CHAPTER 3923: SICKNESS AND ACCIDENT INSURANCE

As used in this chapter, “policy of sickness and accident insurance” includes any policy, contract, or certificate of insurance against loss or expense resulting from the sickness of the insured, or from the bodily injury or death of the insured by accident, or both, that is delivered, issued for delivery, renewed, or used in this state on or after the date occurring six months after the effective date of this amendment.

Effective Date: 11-24-1995

As used in any policy of sickness and accident insurance delivered, issued for delivery, or used in this state, unless otherwise provided in the policy or in an indorsement thereon or in a rider attached thereto:

(A) “Total disability” means inability to perform the duties of any gainful occupation for which the insured is reasonably fitted by training, experience, and accomplishment.

(B) “Confinement to house” includes the activities of a convalescent not able to be gainfully employed.

(C) “Accidental death” means death by accident exclusively and independently of all other causes.

Effective Date: 01-10-1961

No certificate shall be furnished by any insurer in connection with, or pursuant to any provision of, any group sickness and accident insurance policy delivered, issued for delivery, or used in this state, and no policy of sickness and accident insurance shall be delivered, issued for delivery, or used in this state, nor shall any indorsement, rider, or application which becomes or which is designed to become a part of any such policy or certificate be delivered, issued for delivery, or used in this state, until a copy of the form of such policy, certificate, indorsement, rider, or application and of the premium rates and of the classification of risks pertaining thereto has been filed with the superintendent of insurance. No such policy, certificate, indorsement, rider or application shall be delivered, issued for delivery, or used until the expiration of thirty days after the form of such policy, certificate, indorsement, rider, or application has been filed with the superintendent, unless he has previously given to the insurer his written approval thereto. If the superintendent finds that any such form of policy, certificate, indorsement, rider, or application which has been filed with him by an insurer contains any provision which is contrary to the law of this state, or contains inconsistent provisions, or contains any question, provision, title, heading, backing, or other indication of its contents, which is ambiguous, misleading, or deceptive, or likely to mislead or deceive the policyholder, certificate holder or applicant, he shall give written notice of his finding to the insurer which has filed such form, and thereafter no insurer which has filed such form shall deliver, issue for delivery, or use such form in this state.

After the expiration of thirty days from the filing of any such form, or at any time after the superintendent has given written approval thereof, the superintendent may, after a hearing of which at least twenty days’ written notice has been given to the insurer issuing such form, withdraw approval on any ground stated in this section. Such disapproval shall be effected by written order of the superintendent which shall state the ground for disapproval and the date, not less than thirty days after such hearing, when the withdrawal of approval shall become effective. After the date when the withdrawal of approval of any such form becomes effective, such form shall not be delivered, issued for delivery, or used in this state. The form of any certificate furnished by any insurer to a resident of this state in connection with, or pursuant to any provisions of, any group sickness and accident insurance policy which policy is not delivered, issued for delivery, or used in this state but which insures residents of this state shall, upon request of the superintendent, be filed with the superintendent.

Effective Date: 07-01-1956

(A) As used in this section, “benefits provided are not unreasonable in relation to the premium charged” means the rates were calculated in accordance with sound actuarial principles.

(B) With respect to any filing, made pursuant to section 3923.02 of the Revised Code, of any premium rates for any individual policy of sickness and accident insurance or for any indorsement or rider pertaining thereto, the superintendent of insurance may, within thirty days after filing:

(1) Disapprove such filing after finding that the benefits provided are unreasonable in relation to the premium charged. Such disapproval shall be effected by written order of the superintendent, a copy of which shall be mailed to the insurer that has made the filing. In the order, the superintendent shall specify the reasons for the disapproval and state that a hearing will be held within fifteen days after requested in writing by the insurer. If a hearing is so requested, the superintendent shall also give such public notice as the superintendent considers appropriate. The superintendent, within fifteen days after the commencement of any hearing, shall issue a written order, a copy of which shall be mailed to the insurer that has made the filing, either affirming the prior disapproval or approving such filing after finding that the benefits provided are not unreasonable in relation to the premium charged.

(2) Set a date for a public hearing to commence no later than forty days after the filing. The superintendent shall give the insurer making the filing twenty days’ written notice of the hearing and shall give such public notice as the superintendent considers appropriate. The superintendent, within twenty days after the commencement of a hearing, shall issue a written order, a copy of which shall be mailed to the insurer that has made the filing, either approving such filing if the superintendent finds that the benefits provided are not unreasonable in relation to the premium charged, or disapproving such filing if the superintendent finds that the benefits provided are unreasonable in relation to the premium charged. This division does not apply to any insurer organized or transacting the business of insurance under Chapter 3907. or 3909. of the Revised Code.

(3) Take no action, in which case such filing shall be deemed to be approved and shall become effective upon the thirty-first day after such filing, unless the superintendent has previously given to the insurer a written approval.

(C) At any time after any filing has been approved pursuant to this section, the superintendent may, after a hearing of which at least twenty days’ written notice has been given to the insurer that has made such filing and for which such public notice as the superintendent considers appropriate has been given, withdraw approval of such filing after finding that the benefits provided are unreasonable in relation to the premium charged. Such withdrawal of approval shall be effected by written order of the superintendent, a copy of which shall be mailed to the insurer that has made the filing, which shall state the ground for such withdrawal and the date, not less than forty days after the date of such order, when the withdrawal or approval shall become effective.

(D) The superintendent may retain at the insurer’s expense such attorneys, actuaries, accountants, and other experts not otherwise a part of the superintendent’s staff as shall be reasonably necessary to assist in the preparation for and conduct of any public hearing under this section. The expense for retaining such experts and the expenses of the department of insurance incurred in connection with such public hearing shall be assessed against the insurer in an amount not to exceed one one-hundredth of one per cent of the sum of premiums earned plus net realized investment gain or loss of such insurer as reflected in the most current annual statement on file with the superintendent. Any person retained shall be under the direction and control of the superintendent and shall act in a purely advisory capacity.

Effective Date: 03-22-1999

(A) As used in this section:

(1)(a) “Administrative expense” means the amount resulting from the following: the amount of premiums received by the insurer for sickness and accident insurance business minus the sum of the amount of claims for losses paid; the amount of losses incurred but not reported; the amount paid for state fees, federal and state taxes, and reinsurance; and the costs and expenses related, either directly or indirectly, to the payment of commissions, measures to control fraud, and managed care.

(b) “Administrative expense” does not include any amounts collected, or administrative expenses incurred, by an insurer for the administration of an employee health benefit plan subject to regulation by the federal “Employee Retirement Income Security Act of 1974,” 88 Stat. 832, 29 U.S.C.A. 1001, as amended. “Amounts collected or administrative expenses incurred” means the total amount paid to an administrator for the administration and payment of claims minus the sum of the amount of claims for losses paid and the amount of losses incurred but not reported.

(2) “Insurer” means any insurance company authorized under Title XXXIX [39] of the Revised Code to do the business of sickness and accident insurance in this state.

(3) “Sickness and accident insurance business” does not include coverage provided by an insurer for specific diseases or accidents only; any hospital indemnity, medicare supplement, long-term care, disability income, one-time-limited-duration policy of no longer than six months, or other policy that offers only supplemental benefits; or coverage provided to individuals who are not residents of this state.

(B) Notwithstanding section 3941.14 of the Revised Code, the following apply to every insurer:

(1) For calendar year 1993, each insurer shall have aggregate administrative expenses of no more than forty per cent of the premium income of the insurer, based on the premiums received in that year on the sickness and accident insurance business of the insurer.

(2) For calendar year 1994, each insurer shall have aggregate administrative expenses of no more than thirty per cent of the premium income of the insurer, based on the premiums received in that year on the sickness and accident insurance business of the insurer.

(3) For calendar year 1995, each insurer shall have aggregate administrative expenses of no more than twenty-five per cent of the premium income of the insurer, based on the premiums received in that year on the sickness and accident insurance business of the insurer.

(4) For calendar year 1996 and every calendar year thereafter, each insurer shall have aggregate administrative expenses of no more than twenty per cent of the premium income of the insurer, based on the premiums received in that year on the sickness and accident insurance business of the insurer.

(C) Each insurer, on the first day of January or within sixty days thereafter, shall annually prepare, under oath, and deposit in the office of the superintendent of insurance a statement of the aggregate administrative expenses of the insurer, based on the premiums received in the immediately preceding calendar year on the sickness and accident insurance business of the insurer.

(D) No insurer shall fail to comply with division (B) of this section.

(E) If the superintendent determines that an insurer has violated division (D) of this section, the superintendent, pursuant to an adjudication conducted in accordance with Chapter 119. of the Revised Code, may order the suspension of the insurer’s license to do the business of sickness and accident insurance in this state until the superintendent is satisfied that the insurer is in compliance with division (B) of this section. If the insurer continues to do the business of sickness and accident insurance in this state while under the suspension order, the superintendent shall order the insurer to pay one thousand dollars for each day of the violation.

(F) Any money collected by the superintendent under division (E) of this section shall be deposited by him into the state treasury to the credit of the department of insurance operating fund.

Effective Date: 01-14-1993

No policy of sickness and accident insurance shall be delivered, issued for delivery, or used in this state unless all the following requirements are complied with:

(A) The entire money and other considerations therefor are expressed therein.

(B) The time at which insurance takes effect and terminates is expressed therein.

(C) It purports to insure only one person, except that a policy may be issued to the head of a family, who for this purpose may be the husband or the wife and who is considered the policyholder, covering any two or more members of any one family, including husband, wife, dependent children, any children under the age of nineteen, and other dependents living with the family.

(D) Every printed portion of the text matter and of any indorsements or attached papers shall be printed in uniform type of which the face shall be not less than ten point, the “text” to include all printed matter except the name and address of the insurer, name and title of the policy, captions, subcaptions, and form number. The superintendent of insurance shall not disapprove any such policy on the ground that every printed portion of its text matter or of any indorsement or attached paper is not printed in uniform type if it is shown that the type used is required to conform to the laws of another state in which the insurer is licensed.

