ORS 743.106. [Formerly 743.362]
743.105 [1967
c.359 §368; renumbered 743.049 in 1989]
743.106 Reading ease standards for life
and health insurance policies. (1) No policy
form shall be delivered or issued for delivery in this state unless:
(a)
The policy text achieves a score of 40 or more on the Flesch
reading ease test, or an equivalent score on any comparable test as provided in
subsection (3) of this section;
(b)
The policy, except for specification pages, schedules and tables is printed in
not less than 10-point type, one point leaded;
(c)
The style, arrangement and overall appearance of the policy give no undue
prominence to any portion of the text, including the text of any indorsements or riders; and
(d)
The policy contains a table of contents or an index of the principal sections
of the policy, if the policy has more than 3,000 words of text printed on three
or less pages, or regardless of the number of words if the policy has more than
three pages.
(2)
For the purposes of this section, a Flesch reading
ease test score shall be calculated as follows:
(a)
For policy forms containing 10,000 words or less of text, the entire form shall
be analyzed. For policy forms containing more than 10,000 words, two 200-word
samples per page may be analyzed instead of the entire form. The samples shall
be separated by at least 20 printed lines.
(b)
The number of words and sentences in the text shall be counted and the total
number of words divided by the total number of sentences. The figure obtained
shall be multiplied by a factor of 1.015.
(c)
The total number of syllables in the text shall be counted and divided by the
total number of words. The figure obtained shall be multiplied by a factor of
84.6.
(d)
The sum of the figures computed under paragraphs (b) and (c) of this subsection
subtracted from 206.835 equals the Flesch reading
ease test score for the policy form.
(e)
For purposes of paragraphs (b) and (c) of this subsection, the following
procedures shall be used:
(A)
A contraction, hyphenated word or numbers and letters, when separated by
spaces, shall be counted as one word.
(B)
A unit of words ending with a period, semicolon or colon shall be counted as a
sentence.
(C)
A “syllable” means a unit of spoken language consisting of one or more letters
of a word as divided by an accepted dictionary. If the dictionary shows two or
more equally acceptable pronunciations of a word, the pronunciation containing
fewer syllables may be used.
(f)
As used in this section, “text” includes all written matter except the
following:
(A)
The name and address of the insurer; the name, number or title of the policy;
the table of contents or index; captions and subcaptions;
specification pages; schedules or tables; and
(B)
Policy language drafted to conform to the requirements of any state or federal
law, regulation or agency interpretation; policy language required by any
collectively bargained agreement; medical terminology; and words that are
defined in the policy. However, the insurer shall identify the language or
terminology excepted by this subparagraph and shall certify in writing that the
language or terminology is entitled to be excepted by this subparagraph.
(3)
Any other reading test may be approved by the Director of the Department of
Consumer and Business Services as an alternative to the Flesch
reading ease test if it is comparable in result to the Flesch
reading ease test.
(4)
Each policy filing shall be accompanied by a certificate signed by an officer
of the insurer stating that the policy meets the minimum required reading ease
score on the test used, or stating that the score is lower than the minimum
required but should be authorized in accordance with ORS 743.107. To confirm
the accuracy of a certification, the director may require the submission of
further information.
(5)
At the option of the insurer, riders, indorsements,
applications and other forms made a part of the policy may be scored as
separate forms or as part of the policy with which they may be used. [Formerly
743.365]
743.107 When director may authorize lower
standards. The Director of the Department of
Consumer and Business Services may authorize a lower score than the Flesch reading ease test score required by ORS 743.106
when, in the director’s sole discretion, the director finds that a lower
required score: