Chapter 3902: INSURANCE POLICIES AND CONTRACTS

3902.01 Purpose of sections.

(A) The purpose of sections 3902.01 to 3902.08 of the Revised Code is to establish minimum standards for language used in policies and certificates of life insurance and annuities, credit life insurance and credit disability insurance, and sickness and accident insurance, and subscriber policies or certificates of health insuring corporations, delivered or issued for delivery in this state, to facilitate ease of reading by insureds and subscribers.

(B) Sections 3902.01 to 3902.08 of the Revised Code are not intended to increase the risk assumed by insurance companies or other entities subject to sections 3902.01 to 3902.08 of the Revised Code or to supersede their obligation to comply with the substance of other applicable insurance laws. Sections 3902.01 to 3902.08 of the Revised Code are 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.

Cite as R.C. § 3902.01

Effective Date: 06-04-1997

3902.02 Insurance policy and contract definitions.

As used in sections 3902.01 to 3902.08 of the Revised Code:

(A) "Policy" or "policy form" means any policy, contract, plan or agreement of life insurance and annuities, credit life insurance and credit disability insurance, and sickness and accident insurance, and subscriber policies, contracts, certificates, and agreements of health insuring corporations, delivered or issued for delivery in this state by any company subject to sections 3902.01 to 3902.08 of the Revised Code; any certificate, contract or policy issued by a fraternal benefit society; any certificate issued pursuant to a group insurance policy delivered or issued for delivery in this state; and any evidence of coverage issued by a health insuring corporation.

(B) "Company" or "insurer" means any entity authorized to do the business of life insurance and annuities, sickness and accident insurance, credit life insurance, or credit disability insurance; a fraternal benefit society; and a health insuring corporation.

Cite as R.C. § 3902.02

Effective Date: 06-04-1997

3902.03 Policies to which sections apply - exceptions - non-English language policies.

(A) Sections 3902.01 to 3902.08 of the Revised Code apply to all policies delivered or issued for delivery in this state by any company on or after the date such forms must be approved under sections 3902.01 to 3902.08 of the Revised Code. Sections 3902.01 to 3902.08 of the Revised Code do not apply to:

(1) Any policy that is a security subject to federal jurisdiction;

(2) Any group policy, other than a group credit life insurance policy, or a group credit disability insurance policy. This division does not exempt any certificate issued pursuant to a group policy delivered or issued for delivery in this state.

(3) Any group annuity contract that serves as a funding vehicle for pension, profit-sharing, or deferred compensation plans;

(4) Any form used in connection with, as a conversion from, as an addition to, or in exchange pursuant to a contractual provision for, a policy delivered or issued for delivery on a form approved, or permitted to be issued prior to the dates such forms must be approved pursuant to sections 3902.01 to 3902.08 of the Revised Code;

(5) The renewal of a policy delivered or issued for delivery prior to the dates such forms must be approved under sections 3902.01 to 3902.08 of the Revised Code.

(B) Any non-English language policy delivered or issued for delivery in this state is deemed to be in compliance with division (A)(1) of section 3902.04 of the Revised Code if the insurer certifies that such policy is translated from an English language policy that complies with division (A)(1) of section 3902.04 of the Revised Code.

Cite as R.C. § 3902.03

Effective Date: 01-09-1980

3902.04 Requirements for policy forms.

(A) No policy forms, except as stated in section 3902.03 of the Revised Code, shall be delivered or issued for delivery in this state on or after the dates such forms must be approved under sections 3902.01 to 3902.08 of the Revised Code, unless:

(1) The text achieves a minimum score of forty on the Flesch reading ease test, or an equivalent score on any other comparable test as provided in division (C) of this section;

(2) It is printed, except for specification pages, schedules, and tables, in not less than ten-point type, one point leaded;

(3) The style, arrangement, and overall appearance of the policy give no undue prominence to any portion of the text of the policy, or to any endorsements or riders;

(4) It contains a table of contents or an index of the principal sections of the policy, if the policy has more than three thousand words printed on three or fewer pages of text, or if the policy has more than three pages regardless of the number of words.

