§36-3611. Grounds for disapproval of forms - Prevention of delivery

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of certain policies - Exemptions.

A. The Insurance Commissioner shall disapprove any form of policy, application, rider or endorsement or withdraw any previous approval thereof only:

1. If it is in any respect in violation of or does not comply with this code, including Section 4509 of this title or any other applicable statute in the State of Oklahoma;

2. If it contains or incorporates by reference any inconsistent, ambiguous, or misleading clauses, or exceptions and conditions which deceptively affect the risks purported to be assumed in the general coverage of the contract; and

3. If it has any title, heading, or other indication of its provisions which is misleading.

B. 1. No individual or family accident and health insurance policy, shall be delivered, or issued for delivery, in this state unless:

accompanied by an appropriate outline of coverages in

plain and simple language, in no less than 10-point

type, and provided further, at the top of the front

page of the outline of coverage, in no less than 14-

point type, shall state the policy described herein is

a limited policy or a substandard policy or other

appropriate information, as prescribed by the

Insurance Commissioner, and

b. an appropriate outline of coverage is completed and

delivered to the applicant at the time application is

made, and an acknowledgment of receipt or certificate

of delivery of such outline is provided to the insurer

with the application.

In the case of a direct response, such as a written application to the insurance company from an applicant, the outline of coverage shall accompany the policy when issued.

2. Such outline of coverage shall contain:

a. a statement identifying the applicable category of

coverage afforded by the policy as based on the

minimum basic standards set forth in the rules and

regulations issued to effect compliance with paragraph

3 of this section and Title 36 of the Oklahoma

Statutes,

b. a brief description of the principal benefits and

coverage provided in the policy,

c. a summary statement of the principal exclusions and

limitations or reductions contained in the policy,

including, but not limited to, pre-existing

conditions, probationary periods, elimination periods,

and any age limitations or reductions,

d. a summary statement of the renewal provision,

including any reservation of the insurer of a right to

change premiums, and

e. a statement that the outline contains a summary only

of the details of the policy as issued or of the

policy as applied for and that the issued policy

should be referred to for the actual contractual

governing provisions.

3. The department shall adopt rules and regulations which establish minimum standards for the general content of forms of individual and family health policies, which shall be inclusive of terms of renewability, initial and subsequent conditions of eligibility, termination of insurance, probationary periods, exclusions, limitations, and reductions. The minimum standards expressed in such rules and regulations shall be in addition to, and in accordance with, individual accident and sickness policy provisions as provided in this title.

4. The department shall adopt rules and regulations which establish minimum standards of benefits and identification for each of the following categories of coverage in individual and family forms, other than conversion policies, of accident and health insurance:

a. basic hospital expense insurance,

b. basic medical expense insurance,

c. basic surgical expense insurance,

d. hospital confinement indemnity insurance,

e. major medical expense insurance,

f. disability income protection insurance,

g. accident-only insurance, and

h. limited benefit insurance.

Nothing in this section shall preclude the issuance of any policy which combines two or more of the categories of coverage enumerated in subparagraphs a through e, or any policy which does not meet the prescribed minimum standards for categories of coverage in subparagraphs a through g when such policy is, in the opinion of the department, either experimental in nature or is demonstrated to be a type of coverage that will fulfill a reasonable need of the person or persons to be insured. Any policy so approved will be identified as to category only as prescribed by the department.

5. The department may, within such time as provided by law for the disapproval of an individual or family form of accident or health insurance, group accident and health insurance, or life and annuity insurance, disapprove any such form if it finds that it does not comply with applicable law in this state or it finds that such form is unjust, unfair, or inequitable to the policyholder, any person insured thereunder, or any beneficiary. In acting upon any such submission, the Commissioner shall, under this section, consider whether the benefits afforded under the submitted policy or benefit form would fulfill a reasonable need of a policyholder.

Laws 1957, p. 366, § 3611; Laws 1979, c. 183, § 1, eff. Jan. 1, 1982; Laws 1987, c. 210, § 36, eff. July 1, 1987; Laws 1993, c. 248, § 3, eff. Sept. 1, 1993.