ORS 743.655
Rules

  • disclosure
  • contents of policy

(1)

Intentionally left blank —Ed.

(a)

The Director of the Department of Consumer and Business Services shall adopt rules that include standards for full and fair disclosure setting forth the manner, content and required disclosures for the sale of long term care insurance policies, terms of renewability, initial and subsequent conditions of eligibility, nonduplication of coverage provisions, coverage of dependents, preexisting conditions, termination of insurance, program for public understanding, continuation or conversion, probationary periods, limitations, exceptions, reductions, elimination periods, underwriting at time of application, requirements for replacement, recurrent conditions and definitions of terms and that include required procedures for internal and external review of whether the conditions of a benefit trigger have been met.

(b)

In adopting rules under this section, the Director of the Department of Consumer and Business Services must give timely notice to, and shall consider recommendations from the Director of Human Services.

(2)

A long term care insurance policy may not:

(a)

Be canceled, nonrenewed or otherwise terminated on the grounds of the age or the deterioration of the mental or physical health of the insured individual or certificate holder;

(b)

Contain a provision establishing a new waiting period in the event existing coverage is converted to or replaced by a new or other form within the same company, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder;

(c)

Provide coverage for skilled nursing care only or provide significantly more coverage for skilled care in a facility than coverage for lower levels of care;

(d)

Exclude coverage for Alzheimer’s disease and related dementias;

(e)

Be nonrenewed or otherwise terminated for nonpayment of premiums until 31 days overdue and then only after notice of nonpayment is given the policyholder prior to expiration of the 31 days, except as otherwise provided by rule; or

(f)

Be sold to provide less than 24 months’ coverage.

(3)

Intentionally left blank —Ed.

(a)

A long term care insurance policy or certificate other than a policy or certificate issued to a group described in ORS 743.652 (Definitions for ORS 743.650 to 743.665) (4)(a), (b) or (c) may not use a definition of “preexisting condition” that is more restrictive than the following: “Preexisting condition” means a condition for which medical advice or treatment was recommended by, or received from a provider of health care services, within six months preceding the effective date of coverage of an insured person.

(b)

A long term care insurance policy or certificate other than a policy or certificate thereunder issued to a group described in ORS 743.652 (Definitions for ORS 743.650 to 743.665) (4)(a), (b) or (c) may not exclude coverage for a loss or confinement that is the result of a preexisting condition unless the loss or confinement begins within six months following the effective date of coverage of an insured person.

(c)

The Director of the Department of Consumer and Business Services may extend the limitation periods set forth in paragraphs (a) and (b) of this subsection as to specific age group categories or specific policy forms upon findings that the extension is in the best interest of the public.

(d)

The definition of preexisting condition does not prohibit an insurer from using an application form designed to elicit the complete health history of an applicant, over the 10 years immediately prior to the date of application, and, on the basis of the answers on the application, from underwriting in accordance with that insurer’s established underwriting standards. Unless otherwise provided in the policy or certificate, a preexisting condition, regardless of whether it is disclosed on the application, need not be covered until the waiting period described in paragraph (b) of this subsection expires. A long term care insurance policy or certificate may not exclude or use waivers or riders of any kind to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions beyond the waiting period described in paragraph (b) of this subsection.

(4)

A long term care insurance policy may not be delivered or issued for delivery in this state if the policy:

(a)

Conditions eligibility for any benefits on a prior hospitalization requirement;

(b)

Conditions eligibility for benefits provided in an institutional care setting on the receipt of a higher level of institutional care; or

(c)

Conditions eligibility for any benefits other than waiver of premium or post-confinement, post-acute care or recuperative benefits on a prior institutionalization requirement.

(5)

Intentionally left blank —Ed.

(a)

A long term care insurance policy containing post-confinement, post-acute care or recuperative benefits must clearly label in a separate paragraph of the policy or certificate titled “Limitations or Conditions of Eligibility for Benefits” all such limitations or conditions, including any required number of days of confinement.

(b)

A long term care insurance policy or rider that conditions eligibility of noninstitutional benefits on the prior receipt of institutional care may not require a prior institutional stay of more than 30 days.

(6)

Individual long term care insurance applicants shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason. Long term care insurance policies and certificates must have a notice prominently printed on the first page or attached thereto stating in substance that the applicant has the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, other than a certificate issued pursuant to a policy issued to a group described in ORS 743.652 (Definitions for ORS 743.650 to 743.665) (4)(a), the applicant is not satisfied for any reason. This subsection also applies to denials of applications. Any refund must be made within 30 days of the return or denial.
(7)(a)(A) An outline of coverage shall be delivered to a prospective applicant for long term care insurance at the time of initial solicitation through means that prominently direct the attention of the recipient to the document and its purpose.