(B) For the purposes of this section, a Flesch reading ease test score shall be measured by the following method:

(1) For policy forms containing ten thousand words or less of text, the entire form shall be analyzed. For policy forms containing more than ten thousand words, the readability of two two-hundred word samples per page may be analyzed instead of the entire form. The samples shall be separated by at least twenty printed lines.

(2) 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 one and fifteen thousandths.

(3) The total number of syllables shall be counted and divided by the total number of words. The figure obtained shall be multiplied by a factor of eighty-four and six-tenths.

(4) The sum of the figures computed under divisions (B)(2) and (3) of this section subtracted from two hundred six and eight hundred thirty-five thousandths equals the Flesch reading ease score for the policy form.

(5) For purposes of divisions (B)(2), (3), and (4) of this section, 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, but excluding headings and captions, 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. Where the dictionary shows two or more equally acceptable pronunciations of a word, the pronunciation containing fewer syllables may be used.

(6) As used in this section, "text" includes all printed 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;

(b) Any policy language that is drafted to conform to the requirements of any federal law, regulation, or agency interpretation; any policy language required by any collectively bargained agreement; any medical terminology; any words that are defined in the policy; and any policy language required by law or regulation; provided however, the insurer identifies the language or terminology excepted by this paragraph and certifies, in writing, that the language or terminology is entitled to be excepted by this paragraph.

(C) Any other reading test may be approved by the superintendent of insurance for use as an alternative to the Flesch reading ease test if it is comparable in result to the Flesch reading ease test.

(D) Every filing subject to this section shall be accompanied by a certificate signed by an officer of the insurer stating that the filing meets the minimum reading ease score on the test used, or stating that the score is lower than the minimum required but should be approved in accordance with section 3902.06 of the Revised Code. To confirm the accuracy of any certification, the superintendent may require the submission of further information to verify the certification in question.

(E) At the option of the insurer, riders, endorsements, 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.

Cite as R.C. § 3902.04

Effective Date: 01-09-1980

3902.05 Construction.

Nothing in sections 3902.01 to 3902.08 of the Revised Code shall be construed to negate any law of this state permitting the issuance of any policy form after it has been on file for the time period specified.

Cite as R.C. § 3902.05

Effective Date: 01-09-1980

3902.06 Superintendent may authorize lower test score.

The superintendent of insurance may authorize a lower score than the Flesch reading ease score required in division (A)(1) of section 3902.04 of the Revised Code whenever, in his discretion, he finds that a lower score meets any of the following conditions:

(A) The lower score will provide a more accurate reflection of the readability of a policy form;

(B) The lower score is warranted by the nature of a particular policy form or type or class of policy forms;

(C) The lower score is caused by certain policy language that is drafted to conform to the requirements of any law, rule, or agency interpretation.

Cite as R.C. § 3902.06

Effective Date: 01-09-1980

3902.07 Approval of policy form notwithstanding provisions of other laws.

A policy form meeting the requirements of section 3902.04 of the Revised Code shall be approved notwithstanding the provisions of any other laws that specify the content of policies, if the policy form provides the policyholders and claimants protection not less favorable than they would be entitled to under such laws.

Cite as R.C. § 3902.07

Effective Date: 01-09-1980

3902.08 Policy forms compliance date.

(A) Except as provided in section 3902.03 of the Revised Code, sections 3902.01 to 3902.08 of the Revised Code apply to all policy forms filed on or after three years after the effective date of sections 3902.01 to 3902.08 of the Revised Code. No policy form shall be delivered or issued for delivery in this state on or after five years after the effective date of sections 3902.01 to 3902.08 of the Revised Code unless approved by the superintendent of insurance, or permitted to be issued, pursuant to sections 3902.01 to 3902.08 of the Revised Code. Any policy form that has been approved or permitted to be issued prior to five years after the effective date of sections 3902.01 to 3902.08 of the Revised Code, and that meets the standards set by sections 3902.01 to 3902.08 of the Revised Code need not be refiled for approval, but may continue to be lawfully delivered or issued for delivery in this state upon the filing with the superintendent of a list of such forms identified by form number and accompanied by a certificate as to each such form in the manner provided in division (D) of section 3902.05 of the Revised Code.

