§ 1250.5. Acts by an insurer constituting an unfair claim settlement practice
Oklahoma Statutes AnnotatedTitle 36. InsuranceEffective: November 1, 2023
Effective: November 1, 2023
36 Okl.St.Ann. § 1250.5
§ 1250.5. Acts by an insurer constituting an unfair claim settlement practice
Any of the following acts by an insurer, if committed in violation of Section 1250.3 of this title, constitutes an unfair claim settlement practice exclusive of paragraph 16 of this section which shall be applicable solely to health benefit plans:
7. Except where there is a time limit specified in the policy, making statements, written or otherwise, which require a claimant to give written notice of loss or proof of loss within a specified time limit and which seek to relieve the company of its obligations if the time limit is not complied with unless the failure to comply with the time limit prejudices the rights of an insurer. Any policy that specifies a time limit covering damage to a roof due to wind or hail must allow the filing of claims after the first anniversary but no later than twenty-four (24) months after the date of the loss, if the damage is not evident without inspection;
10. Denying payment to a claimant on the grounds that services, procedures, or supplies provided by a treating physician, hospital, or person or entity licensed or otherwise authorized to provide health care services were not medically necessary unless the health insurer or administrator, as defined in Section 1442 of this title, first obtains an opinion from any provider of health care licensed by law and preceded by a medical examination or claim review, to the effect that the services, procedures or supplies for which payment is being denied were not medically necessary. In the event that claims for mental health or substance use disorder treatments and services are under review, the reviewing health care provider shall have appropriate, qualified, and specialized credentials with respect to the services and treatments. Upon written request of a claimant, treating physician, hospital, or authorized person or entity, the opinion shall be set forth in a written report, prepared and signed by the reviewing physician. The report shall detail which specific services, procedures, or supplies were not medically necessary, in the opinion of the reviewing physician, and an explanation of that conclusion. A copy of each report of a reviewing physician shall be mailed by the health insurer, or administrator, postage prepaid, to the claimant, treating physician, hospital, or authorized person or entity requesting same within fifteen (15) days after receipt of the written request. As used in this paragraph, “physician” means a person holding a valid license to practice medicine and surgery, osteopathic medicine, podiatric medicine, dentistry, chiropractic, or optometry, pursuant to the state licensing provisions of Title 59 of the Oklahoma Statutes;
12. Violating the provisions of the Health Care Fraud Prevention Act;1
13. Compelling, without just cause, policyholders to institute suits to recover amounts due under its insurance policies or insurance contracts by offering substantially less than the amounts ultimately recovered in suits brought by them, when the policyholders have made claims for amounts reasonably similar to the amounts ultimately recovered;
14. Failing to maintain a complete record of all complaints which it has received during the preceding three (3) years or since the date of its last financial examination conducted or accepted by the Commissioner, whichever time is longer. This record shall indicate the total number of complaints, their classification by line of insurance, the nature of each complaint, the disposition of each complaint, and the time it took to process each complaint. For the purposes of this paragraph, “complaint” means any written communication primarily expressing a grievance;
18. As a health insurer that provides pharmacy benefits or a pharmacy benefits manager that administers pharmacy benefits for a health plan, failing to include any amount paid by an enrollee or on behalf of an enrollee by another person when calculating the enrollee's total contribution to an out-of-pocket maximum, deductible, copayment, coinsurance or other cost-sharing requirement.
However, if, under federal law, application of this paragraph would result in health savings account ineligibility under Section 223 of the federal Internal Revenue Code, as amended, this requirement shall apply only for health savings accounts with qualified high-deductible health plans with respect to the deductible of such a plan after the enrollee has satisfied the minimum deductible, except with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the federal Internal Revenue Code, as amended, in which case the requirements of this paragraph shall apply regardless of whether the minimum deductible has been satisfied.
Credits
Laws 1986, c. 251, § 16, eff. Nov. 1, 1986; Laws 1989, c. 238, § 1, eff. Nov. 1, 1989; Laws 1991, c. 134, § 9, eff. July 1, 1991; Laws 1993, c. 24, § 1, eff. Sept. 1, 1993. Renumbered from Title 36, § 1254 and amended by Laws 1994, c. 342, §§ 5, 20, eff. Sept. 1, 1994. Laws 1997, c. 156, § 2, eff. Nov. 1, 1997; Laws 1997, c. 404, § 3, eff. Nov. 1, 1997; Laws 1997, c. 418, § 52, eff. Nov. 1, 1997; Laws 1999, c. 256, § 1, eff. Nov. 1, 1999; Laws 2000, c. 353, § 7, eff. Nov. 1, 2000; Laws 2009, c. 323, § 2, eff. July 1, 2010; Laws 2012, c. 105, § 1; Laws 2021, c. 37, § 1, eff. Nov. 1, 2021; Laws 2021, c. 478, § 7, emerg. eff. May 12, 2021; Laws 2022, c. 266, § 1, emerg. eff. May 16, 2022; Laws 2023, c. 214, § 1, eff. Nov. 1, 2023.
Footnotes
Title 36, § 1219.1 et seq.
36 Okl. St. Ann. § 1250.5, OK ST T. 36 § 1250.5
Current with emergency effective legislation through Chapter 257 of the Second Regular Session of the 59th Legislature (2024). Some sections may be more current, see credits for details.
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