(E) The exceptions and reductions of indemnity are adequately captioned and clearly set forth in the policy.

(F) Every such policy, including riders and indorsements, shall be identified by a form number in the lower left-hand corner of its first page.

Effective Date: 10-01-1953

Except as provided in section 3923.07 of the Revised Code, every policy of sickness and accident insurance delivered, issued for delivery, or used in this state shall contain the standard provisions specified in this section in the words in which the same appear in this section. Such standard provisions shall be preceded individually by the caption appearing in this section or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the superintendent of insurance may approve.

(A) A provision as follows: Entire contract; changes. This policy, including the indorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the insurer and unless such approval be indorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions.

No statement made by an applicant for a policy of sickness and accident insurance not included therein shall avoid the policy or be used to deny any claim thereunder or be used in any legal proceeding thereunder.

(B) A provision in two parts as follows: Time limit on certain defenses. (1) After two years from the date of issue of this policy no misstatements, except fraudulent misstatements, made by the applicant in the application for this policy shall be used to void this policy or to deny a claim for loss incurred or disability (as defined in this policy) commencing after the expiration of such two year period.

The policy provision in division (B)(1) of this section shall not be so construed as to affect any legal requirements for avoidance of a policy or denial of a claim during such initial two year period, nor to limit the application of divisions (A), (B), (C), (D), and (E) of section 3923.05 of the Revised Code in the event of misstatement with respect to age, occupation, or other insurance.

A policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums until at least age fifty, or a policy issued after the insured has attained age forty-four and which the insured has the right to continue in force subject to its terms by the timely payment of premiums for at least five years from its date of issue, may contain, in lieu of the foregoing policy provision in division (B)(1) of this section, a provision, from which the clause in parentheses may be omitted at the insurer’s option, under the caption Incontestable, as follows: After this policy has been in force for a period of two years during the lifetime of the insured (excluding any period during which the insured is disabled), it shall become incontestable as to the statements contained in the application.

(2) No claim for loss incurred or disability (as defined in this policy) commencing after two years from the date of issue of this policy shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss had existed prior to the effective date of coverage of this policy.

No chronic disease or chronic physical condition may be excluded from the coverage of a policy of sickness insurance or from the sickness insurance coverage of a policy of sickness and accident insurance except by name or specific description.

(C) A provision as follows: Grace period. A grace period of . . . . days will be granted for the payment of each premium falling due after the first premium, during which grace period this policy shall continue in force.

The insurer shall insert in the blank space in the policy provision in division (C) of this section a number not smaller than seven for weekly premium policies or ten for monthly premium policies or thirty-one for all other policies.

A policy in which the insurer reserves the right to refuse any renewal shall contain a provision, at the beginning of the policy provision in division (C) of this section, as follows: Unless not less than five days prior to the premium due date the insurer has delivered to the insured or has mailed to his last address as shown by the records of the insurer written notice of its intention not to renew this policy beyond the period for which the premium has been accepted. Each such policy, other than an accident insurance only policy, shall provide in substance, in a provision thereof or in an indorsement thereon or in a rider attached thereto, that the insurer may not refuse renewal of the policy before the first anniversary, or between anniversaries, of its date of issue, and that any non-renewal of the policy by the insurer or insured shall be without prejudice to any claim originating prior to the effective date of nonrenewal.

(D) A provision as follows: Reinstatement. If any renewal premium be not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any agent duly authorized by the insurer to accept such premium, without requiring in connection therewith an application for reinstatement, shall reinstate this policy. If the insurer or such agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, this policy will be reinstated upon approval of such application by the insurer or, lacking such approval, upon the forty-fifth day following the date of such conditional receipt unless the insurer has previously notified the insured in writing of its disapproval of such application. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than ten days after such date. In all other respects the insured and insurer shall have the same rights thereunder as they had under this policy immediately before the due date of the defaulted premium, subject to any provisions indorsed hereon or attached hereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than sixty days prior to the date of reinstatement.

The last sentence of the policy provision in division (D) of this section may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums until at least age fifty or from any policy issued after the insured has attained age forty-four and which the insured has the right to continue in force subject to its terms by the timely payment of premiums for at least five years from its date of issue.

(E) A provision as follows: Notice of claim. Written notice of claim must be given to the insurer within twenty days after the occurrence or commencement of any loss covered by this policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or the beneficiary to the insurer at . . . . . . . . or to any authorized agent of the insurer, with information sufficient to identify the insured, shall be deemed notice to the insurer.

The insurer shall insert in the blank space in the policy provision in division (E) of this section the location of such office as it may desire to designate for the purpose of notice.

In a policy providing a loss of time benefit which may be payable for at least two years, an insurer may insert, between the first and second sentences of the policy provision in division (E) of this section, a provision as follows:

Subject to the qualifications set forth below, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least two years, he shall, at least once in every six months after having given notice of claim, give to the insurer notice of continuance of said disability, except in the event of legal incapacity. The period of six months following any filing of proof by the insured or any payment by the insurer on account of such claim or any denial of liability in whole or in part by the insurer shall be excluded in applying this provision. Delay in giving of such notice shall not impair the insured’s right to any indemnity which would otherwise have accrued during the period of six months preceding the date on which such notice is actually given.

(F) A provision as follows: Claim forms. The insurer, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within fifteen days after the giving of such notice the claimant shall be deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in this policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made.

(G) A provision as follows: Proofs of loss. Written proof of loss must be furnished to the insurer at its office in case of claim for loss for which this policy provides any periodic contingent upon continuing loss within ninety days after the termination of the period for which the insurer is liable and in case of claim for any other loss within ninety days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required.

(H) A provision as follows: Time of payment of claims. Indemnities payable under this policy for any loss, other than loss for which this policy provides any periodic payment, will be paid immediately upon, or within thirty days after, receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment will be paid . . . . . . . . and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof.

The insurer shall insert in the blank space in the provision in division (H) of this section a period for payment which must not be less frequently than monthly. The insurer may at its option omit from the provision in division (H) of this section ”, or within thirty days after,”.

(I) A provision as follows: Payment of claims. Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to the estate of the insured. Any other accrued indemnities unpaid at the insured’s death may, at the option of the insurer, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the insured.

The insurer may at its option add at the end of the provision in division (I) of this section, the following provisions or either of the following provisions:

(1) If any indemnity of this policy shall be payable to the estate of the insured, or to an insured or beneficiary who is a minor or otherwise not competent to give a valid release, the insurer may pay such indemnity, up to an amount not exceeding . . . . . . . . dollars, to any relative by blood or connection by marriage of the insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any payment made by the insurer in good faith pursuant to this provision shall fully discharge the insurer to the extent of such payment.

(2) Subject to any written direction of the insured in the application or otherwise all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical, or surgical services may, at the insurer’s option and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the services be rendered by a particular hospital or person.

The insurer shall insert in the blank space in the policy provision in division I [(I)] (1) of this section an amount which shall not exceed one thousand dollars.

(J) A provision as follows: Physical examination and autopsy. The insurer at its own expense shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law.

(K) A provision as follows: Legal actions. No action at law or in equity shall be brought to recover on this policy prior to the expiration of sixty days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished.

(L) A provision as follows: Change of beneficiary. Unless the insured makes an irrevocable designation of beneficiary, the right to change of beneficiary is reserved to the insured and the consent of the beneficiary or beneficiaries shall not be requisite to surrender or assignment of this policy or to any change of beneficiary or beneficiaries, or to any other changes in this policy.

The insurer may at its option omit from the provision in division (L) of this section the following: Unless the insured makes an irrevocable designation of beneficiary.

(M) A provision, which shall be contained in the policy or in an indorsement thereon or in a rider attached thereto, as follows: Cancellation by the insured. Non-cancellation by the insurer. The insured may cancel this policy at any time by written notice delivered or mailed to the insurer, effective upon receipt or on such later date as may be specified in such notice. In the event of cancellation, the insurer will return promptly the unearned portion of any premium paid. The earned premium shall be computed by the use of the short-rate table last filed with the state official having supervision of insurance in the state where the insured resided when this policy was issued. Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation. The insurer may not cancel this policy. This provision nullifies any other provision, contained in this policy or in any indorsement hereon or in any rider attached hereto, which provides for cancellation of this policy by the insurer or by the insured.

Effective Date: 07-01-1956

Effective Date: 10-14-1969

Except as provided in section 3923.07 of the Revised Code, no policy of sickness and accident insurance delivered, issued for delivery, or used in this state shall contain provisions respecting the matters set forth in this section unless such provisions are in the words in which the same appear in this section. Any such provisions in any such policy shall be preceded by the appropriate caption appearing in this section or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the superintendent of insurance may approve.

(A) A provision as follows: Change of occupation. If the insured be injured or contract sickness after having changed his occupation to one classified by the insurer as more hazardous than that stated in this policy or while doing for compensation anything pertaining to an occupation so classified, the insurer will pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for such more hazardous occupation. If the insured changes his occupation to one classified by the insurer as less hazardous than that stated in this policy, the insurer, upon receipt of proof of such change of occupation, will reduce the premium rate accordingly, and will return the excess pro-rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent. In applying this provision, the classification for occupational risk and the premium rates shall be such as have been last filed by the insurer prior to the occurrence of the loss for which the insurer is liable or prior to the date of proof of change in occupation with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued; but if such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the insurer in such state prior to the occurrence of the loss or prior to the date of proof of change in occupation.

(B) A provision as follows: Misstatement of age. If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age.

(C) A provision as follows:

(1) Other insurance in this insurer. If an accident or sickness or accident and sickness policy or policies previously issued by the insurer to the insured be in force concurrently herewith, making the aggregate indemnity for . . . . . . . . in excess of . . . . . . . . dollars, the excess insurance shall be void and all premiums paid for such excess shall be returned to the insured or to his estate.