(B)

The Director of the Department of Consumer and Business Services by rule must prescribe a standard format, including style, arrangement and overall appearance, and the content of an outline of coverage.

(C)

In the case of solicitations by an insurance producer, the insurance producer must deliver the outline of coverage prior to the presentation of an application or enrollment form.

(D)

In the case of direct response solicitations, the outline of coverage must be presented in conjunction with any application or enrollment form.

(E)

In the case of a policy issued to a group described in ORS 743.652 (Definitions for ORS 743.650 to 743.665) (4)(a), an outline of coverage is not required to be delivered as long as the information described in paragraph (b) of this subsection is contained in other materials related to the enrollment. Upon request, these other materials must be made available to the Director of the Department of Consumer and Business Services.

(b)

The outline of coverage must include:

(A)

A description of the principal benefits and coverage provided in the policy;

(B)

A statement of the principal exclusions, reductions and limitations contained in the policy;

(C)

A statement of the terms under which the policy or certificate, or both, may be continued in force or discontinued, including any reservation in the policy of a right to change premium. Continuation or conversion provisions of group coverage shall be specifically described;

(D)

A statement that the outline of coverage is a summary only, not a contract of insurance, and that the policy or group master policy contains governing contractual provisions;

(E)

A description of the terms under which the policy or certificate may be returned and premium refunded;

(F)

A brief description of the relationship of cost of care and benefits; and

(G)

A statement that discloses to the policyholder or certificate holder whether the policy is intended to be qualified long term care insurance as defined in ORS 743.652 (Definitions for ORS 743.650 to 743.665).

(8)

A certificate issued pursuant to a group long term care insurance policy if the policy is delivered or issued for delivery in this state shall include:

(a)

A description of the principal benefits and coverage provided in the policy;

(b)

A statement of the principal exclusions, reductions and limitations contained in the policy; and

(c)

A statement that the group master policy determines governing contractual provisions.

(9)

If an application for a long term care insurance policy or certificate is approved, the insurer must deliver the policy or certificate to the applicant no later than 30 days after the date of approval.

(10)

At the time of policy delivery, a policy summary must be delivered for an individual life insurance policy that provides long term care benefits within the policy or by rider. In the case of direct response solicitations, the insurer must deliver the policy summary upon the applicant’s request, but regardless of request must make delivery not later than at the time of policy delivery. In addition to complying with all applicable requirements, the summary must also include the provisions required in this subsection. The required provision may be incorporated into a basic illustration or into the life insurance policy summary if required by rule. The following provisions must be included in the summary:

(a)

An explanation of how the long term care benefit interacts with other components of the policy, including deductions from death benefits;

(b)

An illustration of the amount of benefits, the length of benefits and the guaranteed lifetime benefits, if any, for each covered person;

(c)

Any exclusions, reductions and limitations on benefits of long term care;

(d)

A statement that any long term care inflation protection option required by rule is not available under the policy; and

(e)

If applicable to the policy type, the following:

(A)

A disclosure of the effects of exercising other rights under the policy;

(B)

A disclosure of guarantees related to long term care costs of insurance charges; and

(C)

Current and projected maximum lifetime benefits.

(11)

When a long term care benefit that is funded through a life insurance policy by an acceleration of the death benefit is in benefit payment status, the insurer must provide a monthly report to the policyholder. The report must include:

(a)

Any long term care benefits paid out during the month;

(b)

An explanation of any changes in the policy, such as death benefits or cash values, owing to payment of long term care benefits; and

(c)

The amount of long term care benefits existing or remaining.

(12)

If a claim under a long term care insurance policy is denied, then not later than the 60th day after the date of a written request by the policyholder or certificate holder, or a personal or authorized representative of either, the insurer must:

(a)

Provide a written explanation of the reasons for the denial; and

(b)

Make available all information directly related to the denial.

(13)

Long term care insurance policies shall include a clear description of the process for appealing and resolving disputes regarding whether the conditions of a benefit trigger have been met.

(14)

A policy may not be advertised, marketed or offered as long term care or nursing home insurance unless it complies with the provisions of ORS 743.650 (Long Term Care Insurance Act) to 743.665 (Prompt pay requirements).

(15)

Rules adopted pursuant to ORS 743.650 (Long Term Care Insurance Act) to 743.665 (Prompt pay requirements) shall be in accordance with the provisions of ORS chapter 183.