(B) The superintendent may, in his discretion, extend the dates in division (A) of this section.

Cite as R.C. § 3902.08

Effective Date: 01-09-1980

3902.11 Coordination of benefits definitions.

As used in sections 3902.11 to 3902.14 of the Revised Code:

(A) "Beneficiary" and "third-party payer" have the same meanings as in section 3901.38 of the Revised Code.

(B) "Plan of health coverage" means any of the following if the policy, contract, or agreement contains a coordination of benefits provision:

(1) An individual or group sickness and accident insurance policy, which policy provides for hospital, dental, surgical, or medical services;

(2) Any individual or group contract of a health insuring corporation, which contract provides for hospital, dental, surgical, or medical services;

(3) Any other individual or group policy or agreement under which a third-party payer provides for hospital, dental, surgical, or medical services.

(C) "Provider" means a hospital, nursing home, physician, podiatrist, dentist, pharmacist, chiropractor, or other licensed health care provider entitled to reimbursement by a third-party payer for services rendered to a beneficiary under a benefits contract.

Cite as R.C. § 3902.11

Effective Date: 07-24-2002

3902.12 Primary or secondary health coverage.

When a plan of health coverage is primary, its benefits are paid without regard to the benefits of another plan. When a plan of health coverage is secondary, its benefits are determined by taking into consideration the payments made or to be made by another plan. When there are more than two plans, a plan may be primary as to one and may be secondary as to another.

Cite as R.C. § 3902.12

Effective Date: 06-29-1988

3902.13 Order of benefits for health coverage plan.

(A) A plan of health coverage determines its order of benefits using the first of the following that applies:

(1) A plan that does not coordinate with other plans is always the primary plan.

(2) The benefits of the plan that covers a person as an employee, member, insured, or subscriber, other than a dependent, is the primary plan. The plan that covers the person as a dependent is the secondary plan.

(3) When more than one plan covers the same child as a dependent of different parents who are not divorced or separated, the primary plan is the plan of the parent whose birthday falls earlier in the year. The secondary plan is the plan of the parent whose birthday falls later in the year. If both parents have the same birthday, the benefits of the plan that covered the parent the longer is the primary plan. The plan that covered the parent the shorter time is the secondary plan. If the other plan's provision for coordination of benefits does not include the rule contained in this division because it is not subject to regulation under this division, but instead has a rule based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule of the other plan will determine the order of benefits.

(4)

(a) Except as provided in division (A)(4)(b) of this section, if more than one plan covers a person as a dependent child of divorced or separated parents, benefits for the child are determined in the following order:

(i) The plan of the parent who is the residential parent and legal custodian of the child;

(ii) The plan of the spouse of the parent who is the residential parent and legal custodian of the child;

(iii) The plan of the parent who is not the residential parent and legal custodian of the child.

(b) If the specific terms of a court decree state that one parent is responsible for the health care expenses of the child, the plan of that parent is the primary plan. A parent responsible for the health care pursuant to a court decree must notify the insurer or health insuring corporation of the terms of the decree.

(5) The primary plan is the plan that covers a person as an employee who is neither laid off or retired, or that employee's dependent. The secondary plan is the plan that covers that person as a laid-off or retired employee, or that employee's dependent.

(6) If none of the rules in divisions (A)(1), (2), (3), (4), and (5) of this section determines the order of benefits, the primary plan is the plan that covered an employee, member, insured, or subscriber longer. The secondary plan is the plan that covered that person the shorter time.

(B) When a plan of health coverage is determined to be a secondary plan it acts to provide benefits in excess of those provided by the primary plan.