The insurer shall insert the type of coverage or coverages in the first blank space in the provision in division (C)(1) of this section and the maximum limit of indemnity or indemnities in the second blank space in the provision in division (C)(1) of this section.

(2) In lieu of the foregoing provision in division (C)(1) of this section, a provision as follows: Other insurance in this insurer. Insurance effective at any time on the insured under a like policy or policies in this insurer is limited to the one such policy elected by the insured, his beneficiary or his estate, as the case may be, and the insurer will return all premiums paid for all other such policies.

(D) A provision as follows: Insurance with other insurers. If there be other valid coverage, not with this insurer, providing benefits for the same loss on a provision of service basis or on an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability under any expense incurred coverage of this policy shall be for such proportion of the loss as the amount which would otherwise have been payable hereunder plus the total of the like amounts under all such other valid coverages for the same loss of which this insurer had notice bears to the total like amounts under all valid coverages for such loss, and for the return of such portion of the premiums paid as shall exceed the pro-rata portion for the amount so determined. For the purpose of applying this provision when other coverage is on a provision of service basis, the “like amount” of such other coverage shall be taken as the amount which the services rendered would have cost in the absence of such coverage.

If the provision in division (D) of this section is included in a policy of sickness and accident insurance which also contains the provision in division (E) of this section, the insurer shall add to the caption of the provision in division (D) of this section the following: Expense incurred benefits.

The insurer may at its option include in the provision in division (D) of this section a definition of “other valid coverage” approved as to form by the superintendent. Such definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of the Dominion of Canada, and by hospital or medical service organizations, and to any other coverage the inclusion of which may be approved by the superintendent. In the absence of such definition in the provision in division (D) of this section, “other valid coverage” as used in such provision shall not include group insurance, automobile medical payments insurance, or coverage provided by hospital or medical service organizations or by union welfare plans or employer or employee benefit organizations.

For the purpose of applying the provision in division (D) of this section with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute, including any workers’ compensation or employer’s liability statute, whether provided by governmental agency or otherwise, shall in all cases be deemed to be “other valid coverage” of which the insurer has had notice.

In applying the provision in division (D) of this section no third party liability coverage shall be included as “other valid coverage.”

(E) A provision as follows: Insurance with other insurers. If there be other valid coverage, not with this insurer, providing benefits for the same loss on other than an expense incurred basis and of which the insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability for such benefits under this policy shall be for such proportion of the indemnities otherwise provided hereunder for such loss as the like indemnities of which the insurer had notice (including the indemnities under this policy) bear to the total amount of all like indemnities for such loss, and for the return of such portion of the premium paid as shall exceed the pro-rata portion for the indemnities thus determined.

If the provision in division (E) of this section is included in a policy of sickness and accident insurance which also contains the provision in division (D) of this section, the insurer shall add to the caption of the provision in division (E) of this section the following: Other benefits.

The insurer may at its option include in the provision in division (E) of this section a definition of “other valid coverage” approved as to form by the superintendent. Such definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of the Dominion of Canada, and to any other coverage the inclusion of which may be approved by the superintendent. In the absence of such definition in the provision in division (E) of this sections [section], “other valid coverage” as used in such provision shall not include group insurance, or benefits provided by union welfare plans or by employer or employee benefit organizations.

For the purpose of applying the provision in division (E) of this section with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute, including any workers’ compensation or employer’s liability statute, whether provided by a governmental agency or otherwise, shall in all cases be deemed to be “other valid coverage” of which the insurer has had notice.

In applying the provision in division (E) of this section no third party liability coverage shall be included as “other valid coverage.”

(F) A provision as follows: Relation of earnings to insurance. If the total monthly amount of loss of time benefits promised for the same loss under all valid loss of time coverage upon the insured, whether payable on a weekly or monthly basis, shall exceed the monthly earnings of the insured at the time disability commenced or his average monthly earnings for the period of two years immediately preceding a disability for which claim is made, whichever is the greater, the insurer will be liable only for such proportionate amount of such benefits under this policy as the amount of such monthly earnings or such average monthly earnings of the insured bears to the total amount of monthly benefits for the same loss under all such coverage upon the insured at the time such disability commences and for the return of such part of the premiums paid during such two years as shall exceed the pro-rata amount of the premiums for the benefits actually paid hereunder; this shall not operate to reduce the total monthly amount of benefits payable under all such coverage upon the insured below the sum of two hundred dollars or the sum of the monthly benefits specified in such coverages, whichever is the lesser, nor shall this operate to reduce benefits other than those payable for loss of time.

The provision in division (F) of this section may be placed only in a policy of sickness and accident insurance which the insured has a right to continue in force subject to its terms by the timely payment of premiums until at least age fifty or in a policy of sickness and accident insurance issued after the insured has attained age forty-four and which the insured has the right to continue in force subject to its terms by the timely payment of premiums for at least five years from its date of issue.

The insurer may at its option include in the provision in division (F) of this section a definition of “valid loss of time coverage” approved as to form by the superintendent. Such definition shall be limited in subject matter to coverage provided by governmental agencies or by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of the Dominion of Canada or to any other coverage the inclusion of which may be approved by the superintendent or any combination of such coverages. In the absence of such definition in the provision in division (F) of this section “valid loss of time coverage” as used in such provision shall not include any coverage provided for such insured pursuant to any compulsory benefit statute, including any workers’ compensation or employer’s liability statute, whether provided by a governmental agency or otherwise, or benefits provided by union welfare plans or by employer or employee benefit organizations.

(G) A provision as follows: Unpaid premium. Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom.

(H) A provision as follows: Conformity with state statutes. Any provision of this policy which, on its effective date, is in conflict with the statutes of the state in which the insured resides on such date is hereby amended to conform to the minimum requirements of such statutes.

(I) A provision as follows: Illegal occupation. The insurer shall not be liable for any loss to which a contributing cause was the insured’s commission of or attempt to commit a felony or to which a contributing cause was the insured’s being engaged in an illegal occupation.

(J) A provision as follows: Intoxicants and narcotics. The insurer shall not be liable for any loss sustained or contracted in consequence of the insured’s being intoxicated or under the influence of any narcotic unless administered on the advice of a physician.

Effective Date: 01-17-1977

The policy provisions set forth in sections 3923.04 and 3923.05 of the Revised Code or any corresponding policy provisions used in lieu thereof in accordance with section 3923.07 of the Revised Code shall be printed in each policy of sickness and accident insurance in the order in which such policy provisions are set forth in sections 3923.04 and 3923.05 of the Revised Code or, at the option of the insurer, any such policy provision may be printed as a unit in any part of any such policy along with other policy provisions to which such policy provision may be logically related, provided the resulting policy shall not be wholly or partly unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to whom such policy is offered, delivered, or issued.

As used in sections 3923.01, 3923.04, 3923.05, 3923.06, 3923.07, 3923.10, 3923.13, 3923.15, 3923.19 and 3923.20 of the Revised Code, “insured” shall not be construed as preventing a person other than the insured with a proper insurable interest from making application for and owning a policy of sickness and accident insurance covering the insured or from being entitled under such policy to any indemnities, benefits, and rights provided therein.

Any policy of sickness and accident insurance may contain a provision for paying not exceeding two hundred dollars as an extended disability benefit upon the insured’s death from any cause, which benefit shall not be construed as life insurance.

If any such policy contains a provision establishing, as an age limit or otherwise, a date after which the coverage provided by the policy will not be effective, and if such date falls within a period for which premium is accepted by the insurer or if the insurer accepts a premium after such date, the coverage provided by the policy will continue in force subject to the right of cancellation by the insured until the end of the period for which premium has been accepted. The insurer may not refuse to accept any premium due before the first anniversary, or between anniversaries, of the date of issue of any policy other than an accident insurance only policy. In the event the age of the insured has been misstated and if, according to the correct age of the insured, the coverage provided by the policy would not have become effective, or would have ceased prior to the acceptance of such premium or premiums, then the liability of the insurer shall be limited to the refund, upon request, of all premiums paid for the period not covered by the policy.

Any such policy may contain a provision making any portion of the charter, constitution, or bylaws of the insurer a part of the policy, but such portion of the charter, constitution, or bylaws shall be set forth in full in the policy, provided that this provision shall not apply to any statement of rates or classification of risks or short rate table filed with the superintendent of insurance.

Effective Date: 07-01-1956

(A) On and after January 1, 2003, any insurance company authorized to do business in this state shall pay interest, in accordance with division (B) of this section and subject to division (C) of this section, on any proceeds that become due pursuant to the terms of a policy of sickness and accident insurance due to the death of the insured by sickness or accident.

(B) The interest payable pursuant to division (A) of this section shall be computed from the date of the death of the insured to the date of the payment of the proceeds and shall be at whichever of the following rates is greater:

(1) The annual short-term applicable federal rate for purposes of section 1274(d) of the Internal Revenue Code, as defined in section 5747.01 of the Revised Code, in effect for the month in which the insured died;

(2) The current rate of interest on proceeds left on deposit with the company under an interest settlement option contained in the policy of sickness and accident insurance.

(C) Division (A) or (B) of this section does not require the payment of interest unless the insured was a resident of this state on the date of the insured’s death and unless the beneficiary under the policy of sickness and accident insurance elects in writing to receive, or a written election has been made for the beneficiary to receive, the proceeds of the policy by means of a lump sum payment.

Effective Date: 07-26-2002

If any policy provision set forth in section 3923.04 or 3923.05 of the Revised Code is in whole or in part inapplicable or inconsistent with the coverage provided by a policy of sickness and accident insurance, the insurer shall, with the approval of the superintendent of insurance, omit from such policy any inapplicable provision or part of a provision and shall, with the approval of the superintendent, modify any inconsistent provision or part of a provision in such manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.