(16)

This section is exempt from ORS 743A.001 (Automatic repeal of certain statutes on individual and group health insurance). [1989 c.1022 §§6,7; 1991 c.67 §200; 2003 c.364 §110; 2007 c.486 §4; 2011 c.69 §5]

Source: Section 743.655 — Rules; disclosure; contents of policy, https://www.­oregonlegislature.­gov/bills_laws/ors/ors743.­html.

743.004
Submission of information by carriers offering health benefit plans
743.005
Protection of health information report
743.007
Data reporting
743.008
Reporting requirements
743.010
Health insurance policy and health benefit plan forms
743.015
Filing and approval of credit life and credit health insurance forms
743.018
Filing of rates for life and health insurance
743.019
Procedure for review of proposed rates for health benefit plans
743.020
Rate filing to include statement of administrative expenses
743.022
Premium rates for individual health benefit plans
743.023
Electronic administration
743.025
Rate filing to include prescription drug cost information
743.028
Uniform health insurance claim forms
743.029
Uniform standards for health care financial and administrative transactions
743.031
Stakeholder work group to recommend uniform standards
743.034
Coordination with Oregon Health Authority concerning uniform standards
743.035
Uniform prior authorization form for prescription drug benefits
743.038
Consent of individual required for life and health insurance
743.039
Alteration of application for life or health insurance
743.040
Personal insurance, insurable interest and beneficiaries
743.041
Payment discharges insurer
743.043
Assignment of policies
743.044
Life insurance for benefit of charity
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
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
743.100
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
743.150
Scope of ORS 743.150, 743.153 and 743.156
743.153
Statement of benefits
743.154
Acceleration of death benefits
743.156
Statement of premium
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
743.189
Reinstatement
743.192
Payment of claim
743.195
Installment payments
743.198
Title
743.201
Beneficiary of industrial policies
743.204
Standard Nonforfeiture Law for Life Insurance
743.207
Required provisions relating to nonforfeiture
743.210
Determination of cash surrender values
743.213
Determination of paid-up nonforfeiture benefits
743.215
Calculation of adjusted premiums
743.216
Adjusted premiums
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
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
743.278
Required provisions in annuity policies
743.284
Computation of benefits
743.287
Commencement of annuity payments at optional maturity dates
743.290
Notice of nonpayment of certain benefits to be included in annuity policy
743.293
Minimum forfeiture amounts for annuity policies
743.295
Effect of certain life insurance and disability benefits on minimum nonforfeiture amounts
743.298
Penalties, fees or charges
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
743.321
Evidence of insurability
743.324
Misstatement of age
743.327
Payments under policy
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
743.354
Requirements for certain group life policies issued to trustees of certain funds
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
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
743.378
Charges and refunds to debtor
743.379
Status of remuneration to creditor
743.380
Claim report and payment
743.402
Exceptions to individual health insurance policy requirements
743.405
General requirements for health insurance policies
743.406
Required provisions in group health insurance policies
743.408
Mandatory provisions
743.411
Entire contract
743.414
Time limit on certain defenses
743.416
Due date for first premium payment
743.417
Grace period for subsequent premium payments
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
743.462
Insurance with other insurers
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
743.492
Policy return and premium refund provision
743.495
Use of terms “noncancelable” or “guaranteed renewable”
743.498
Statement in policy of cancelability or renewability
743.521
Leased workers
743.522
Additional groups designated by director
743.523
Certain sales practices prohibited
743.524
Eligibility of association to be group health policyholder
743.526
Determination of whether trustees are policyholders
743.535
Health benefit coverage for guaranteed association
743.536
“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
743.550
Student health insurance
743.551
Student health benefit plans
743.650
Long Term Care Insurance Act
743.652
Definitions for ORS 743.650 to 743.665
743.653
Prohibition on certain policies
743.655
Rules
743.656
Eligibility for benefits
743.658
Notice of lapse or termination
743.662
Rescission of policy and denial of claims
743.664
Offer of nonforfeiture benefit
743.665
Prompt pay requirements
743.680
Definitions for ORS 743.680 to 743.689
743.682
Application of ORS 743.680 to 743.689
743.683
Policy contents
743.684
Filing of policy
743.685
Outline of coverage
743.686
Right to return of policy
743.687
Advertising
743.688
Rules
743.689
Director’s authority upon violation of ORS 743.680 to 743.689
743.787
Definitions for ORS 743.788
743.788
Prescription drug identification card
743.790
Rules for prescription drug identification cards
743.824
Cash dividends for healthy behaviors
743.826
Requirements for catastrophic plans
Green check means up to date. Up to date