(C) The secondary plan shall not be required to make payment in an amount which exceeds the amount it would have paid if it were the primary plan, but in no event, when combined with the amount paid by the primary plan, shall payments by the secondary plan exceed one hundred per cent of expenses allowable under the provisions of the applicable policies and contracts.

(D) A third-party payer may require a beneficiary to file a claim with the primary plan before it determines the amount of its payment obligation, if any, with regard to that claim.

(E) Nothing in this section shall be construed to require a plan to make a payment until it determines whether it is the primary plan or the secondary plan and what benefits are payable under the primary plan.

(F) A plan may obtain any facts and information necessary to apply the provisions of this section, or supply this information to any other third-party payer or provider, or any agent of such third-party payer or provider, without the consent of the beneficiary. Each person claiming benefits under the plan shall provide any information necessary to apply the provisions of this section.

(G) If the amount of payments made by any plan is more than should have been paid, the plan may recover the excess from whichever party received the excess payment.

(H) No third-party payer shall administer a plan of health coverage delivered, issued for delivery, or renewed on or after June 29, 1988, unless such plan complies with this section.

(I)

(1) A third-party payer that is subject to this section and has reason to believe payment has been made by another third-party payer for the same service may request from that third-party payer, and shall be provided by the third-party payer, such data as necessary to determine whether duplicate payment has been made.

(2) A third-party payer that meets the criteria of a secondary payer in accordance with this section may seek repayment of any duplicate payment that may have been made from the person to whom it made payment. If the person who received the duplicate payment is a provider, absent a finding of a court of competent jurisdiction that the provider has engaged in civil or criminal fraudulent activities, the request for the return of any duplicate payment shall be made within three years after the close of the provider's fiscal year in which the duplicate payment has been made.

(J) Nothing in this section shall be construed to affect the prohibition of section 3923.37 of the Revised Code.

(K)

(1) No third-party payer shall knowingly fail to comply with the order of benefits as set forth in division (A) of this section.

(2) No primary plan shall direct or encourage an insured to use the benefits of a secondary plan that results in a reduction of payment by such primary plan.

(L) Whoever violates division (K) of this section is deemed to have engaged in an unfair and deceptive insurance act or practice under sections 3901.19 to 3901.26 of the Revised Code, and is subject to proceedings pursuant to those sections.

Cite as R.C. § 3902.13

Effective Date: 06-04-1997

3902.14 Rules.

The superintendent of insurance may, pursuant to Chapter 119. of the Revised Code, adopt rules to carry out the purposes of sections 3902.11 to 3902.14 of the Revised Code.

Cite as R.C. § 3902.14

Effective Date: 06-29-1988

3902.21 Standard claim form definitions.

As used in sections 3902.22 and 3902.23 of the Revised Code, "third-party payer" has the same meaning as in section 3901.38 of the Revised Code.

Cite as R.C. § 3902.21

Effective Date: 07-24-2002

3902.22 Superintendent to develop standard claim form.

The superintendent of insurance shall develop a standard claim form to be used by all third-party payers and providers for reimbursement of health care services and supplies, taking into consideration the special needs of, and differences between, third-party payers. The standard claim form shall be prescribed in rules the superintendent shall adopt in accordance with Chapter 119. of the Revised Code. The superintendent may prescribe a separate claim form for each third-party payer. If a national standard claim form is established by the sickness and accident insurance industry, the superintendent shall amend the rules to comply with the national standards. The standard claim form shall include a method to specify the national provider identifiers assigned to the physical therapists and other health care professionals rendering services designated as physical therapy, as required under section 4755.56 of the Revised Code.

Cite as R.C. § 3902.22

Effective Date: 07-24-2002; 04-06-2007

3902.23 Use of form mandatory.

Beginning one hundred eighty days after rules adopted under section 3902.22 of the Revised Code take effect, no third-party payer shall fail to use the standard claim form prescribed in those rules.

Cite as R.C. § 3902.23

Effective Date: 07-24-2002