In any such policy an insurer may at its option substitute for, or use in lieu of, any one or more of the policy provisions set forth in sections 3923.04 and 3923.05 of the Revised Code a corresponding policy provision or corresponding policy provisions of different wording approved by the superintendent which is not less favorable in any respect to the insured or the beneficiary.

No policy provision not subject to sections 3923.04 and 3923.05 of the Revised Code shall make any policy of sickness and accident insurance or any part of any such policy less favorable in any respect to the insured or the beneficiary than the provisions thereof which are subject to such sections.

Effective Date: 10-14-1953

Any policy of sickness and accident insurance, indorsement, rider, or application which could have been lawfully delivered, issued for delivery, or used in this state on October 1, 1953, may be delivered, issued for delivery, or used in this state until January 1, 1956, without being subject to sections 3923.04 to 3923.07, inclusive, of the Revised Code.

A copy of the form of any policy of sickness and accident insurance, indorsement, rider, or application which could have been lawfully delivered, issued for delivery, or used in this state on October 1, 1953, may be filed with and approved by the superintendent at any time after October 1, 1953, for subsequent delivery, issuance for delivery, and use in this state until January 1, 1956, without being subject to sections 3923.04 to 3923.07, inclusive, of the Revised Code.

A copy of the form of any rider or indorsement which could have been lawfully delivered, issued for delivery, or used in this state on October 1, 1953, may be filed with and approved by the superintendent at any time after October 1, 1953, for subsequent delivery, issuance for delivery, or use in this state at any time after October 1, 1953, in connection with and as a part of policies of sickness and accident insurance issued before January 1, 1956, on any policy form which could have been lawfully delivered, issued for delivery, or used in this state on October 1, 1953, regardless of when such policy form was filed with and approved by the superintendent, without such rider or indorsement being subject to sections 3923.04 to 3923.07, inclusive, of the Revised Code.

Effective Date: 10-14-1953

Any foreign or alien insurer authorized to do business in this state may, with the approval of the superintendent of insurance, insert in any policy of sickness and accident insurance, delivered, issued for delivery, or used in this state, any provision required by the laws of the state or the country in which such insurer is domiciled, if such provision is not substantially in conflict with any law of this state.

Any domestic insurer may insert in any such policy issued for delivery in another state or foreign country, and governed by the laws thereof, any provision required by the laws of such other state or country applicable to such policy.

Effective Date: 10-01-1953

A policy of sickness and accident insurance issued in violation of sections 3923.01 to 3923.22, inclusive, of the Revised Code, is valid but shall be construed as provided by such sections, and when any provision in such policy is in conflict with such sections, the rights, duties, and obligations of the insurer, the policyholder, and the beneficiary shall be governed by such sections.

Effective Date: 10-01-1953

Industrial sickness and accident insurance is that form of sickness and accident insurance under individual policies for which the premium is payable weekly, and includes any such policy which covers sickness only or accident only.

Any insurer authorized to make, transact, or issue sickness and accident insurance in this state may make, transact, or issue industrial sickness and accident insurance in this state.

No policy of industrial sickness and accident insurance may be delivered, issued for delivery, or used in this state unless it has printed thereon the words “industrial policy.”

Each such policy shall be subject to sections 3923.01 to 3923.22, inclusive, of the Revised Code. Such policy may contain a provision that, upon proper written request, a named beneficiary shall be designated in or by indorsement on the policy to receive the proceeds thereof on the death of the insured, and there shall be reserved to the insured the power to change the beneficiary at any time by written notice to the insurer at its home office, accompanied by the policy for indorsement of the change thereon by the insurer. The insurer may refuse to designate a beneficiary if evidence satisfactory to the company of such beneficiary’s insurable interest in the life of the insured is not furnished on request. Any such policy may provide in substance that any payment thereunder may be made to the insured or the insured’s estate, or to any relative by blood or connection by marriage of the insured, or to the extent of such portion of any payment under the policy as may reasonably appear to the insurer to be due to such person, or to any other person equitably entitled thereto by reason of having incurred expense occasioned by the maintenance, illness, or burial of the insured. If the policy is in force at the death of the insured, the proceeds thereof shall be payable to the named beneficiary if he is living, but upon the expiration of fifteen days after the death of the insured, unless proof of claim in the manner and form required by the policy, accompanied by the policy for surrender, has previously been made by such beneficiary, the insurer may pay said proceeds to any other person permitted by the policy.

Effective Date: 07-01-1956

Sickness and accident insurance on a franchise plan is that form of sickness and accident insurance issued to either of the following:

(A) Five or more employees of any corporation, copartnership, or individual employer, or of any governmental corporation or agency or a department thereof;

(B) Ten or more members of any trade or professional association, or labor union, or any other association having had an active existence for at least two years where such association or union has a constitution or bylaws and is formed in good faith for purposes other than that of obtaining insurance. In order that such sickness and accident insurance be considered as issued on a franchise plan, such employees or such members, with or without one or more of their dependents and members of their immediate families, must be issued the same form of an individual policy, varying only as to amounts and kinds of coverage applied for by such employees or such members, under an arrangement by which the premiums on such policies may be paid to the insurer periodically by the employer, with or without payroll deductions, or by the association for its members, or by some designated person acting on behalf of such employer or association.

Effective Date: 10-01-1953

(A) Group sickness and accident insurance is that form of sickness and accident insurance covering any group of two or more employees, members, or other persons, with or without one or more of their dependents and members of their immediate families. Such insurance may be offered to groups without regard to the purpose or type of group or the occupation of the employees, members, or other persons insured under the policy.

(B) As used in this section:

(1) “Employees” includes the officers, managers, and employees of the employer, the partners, if the employer is a partnership, the officers, managers, and employees of subsidiary or affiliated corporations of a corporation employer, and the individual proprietors, partners, and employees of individuals and firms, the business of which is controlled by the insured employer through stock ownership, contract, or otherwise.

(2) “Employer” includes any municipal or governmental corporation, unit, agency, or department thereof, as well as private individuals, partnerships, and corporations.

(C) Each such policy shall contain in substance the following provisions:

(1) A provision that the policy, the application of the policyholder, if the application or copy thereof is attached to the policy, and the individual applications submitted in connection with the policy by the employees or members, shall constitute the entire contract between the parties, and that all statements, in the absence of fraud, made by any applicant shall be deemed representations and not warranties, and that no such statement shall avoid the insurance or reduce benefits thereunder unless contained in a written application;

(2) A provision that the insurer will furnish to the policyholder, for delivery to each employee or member of the insured group, an individual certificate setting forth in summary form a statement of the essential features of the insurance coverage of the employee or member and to whom benefits thereunder are payable. If dependents or members of the immediate family of the employee or member are included in the coverage, only one certificate need be issued for each family unit.

(3) A provision that to the group originally insured may be added from time to time eligible new employees or members, their dependents, or members of their immediate families, in accordance with the terms of the policy.

(D) Each such policy together with any application in connection therewith shall be available for inspection at all reasonable times at the place of business or principal residence of the policyholder where the policy is on file, by any beneficiary thereunder, or by an authorized representative of the beneficiary.

Effective Date: 04-11-1991

(A) As used in this section:

(1) “Association” means a voluntary unincorporated association of insurers formed for the sole purpose of enabling cooperative action to provide sickness and accident insurance in accordance with this section.

(2) “Insurer” means any insurance company authorized to do the business of sickness and accident insurance in this state.

(3) “Insured” means a person covered under a group policy issued pursuant to this section.

(B) Any insurer may join with one or more other insurers, in an association, to offer, sell, and issue to a policyholder selected by the association a policy of group insurance against major financial loss from sickness and accident covering residents of this state who are sixty-five years of age or older and the spouses of such residents. The insurance shall be offered, issued, and administered in the name of the association. Membership in the association shall be open to any insurer and each insurer which participates shall be liable for a specified percentage of the risks. The policy may be executed on behalf of the association by a duly authorized person and need not be countersigned by an agent.

(C) The persons eligible for coverage under the policy shall be all residents of this state who are sixty-five years of age or older and their spouses, subject to reasonable underwriting restrictions to be set forth in the plan of the association. The policy may provide basic hospital and surgical coverage, basic medical coverage, major medical coverage, and any combination of these; provided that it shall not be required as a condition for obtaining major medical coverage that any basic coverage be taken.

(D) The association shall file with the superintendent of insurance any policy, contract, certificate, or other evidence of insurance, application, or other forms pertaining to such insurance together with the premium rates to be charged therefor. The superintendent may approve, disapprove, and withdraw approval of the forms in accordance with section 3923.02 of the Revised Code, or the premium rates if by reasonable assumptions such rates are excessive in relation to the benefits provided. In determining whether such rates by reasonable assumptions are excessive in relation to the benefits provided the superintendent shall give due consideration to past and prospective claim experience, within and outside this state, and to fluctuations in such claim experience, to a reasonable risk charge, to contribution to surplus and contingency funds, to past and prospective expenses, both within and outside this state, and to all other relevant factors within and outside this state, including any differing operating methods of the insurers joining in the issuance of the policy. In reviewing the forms the superintendent shall not be bound by the requirements of sections 3923.04 to 3923.07 of the Revised Code with respect to standard provisions to be included in sickness and accident policies or forms.

(E) The association may enroll eligible persons for coverage under the policy through any insurance agent licensed to sell sickness and accident insurance pursuant to Chapter 3905. of the Revised Code or section 3941.02 of the Revised Code.

(F) The association shall file annually with the superintendent on such date and in such form as the superintendent may prescribe, a financial summary of its operations.

(G) The association may sue and be sued in its associate name and for such purposes only shall be treated as a domestic corporation. Service of process against the association made upon a managing agent, any member thereof, or any agent authorized by appointment to receive service of process, shall have the same force and effect as if the service had been made upon all members of the association.

(H) Under any policy issued as provided in this section, the policyholder, or such person as the policyholder shall designate, shall alone be a member of each domestic mutual insurance company joining in the issue of the policy and shall be entitled to one vote by virtue of such policy at the meetings of each such mutual insurance company. Notice of the annual meetings of each such mutual insurance company may be given by written notice to the policyholder or as otherwise prescribed in the policy.

Effective Date: 09-01-2002

(A) Every policy of group sickness and accident insurance providing hospital, surgical, or medical expense coverage for other than specific diseases or accidents only, and delivered, issued for delivery, or renewed in this state on or after January 1, 1976, shall include a provision giving each insured the option to convert to the following:

(1) In the case of an individual who is not a federally eligible individual, any of the individual policies of hospital, surgical, or medical expense insurance then being issued by the insurer with benefit limits not to exceed those in effect under the group policy;

(2) In the case of a federally eligible individual, a basic or standard plan established by the board of directors of the Ohio health reinsurance program or plan substantially similar to the basic and standard plan in benefit design and scope of covered services. For purposes of division (A)(2) of this section, the superintendent of insurance shall determine whether a plan is substantially similar to the basic or standard plan in benefit design and scope of covered services.

(B) An option for conversion to an individual policy shall be available without evidence of insurability to every insured, including any person eligible under division (D) of this section, who terminates employment or membership in the group holding the policy after having been continuously insured thereunder for at least one year.

Upon receipt of the insured’s written application and upon payment of at least the first quarterly premium not later than thirty-one days after the termination of coverage under the group policy, the insurer shall issue a converted policy on a form then available for conversion. The premium shall be in accordance with the insurer’s table of premium rates in effect on the later of the following dates:

(1) The effective date of the converted policy;

(2) The date of application therefor; and shall be applicable to the class of risk to which each person covered belongs and to the form and amount of the policy at the person’s then attained age. However, premiums charged federally eligible individuals may not exceed an amount that is two times the midpoint of the standard rate charged any other individual of a group to which the insurer is currently accepting new business and for which similar copayments and deductibles are applied.

At the election of the insurer, a separate converted policy may be issued to cover any dependent of an employee or member of the group.

Except as provided in division (H) of this section, any converted policy shall become effective as of the day following the date of termination of insurance under the group policy.

Any probationary or waiting period set forth in the converted policy is deemed to commence on the effective date of the insured’s coverage under the group policy.

(C) No insurer shall be required to issue a converted policy to any person who is, or is eligible to be, covered for benefits at least comparable to the group policy under:

(1) Title XVIII of the Social Security Act, as amended or superseded;

(2) Any act of congress or law under this or any other state of the United States that duplicates coverage offered under division (C)(1) of this section;

(3) Any policy that duplicates coverage offered under division (C)(1) of this section;

(4) Any other group sickness and accident insurance providing hospital, surgical, or medical expense coverage for other than specific diseases or accidents only.

(D) The option for conversion shall be available:

(1) Upon the death of the employee or member, to the surviving spouse with respect to such of the spouse and dependents as are then covered by the group policy;

(2) To a child solely with respect to the child upon attaining the limiting age of coverage under the group policy while covered as a dependent thereunder;

(3) Upon the divorce, dissolution, or annulment of the marriage of the employee or member, to the divorced spouse, or former spouse in the event of annulment, of such employee or member, or upon the legal separation of the spouse from such employee or member, to the spouse.

Persons possessing the option for conversion pursuant to this division shall be considered members for the purposes of division (H) of this section.

(E) If coverage is continued under a group policy on an employee following retirement prior to the time the employee is, or is eligible to be, covered by Title XVIII of the Social Security Act, the employee may elect, in lieu of the continuance of group insurance, to have the same conversion rights as would apply had the employee’s insurance terminated at retirement by reason of termination of employment.

(F) If the insurer and the group policyholder agree upon one or more additional plans of benefits to be available for converted policies, the applicant for the converted policy may elect such a plan in lieu of a converted policy.

(G) The converted policy may contain provisions for avoiding duplication of benefits provided pursuant to divisions (C)(1), (2), (3), and (4) of this section or provided under any other insured or noninsured plan or program.

(H) If an employee or member becomes entitled to obtain a converted policy pursuant to this section, and if the employee or member has not received notice of the conversion privilege at least fifteen days prior to the expiration of the thirty-one-day conversion period provided in division (B) of this section, then the employee or member has an additional period within which to exercise the privilege. This additional period shall expire fifteen days after the employee or member receives notice, but in no event shall the period extend beyond sixty days after the expiration of the thirty-one-day conversion period.

Written notice presented to the employee or member, or mailed by the policyholder to the last known address of the employee or member as indicated on its records, constitutes notice for the purpose of this division. In the case of a person who is eligible for a converted policy under division (D)(2) or (D)(3) of this section, a policyholder shall not be responsible for presenting or mailing such notice, unless such policyholder has actual knowledge of the person’s eligibility for a converted policy.

If an additional period is allowed by an employee or member for the exercise of a conversion privilege, and if written application for the converted policy, accompanied by at least the first quarterly premium, is made after the expiration of the thirty-one-day conversion period, but within the additional period allowed an employee or member in accordance with this division, the effective date of the converted policy shall be the date of application.

(I) The converted policy may provide that any hospital, surgical, or medical expense benefits otherwise payable with respect to any person may be reduced by the amount of any such benefits payable under the group policy for the same loss after termination of coverage.

(J) The converted policy may contain:

(1) Any exclusion, reduction, or limitation contained in the group policy or customarily used in individual policies issued by the insurer;

(2) Any provision permitted in this section;

(3) Any other provision not prohibited by law.

Any provision required or permitted in this section may be made a part of any converted policy by means of an endorsement or rider.

(K) The time limit specified in a converted policy for certain defenses with respect to any person who was covered by a group policy shall commence on the effective date of such person’s coverage under the group policy.

(L) No insurer shall use deterioration of health as the basis for refusing to renew a converted policy.

(M) No insurer shall use age as the basis for refusing to renew a converted policy.

(N) A converted policy made available pursuant to this section shall, if delivery of the policy is to be made in this state, comply with this section. If delivery of a converted policy is to be made in another state, it may be on a form offered by the insurer in the jurisdiction where the delivery is to be made and which provides benefits substantially in compliance with those required in a policy delivered in this state.

(O) As used in this section, “federally eligible individual” means an eligible individual as defined in 45 C.F.R. 148.103.

Effective Date: 03-22-1999

(A) As used in this section:

(1) “Association” means a voluntary unincorporated association of insurers formed for the sole purpose of enabling cooperative action to provide health coverage in accordance with this section.

(2) “Insurer” includes any insurance company authorized to do the business of sickness and accident insurance in this state and any health insuring corporation holding a certificate of authority under Chapter 1751. of the Revised Code.

(3) “Insured” means a person covered under a group policy or contract issued pursuant to this section.

(4) “Qualified unemployed person” means one who became unemployed while a resident of this state from employment or self-employment and has since been continuously unemployed or is employed only so that the person does not have, or have a right to purchase, group health coverage. An individual who is, or who becomes, covered by medicare is not a qualified unemployed person. A person eligible for coverage under this section, who is also eligible for continuation of coverage under section 1751.53 or 3923.38 of the Revised Code, may elect either coverage, but not both. A person who elects continuation of coverage under either of such sections may, upon the termination of the continuation of coverage, elect any coverage available under this section.

(B) Any insurer may join with one or more other insurers, in an association, to offer, sell, and issue to a policyholder or subscriber selected by the association a policy or contract of group health coverage, covering residents of this state who are qualified unemployed persons and the spouses or dependents of such residents. The coverage shall be offered, issued, and administered in the name of the association. Membership in the association shall be open to any insurer and each insurer which participates shall be liable for a specified percentage of the risks. The policy or contract may be executed on behalf of the association by a duly authorized person.

(C) The persons eligible for coverage under the policy or contract shall be all residents of this state who are qualified unemployed persons and their spouses and dependents, subject to reasonable underwriting restrictions to be set forth in the plan of the association. The policy or contract may provide basic hospital and surgical coverage, basic medical coverage, major medical coverage, and any combination of these; provided that it shall not be required as a condition for obtaining major medical coverage that any basic coverage be taken.

(D) The association shall file with the superintendent of insurance any policy, contract, certificate, or other evidence of coverage, application, or other forms pertaining to such insurance together with the premium rates to be charged therefor. The superintendent may approve, disapprove, and withdraw approval of the forms in accordance with section 3923.02 of the Revised Code, or the premium rates if by reasonable assumptions such rates are excessive in relation to the benefits provided. In determining whether such rates by reasonable assumptions are excessive in relation to the benefits provided, the superintendent shall give due consideration to past and prospective claim experience, within and outside this state, and to fluctuations in such claim experience, to a reasonable risk charge, to contribution to surplus and contingency funds, to past and prospective expenses, both within and outside this state, and to all other relevant factors within and outside this state, including any differing operating methods of the insurers joining in the issuance of the policy or contract. In reviewing the forms the superintendent shall not be bound by the requirements of sections 3923.04 to 3923.07 of the Revised Code with respect to standard provisions to be included in sickness and accident policies or forms.

(E) The association may enroll eligible persons for coverage under the policy or contract through any person licensed by, or authorized under the law of, this state to sell the policies or contracts, or to enroll persons in the health plans, of any of the insurers participating in the association.

(F) The association shall file annually with the superintendent on such date and in such form as the superintendent may prescribe, a financial summary of its operations.

(G) The association may sue and be sued in its associate name and for such purposes only shall be treated as a domestic corporation. Service of process against such association made upon a managing agent, any member thereof, or any agent authorized by appointment to receive service of process, shall have the same force and effect as if such service had been made upon all members of the association.

(H) Under any policy issued as provided in this section, the policyholder, or such person as the policyholder shall designate, shall alone be a member of each domestic mutual insurance company joining in the issue of the policy and shall be entitled to one vote by virtue of such policy at the meetings of each such mutual insurance company. Notice of the annual meetings of each such mutual insurance company may be given by written notice to the policyholder or as otherwise prescribed in said policy.

Effective Date: 06-04-1997

Blanket sickness and accident insurance is that form of sickness and accident insurance covering special groups of persons as enumerated in one of the following divisions:

(A) Under a policy issued to any common carrier, which shall be deemed the policyholder, covering a group defined as all persons who may become passengers on such common carrier;

(B) Under a policy issued to an employer, who shall be deemed the policyholder, covering any group of employees defined by reference to exceptional hazards incident to such employment;

(C) Under a policy issued to a college, school, or other institution of learning, or to the head or principal thereof, who or which shall be deemed the policyholder, covering students or teachers;

(D) Under a policy issued in the name of any volunteer fire department or first aid or other similar volunteer group, which shall be deemed the policyholder, covering all of the members of such department or group;

(E) Under a policy issued to any other substantially similar group which, in the discretion of the superintendent of insurance, may be subject to the issuance of a blanket sickness and accident policy.

An individual application is not required from a person covered under a blanket sickness or accident policy, nor is it necessary for the insurer to furnish each person a certificate.

All benefits under any blanket sickness and accident policy shall be payable to the person insured, or to his designated beneficiary, or to his estate, except that if the person insured is a minor, such benefits may be made payable to his parent, guardian, or other person actually supporting him.

This section does not affect the legal liability of policyholders for the death of, or injury to, any member of any such group.

Effective Date: 10-01-1953

The falsity of any statement in the application for any policy of sickness and accident insurance shall not bar the right to recovery thereunder, or be used in evidence at any trial to recover upon such policy, unless it is clearly proved that such false statement is willfully false, that it was fraudulently made, that it materially affects either the acceptance of the risk or the hazard assumed by the insurer, that it induced the insurer to issue the policy, and that but for such false statement the policy would not have been issued.

No alteration of any written application for any such policy, by erasure, insertion, or otherwise, shall be made by any person other than the applicant without the written consent of said 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.

Effective Date: 07-01-1956

Any person who solicits an application for, or for reinstatement of, a policy of sickness and accident insurance to insure any other person shall be considered the agent of the insurer and not of the insured in any controversy between the insured or his beneficiary and the insurer issuing or reinstating a policy upon such application or accepting or making a renewal of such policy.

Effective Date: 07-01-1956

No insurer doing the business of sickness and accident insurance in this state shall make or permit any unfair discrimination between individuals of substantially the same hazard in the amount of premium rates charged for any policy or contract of such insurance or in the benefits payable thereunder. This section does not prohibit different premium rates, different benefits, or different underwriting procedure for individuals insured under group, franchise, or blanket plans of insurance, or for individuals insured under a policy issued to the head of a family as provided in section 3923.03 of the Revised Code.

Effective Date: 10-01-1953

No insurer doing business in this state, and no insurance agent, solicitor, or broker, shall use in connection with the solicitation of sickness and accident insurance any advertising copy, advertising practice, or plan of solicitation which is materially misleading or deceptive. An advertising copy, advertising practice, or plan of solicitation is materially misleading or deceptive if, by implication or otherwise, it transmits information in such manner or of such substance that a prospective applicant for sickness and accident insurance may be led thereby to his material damage.

If, after due notice and hearing, the superintendent of insurance finds that any such advertising copy, advertising practice, or plan of solicitation is materially misleading or deceptive, he shall order the insurer, agent, solicitor, or broker using such copy, practice, or plan to cease such use. Upon making such a finding the superintendent may also, by order, suspend the certificate of authority of such insurer to transact business within this state, or suspend the license issued to such agent, solicitor, or broker, for a period of not more than ninety days.

If the superintendent finds, after due notice and hearing, that any authorized insurer, licensed insurance agent, licensed insurance solicitor, or licensed insurance broker has willfully violated any such order to cease, he may suspend or revoke the certificate of authority of such insurer, or the license issued to such agent, solicitor, or broker.

Effective Date: 07-01-1956

(A) No insurer doing business in this state, and no insurance agent, solicitor, or broker, shall, in connection with any advertising copy, advertising practice, or plan of solicitation, refer to noncancellation provisions of a sickness and accident insurance policy without successively describing the cancellability and the renewability provisions of the policy clearly and with equal prominence or emphasis.

(B) Violation of this section is an unfair and deceptive act or practice under section 3923.16 and sections 3901.19 to 3901.22 of the Revised Code.

(C) As used in this section, “advertising copy,” “advertising practice,” or “plan of solicitation” includes oral or written representations.

Effective Date: 01-01-1980

The laws of this state prohibiting rebates do not prohibit any of the following:

(A) The payment of a commission or other compensation to any licensed agent or broker;

(B) Any insurer from allowing or returning to its participating policyholders dividends, savings, or unused premium deposits;

(C) Any insurer from returning or otherwise abating, in full or in part, the premiums of its policyholders out of surplus accumulated from nonparticipating insurance;

(D) The taking of a bona fide obligation, with interest at a rate not exceeding six per cent per annum, in the payment of any premium.

Effective Date: 10-01-1953

The acknowledgment by an insurer of the receipt of notice given under any policy of sickness and accident insurance, or the furnishing by him of forms for filing proofs of loss, or his acceptance of such proofs, or his investigation of any claim thereunder, shall not operate as a waiver of any of the rights of the insurer in defense of any claim arising under such policy.

Effective Date: 10-01-1953

The portion of any benefits under all policies of sickness and accident insurance as does not exceed six hundred dollars for each month during any period of disability covered by the policies, is not liable to attachment or other process, or to be taken, appropriated, or applied by any legal or equitable process or by operation of law, either before or after payment of the benefits, to pay any liabilities of the person insured under any such policy. This exemption does not apply if an action is brought to recover for necessaries contracted for during the period of disability, and if the complaint contains a statement to that effect.

When a policy provides for a lump sum payment because of a dismemberment or other loss insured, the payment is exempt from execution by the insured’s creditors.

Effective Date: 09-28-1979

Sections 3923.01 to 3923.22, inclusive, of the Revised Code, do not apply to or affect:

(A)(1) Any policy of liability insurance, with or without supplementary expense coverage therein;

(2) Any policy of motor vehicle liability insurance with supplementary coverage protecting the insured against loss where said insured has secured a judgment against a party for bodily injury or death as a result of a motor vehicle accident and where said judgment remains unsatisfied.

(3) Any policy of motor vehicle liability insurance with supplementary coverage which insures against the hazards which arise out of a motor vehicle accident as defined in section 4509.01(J) of the Revised Code.

(B) Any life insurance, endowment, or annuity policy or contract, or any contract supplemental thereto, which contains only such provisions relating to sickness and accident insurance as:

(1) Provide additional benefits in case of death or dismemberment by accident;

(2) Operate to safeguard such policy or contract against lapse, or to give a special surrender value or special benefit or annuity in the event that the insured or annuitant becomes totally and permanently disabled, as defined by the policy, contract, or supplemental contract.

Sections 3923.03 to 3923.07, inclusive, of the Revised Code, do not apply to those forms of sickness and accident policies enumerated in sections 3923.12 and 3923.13 of the Revised Code, provided that no such policy shall contain any provision relative to notice or proof of loss, or the time for paying benefits, or the time within which suit may be brought upon the policy, which in the opinion of the superintendent of insurance is less favorable to the insured than would be permitted by the standard provisions set forth in section 3923.04 of the Revised Code.

Effective Date: 08-30-1955

If, after notice and hearing, the superintendent of insurance finds that any insurer, insurance agent, solicitor, or broker has delivered or issued for delivery or use in this state any policy of sickness and accident insurance on a form which has been disapproved by the superintendent of insurance or has violated sections 3923.01 to 3923.22, inclusive, of the Revised Code, or an order of the superintendent made in accordance with such sections, the superintendent may suspend the authority of such insurer to transact business within this state for a period of not more than ninety days. In the case of an agent, solicitor, or broker the superintendent may suspend the license issued to such agent, solicitor, or broker for a period of not more than ninety days.

If the superintendent finds that any such insurer, insurance agent, solicitor, or broker has willfully done any of the acts referred to in the preceding paragraph he may revoke the license of such insurer, agent, solicitor, or broker for any such willful violation.

Effective Date: 09-29-1955

Any person, partnership, or corporation adversely affected by an order, finding, or determination of the superintendent of insurance may appeal to the court of common pleas of Franklin county in accordance with sections 119.01 to 119.13, inclusive, of the Revised Code. Said sections are also applicable to sections 3923.01 to 3923.22, inclusive, of the Revised Code.

Effective Date: 10-01-1953

Notwithstanding any provision of any certificate furnished by an insurer in connection with, or pursuant to any group sickness and accident insurance policy delivered, issued for delivery, renewed or used, in or outside this state, on or after the effective date of this amendment, July 1, 1980, and notwithstanding any provision of any policy of insurance delivered, issued for delivery, renewed or used, in or outside this state, on or after the effective date of this amendment, July 1, 1980, whenever such policy or certificate is subject to the jurisdiction of this state and provides for reimbursement for any service which may be legally performed by a person licensed in this state for the practice of osteopathy, optometry, chiropractic, or podiatry, reimbursement under such policy or certificate shall not be denied when such service is rendered by a person so licensed.

Effective Date: 07-01-1980

Notwithstanding any provision of any certificate furnished by an insurer in connection with, or pursuant to any group sickness and accident insurance policy delivered, issued, renewed or used, in or outside this state, on or after the effective date of this amendment, July 1, 1980, and notwithstanding any provision of any policy of insurance delivered, issued for delivery, renewed or used, in or outside this state, on or after the effective date of this amendment, July 1, 1980, whenever such policy or certificate is subject to the jurisdiction of this state and provides for reimbursement for any service that may be legally performed by a person licensed in this state as a psychologist as defined in division (A) of section 4732.01 of the Revised Code, reimbursement under such policy or certificate shall not be denied when such service is rendered by a person so licensed who has received a doctorate of psychology or has a minimum of five years clinical experience.

Effective Date: 07-01-1980

Notwithstanding any provision of any certificate furnished by an insurer in connection with, or pursuant to any group sickness and accident insurance policy delivered, issued, renewed or used, in or outside this state, on or after the effective date of this amendment, July 1, 1980, and notwithstanding any provision of any policy of insurance delivered, issued for delivery, renewed or used, in or outside this state, on or after the effective date of this amendment, July 1, 1980, whenever such policy or certificate is subject to the jurisdiction of this state and provides for reimbursement for any service that may be legally performed by a person licensed in this state for the practice of dentistry, reimbursement under such policy or certificate shall not be denied when such service is rendered by a person so licensed.

Effective Date: 07-01-1980

Notwithstanding any provision of any certificate furnished by an insurer in connection with or pursuant to any group sickness and accident insurance policy delivered, issued, renewed, or used, in or outside this state, on or after January 1, 1985, and notwithstanding any provision of any policy of insurance delivered, issued for delivery, renewed, or used, in or outside this state, on or after January 1, 1985, whenever the policy or certificate is subject to the jurisdiction of this state and provides for reimbursement for any service that may be legally performed by a certified nurse-midwife who is authorized under section 4723.42 of the Revised Code to practice nurse-midwifery, reimbursement under the policy or certificate shall not be denied to a certified nurse-midwife performing the service in collaboration with a licensed physician. The collaborating physician shall be identified on an insurance claim form.

The cost of collaboration with a certified nurse-midwife by a licensed physician as required under section 4723.43 of the Revised Code is a reimbursable expense.

The division of any reimbursement payment for services performed by a certified nurse-midwife between the nurse-midwife and the nurse-midwife’s collaborating physician shall be determined and mutually agreed upon by the certified nurse-midwife and the physician. The division of fees shall not be considered a violation of division (B)(17) of section 4731.22 of the Revised Code. In no case shall the total fees charged exceed the fee the physician would have charged had the physician provided the entire service.

Effective Date: 09-10-1996

Notwithstanding any provision of any certificate furnished by an insurer in connection with, or pursuant to any group sickness and accident insurance policy delivered, issued, renewed, or used, in or outside this state, on or after July 20, 1988, and notwithstanding any provision of any policy of insurance delivered, issued for delivery, renewed, or used, in or outside this state, on or after July 20, 1988, whenever the policy or certificate is subject to the jurisdiction of this state and provides for reimbursement for any service that may be legally performed by a mechanotherapist, who was issued a certificate as a mechanotherapist under section 4731.15 of the Revised Code and practices in accordance with rules adopted under section 4731.151 of the Revised Code, reimbursement under the policy or certificate shall not be denied when the service is rendered by a person so registered, but only if that person completed educational requirements in mechanotherapy on or before November 3, 1975.

As used in this section, “educational requirements” has the same meaning as in section 4731.151 of the Revised Code.

Effective Date: 04-30-1992

Every certificate furnished by an insurer in connection with, or pursuant to any provision of, any group sickness and accident insurance policy delivered, issued for delivery, renewed, or used in this state on or after January 1, 1972, and every policy of sickness and accident insurance delivered, issued for delivery, renewed, or used in this state on or after January 1, 1972, which provides that coverage of an unmarried dependent child will terminate upon attainment of the limiting age for dependent children specified in the contract shall also provide in substance that attainment of such limiting age shall not operate to terminate the coverage of such child if the child is and continues to be both:

(A) Incapable of self-sustaining employment by reason of mental retardation or physical handicap;

(B) Primarily dependent upon the policyholder or certificate holder for support and maintenance.

Proof of such incapacity and dependence shall be furnished by the policyholder or by the certificate holder to the insurer within thirty-one days of the child’s attainment of the limiting age. Upon request, but not more frequently than annually after the two-year period following the child’s attainment of the limiting age, the insurer may require proof satisfactory to it of the continuance of such incapacity and dependency.

Nothing in this section shall require an insurer to cover a dependent child who is mentally retarded or physically handicapped if the contract is underwritten on evidence of insurability based on health factors set forth in the application, or if such dependent child does not satisfy the conditions of the contract as to any requirement for evidence of insurability or other provision of the contract, satisfaction of which is required for coverage thereunder to take effect. In any such case, the terms of the contract shall apply with regard to the coverage or exclusion of the dependent from such coverage. Nothing in this section shall apply to accidental death or dismemberment benefits provided by any such policy of sickness and accident insurance.

Effective Date: 12-20-1971

Every certificate furnished by an insurer in connection with, or pursuant to any provision of any group sickness and accident insurance policy delivered, issued for delivery, renewed, or used in this state, provided such policy was delivered, issued for delivery, or renewed on or after July 1, 1972, and every policy of sickness and accident insurance delivered, issued for delivery, renewed, or used in this state, provided such policy was delivered, issued for delivery, or renewed on or after July 1, 1972, which provides for kidney dialysis benefits, shall be deemed to include such benefits on an equal basis if the dialysis is performed on an out-patient basis. For purpose of this section, “out-patient basis” includes care rendered at any location whether or not at a hospital, upon approval by the attending physician.

Effective Date: 04-03-1972

Every group policy or certificate of sickness and accident insurance delivered, issued for delivery, or renewed in this state providing coverage on an expense-incurred basis, and every individual policy of sickness and accident insurance delivered, issued for delivery, or renewed in this state which provides coverage on an expense-incurred basis, either of which makes coverage available for family members of the insured, shall, as to such family members’ coverage, also provide that any sickness and accident insurance benefits applicable for children shall be payable with respect to a newly born child of the insured from the moment of birth.

The coverage for newly born children shall consist of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.

If payment of a specific premium is required to provide coverage for an additional child, the certificate or policy may require that notification of birth of a newly born child and payment of the required premium must be furnished to the insurer within thirty-one days after the date of birth in order to have the coverage continue beyond such period.

The requirements of this section apply to all such individual or group sickness and accident insurance policies delivered or issued for delivery in this state on or after January 1, 1975,. and all such individual or group sickness and accident insurance policies renewed in this state on or after January 1, 1978.

Effective Date: 06-30-1997

No policy of sickness and accident insurance delivered, issued for delivery, or renewed in this state after August 26, 1976, including both individual and group policies, that provides hospitalization coverage for mental illness shall exclude such coverage for the reason that the insured is hospitalized in an institution or facility receiving tax support from the state, any municipal corporation, county, or joint county board, whether such institution or facility is deemed charitable or otherwise, provided the institution or facility or portion thereof is fully accredited by the joint commission on accreditation of hospitals or certified under Titles XVIII and XIX of the “Social Security Act of 1935,” 79 Stat. 291, 42 U.S.C.A. 1395, as amended. The insurance coverage shall provide payment amounting to the lesser of either the full amount of the statutory charge for the cost of the services pursuant to section 5121.33 of the Revised Code or the benefits payable for the services under the applicable insurance policy. Insurance benefits for the coverage shall be paid so long as patients and their liable relatives retain their statutory liability pursuant to section 5121.33 of the Revised Code. Only that portion or per cent of the benefits shall be payable that has been assigned, or ordered to be paid, to the state or other appropriate provider for services rendered by the institution or facility.

Effective Date: 08-26-1976; 09-29-2005

(A) Every policy of group sickness and accident insurance providing hospital, surgical, or medical expense coverage for other than specific diseases or accidents only, and delivered, issued for delivery, or renewed in this state on or after January 1, 1979, and that provides coverage for mental or emotional disorders, shall provide benefits for services on an outpatient basis for each eligible person under the policy who resides in this state for mental or emotional disorders, or for evaluations, that are at least equal to five hundred fifty dollars in any calendar year or twelve-month period. The services shall be legally performed by or under the clinical supervision of a physician authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery; a psychologist licensed under Chapter 4732. of the Revised Code; a professional clinical counselor, professional counselor, or independent social worker licensed under Chapter 4757. of the Revised Code; or a clinical nurse specialist licensed under Chapter 4723. of the Revised Code whose nursing specialty is mental health, whether performed in an office, in a hospital, or in a community mental health facility so long as the hospital or community mental health facility is approved by the joint commission on accreditation of healthcare organizations, the council on accreditation for children and family services, the rehabilitation accreditation commission, or, until two years after June 6, 2001, certified by the department of mental health as being in compliance with standards established under division (H) of section 5119.01 of the Revised Code.

(B) Outpatient benefits offered under division (A) of this section shall be subject to reasonable contract limitations and may be subject to reasonable deductibles and co-insurance costs. Persons entitled to such benefit under more than one service or insurance contract may be limited to a single five-hundred-fifty-dollar outpatient benefit for services under all contracts.

(C) In order to qualify for participation under division (A) of this section, every facility specified in such division shall have in effect a plan for utilization review and a plan for peer review and every person specified in such division shall have in effect a plan for peer review. Such plans shall have the purpose of ensuring high quality patient care and effective and efficient utilization of available health facilities and services.

(D) Nothing in this section shall be construed to require an insurer to pay benefits which are greater than usual, customary, and reasonable.

(E)(1) Services performed under the clinical supervision of a health care professional identified in division (A) of this section, in order to be reimbursable under the coverage required in division (A) of this section, shall meet both of the following requirements:

(a) The services shall be performed in accordance with a treatment plan that describes the expected duration, frequency, and type of services to be performed;

(b) The plan shall be reviewed and approved by the health care professional every three months.

(2) Payment of benefits for services reimbursable under division (E)(1) of this section shall not be restricted to services described in the treatment plan or conditioned upon standards of clinical supervision that are more restrictive than standards of a health care professional described in division (A) of this section, which at least equal the requirements of division (E)(1) of this section.

(F) The benefits provided by this section for mental and emotional disorders shall not be reduced by the cost of benefits provided pursuant to section 3923.281 of the Revised Code for diagnostic and treatment services for biologically based mental illnesses. This section does not apply to benefits for diagnostic and treatment services for biologically based mental illnesses.

Effective Date: 06-06-2001; 03-30-2007

(A) As used in this section:

(1) “Biologically based mental illness” means schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, and panic disorder, as these terms are defined in the most recent edition of the diagnostic and statistical manual of mental disorders published by the American psychiatric association.

(2) “Policy of sickness and accident insurance” has the same meaning as in section 3923.01 of the Revised Code, but excludes any hospital indemnity, medicare supplement, long-term care, disability income, one-time-limited-duration policy of not longer than six months, supplemental benefit, or other policy that provides coverage for specific diseases or accidents only; any policy that provides coverage for workers’ compensation claims compensable pursuant to Chapters 4121. and 4123. of the Revised Code; and any policy that provides coverage to beneficiaries enrolled in Title XIX of the “Social Security Act,” 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, known as the medical assistance program or medicaid, as provided by the Ohio department of job and family services under Chapter 5111. of the Revised Code.

(B) Notwithstanding section 3901.71 of the Revised Code, and subject to division (E) of this section, every policy of sickness and accident insurance shall provide benefits for the diagnosis and treatment of biologically based mental illnesses on the same terms and conditions as, and shall provide benefits no less extensive than, those provided under the policy of sickness and accident insurance for the treatment and diagnosis of all other physical diseases and disorders, if both of the following apply:

(1) The biologically based mental illness is clinically diagnosed by a physician authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery; a psychologist licensed under Chapter 4732. of the Revised Code; a professional clinical counselor, professional counselor, or independent social worker licensed under Chapter 4757. of the Revised Code; or a clinical nurse specialist licensed under Chapter 4723. of the Revised Code whose nursing specialty is mental health.

(2) The prescribed treatment is not experimental or investigational, having proven its clinical effectiveness in accordance with generally accepted medical standards.

(C) Division (B) of this section applies to all coverages and terms and conditions of the policy of sickness and accident insurance, including, but not limited to, coverage of inpatient hospital services, outpatient services, and medication; maximum lifetime benefits; copayments; and individual and family deductibles.

(D) Nothing in this section shall be construed as prohibiting a sickness and accident insurance company from taking any of the following actions:

(1) Negotiating separately with mental health care providers with regard to reimbursement rates and the delivery of health care services;

(2) Offering policies that provide benefits solely for the diagnosis and treatment of biologically based mental illnesses;

(3) Managing the provision of benefits for the diagnosis or treatment of biologically based mental illnesses through the use of pre-admission screening, by requiring beneficiaries to obtain authorization prior to treatment, or through the use of any other mechanism designed to limit coverage to that treatment determined to be necessary;

(4) Enforcing the terms and conditions of a policy of sickness and accident insurance.

(E) An insurer that offers any policy of sickness and accident insurance is not required to provide benefits for the diagnosis and treatment of biologically based mental illnesses pursuant to division (B) of this section if all of the following apply:

(1) The insurer submits documentation certified by an independent member of the American academy of actuaries to the superintendent of insurance showing that incurred claims for diagnostic and treatment services for biologically based mental illnesses for a period of at least six months independently caused the insurer’s costs for claims and administrative expenses for the coverage of all other physical diseases and disorders to increase by more than one per cent per year.

(2) The insurer submits a signed letter from an independent member of the American academy of actuaries to the superintendent of insurance opining that the increase described in division (E)(1) of this section could reasonably justify an increase of more than one per cent in the annual premiums or rates charged by the insurer for the coverage of all other physical diseases and disorders.

(3) The superintendent of insurance makes the following determinations from the documentation and opinion submitted pursuant to divisions (E)(1) and (2) of this section:

(a) Incurred claims for diagnostic and treatment services for biologically based mental illnesses for a period of at least six months independently caused the insurer’s costs for claims and administrative expenses for the coverage of all other physical diseases and disorders to increase by more than one per cent per year.

(b) The increase in costs reasonably justifies an increase of more than one per cent in the annual premiums or rates charged by the insurer for the coverage of all other physical diseases and disorders.

Any determination made by the superintendent under this division is subject to Chapter 119. of the Revised Code.

Effective Date: 03-30-2007; 2007 HB119 09-29-2007

(A) As used in this section:

(1) “Biologically based mental illness” means schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, and panic disorder, as these terms are defined in the most recent edition of the diagnostic and statistical manual of mental disorders published by the American psychiatric association.

(2) “Plan of health coverage” includes any private or public employer group self-insurance plan that provides payment for health care benefits for other than specific diseases or accidents only, which benefits are not provided by contract with a sickness and accident insurer or health insuring corporation.

(B) Notwithstanding section 3901.71 of the Revised Code, and subject to division (F) of this section, each plan of health coverage shall provide benefits for the diagnosis and treatment of biologically based mental illnesses on the same terms and conditions as, and shall provide benefits no less extensive than, those provided under the plan of health coverage for the treatment and diagnosis of all other physical diseases and disorders, if both of the following apply:

(1) The biologically based mental illness is clinically diagnosed by a physician authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery; a psychologist licensed under Chapter 4732. of the Revised Code; a professional clinical counselor, professional counselor, or independent social worker licensed under Chapter 4757. of the Revised Code; or a clinical nurse specialist licensed under Chapter 4723. of the Revised Code whose nursing specialty is mental health.

(2) The prescribed treatment is not experimental or investigational, having proven its clinical effectiveness in accordance with generally accepted medical standards.

(C) Division (B) of this section applies to all coverages and terms and conditions of the plan of health coverage, including, but not limited to, coverage of inpatient hospital services, outpatient services, and medication; maximum lifetime benefits; copayments; and individual and family deductibles.

(D) This section does not apply to a plan of health coverage if federal law supersedes, preempts, prohibits, or otherwise precludes its application to such plans. This section does not apply to long-term care, hospital indemnity, disability income, or medicare supplement plans of health coverage, or to any other supplemental benefit plans of health coverage.

(E) Nothing in this section shall be construed as prohibiting an employer from taking any of the following actions in connection with a plan of health coverage:

(1) Negotiating separately with mental health care providers with regard to reimbursement rates and the delivery of health care services;

(2) Managing the provision of benefits for the diagnosis or treatment of biologically based mental illnesses through the use of pre-admission screening, by requiring beneficiaries to obtain authorization prior to treatment, or through the use of any other mechanism designed to limit coverage to that treatment determined to be necessary;

(3) Enforcing the terms and conditions of a plan of health coverage.

(F) An employer that offers a plan of health coverage is not required to provide benefits for the diagnosis and treatment of biologically based mental illnesses in combination with benefits for the treatment and diagnosis of all other physical diseases and disorders as described in division (B) of this section if both of the following apply:

(1) The employer submits documentation certified by an independent member of the American academy of actuaries to the superintendent of insurance showing that incurred claims for diagnostic and treatment services for biologically based mental illnesses for a period of at least six months independently caused the employer’s costs for claims and administrative expenses for the coverage of all other physical diseases and disorders to increase by more than one per cent per year.

(2) The superintendent of insurance determines from the documentation and opinion submitted pursuant to division (F) of this section, that incurred claims for diagnostic and treatment services for biologically based mental illnesses for a period of at least six months independently caused the employer’s costs for claims and administrative expenses for the coverage of all other physical diseases and disorders to increase by more than one per cent per year.

Any determination made by the superintendent under this division is subject to Chapter 119. of the Revised Code.

Effective Date: 03-30-2007

(A) Every policy of group sickness and accident insurance providing hospital, surgical, or medical expense coverage for other than specific diseases or accidents only, and delivered, issued for delivery, or renewed in this state on or after January 1, 1979, shall provide for each eligible person under the policy who resides in this state, outpatient, inpatient, and intermediate primary care benefits for alcoholism that are at least equal to five hundred fifty dollars in any calendar year or twelve month period. The services shall be legally performed by or under the clinical supervision of a licensed physician or a licensed psychologist, whether performed in an office, in a hospital, in a community mental health facility, or in an alcoholism treatment facility so long as the hospital, community mental health facility, or alcoholism treatment facility is approved by the joint commission on accreditation of hospitals or certified by the department of health.

(B) The benefits mandated by division (A) of this section shall be subject to reasonable contract limitations and may be subject to reasonable deductibles and co-insurance costs. Persons entitled to such benefit under more than one service or insurance contract may be limited to a single five hundred fifty dollar benefit for services under all contracts.

(C) For an eligible person, who receives treatment for alcoholism from an approved or certified alcoholism treatment facility, to remain entitled to the benefits mandated by division (A) of this section, a licensed physician or a licensed psychologist shall every three months certify that such person needs to continue utilizing such treatment.

(D) In order to qualify for participation under division (A) of this section, every facility specified in such division shall have in effect a plan for utilization review and a plan for peer review and every person specified in such division shall have in effect a plan for peer review. Such plans shall have the purpose of ensuring high quality patient care and effective and efficient utilization of available health facilities and services. Such person or facility shall also have in effect a program of rehabilitation or a program of rehabilitation and detoxification.

(E) Nothing in this section shall be construed to require an insurer to pay benefits which are greater than usual, customary, and reasonable.

Effective Date: 09-05-2001

Every person, the state and any of its instrumentalities, any county, township, school district, or other political subdivisions and any of its instrumentalities, and any municipal corporation and any of its instrumentalities, which provides payment for health care benefits for any of its employees resident in this state, which benefits are not provided by contract with an insurer qualified to provide sickness and accident insurance, or a health insuring corporation, shall include the following benefits in its plan of health care benefits commencing on or after January 1, 1979:

(A) If such plan of health care benefits provides payment for the treatment of mental or nervous disorders, then such plan shall provide benefits for services on an outpatient basis for each eligible employee and dependent for mental or emotional disorders, or for evaluations, that are at least equal to the following:

(1) Payments not less than five hundred fifty dollars in a twelve-month period, for services legally performed by or under the clinical supervision of a physician authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery; a psychologist licensed under Chapter 4732. of the Revised Code; a professional clinical counselor, professional counselor, or independent social worker licensed u