Ohio Revised Code Search

...(A) A domestic fraternal benefit society may amend its laws in accordance with the provisions of its laws by action of its supreme governing body at any regular or special meeting of that body or, if its laws so provide, by referendum. A referendum may be held in accordance with the provisions of its laws by the vote of the voting members of the society, by the vote of delegates or representatives of voting members,...

...(A) A fraternal benefit society may create, maintain, and operate charitable, benevolent, or educational institutions for the benefit of its members and their families and dependents and for the benefit of children insured by the society. For such purpose it may own, hold, or lease personal property or real property located within or without this state, with necessary buildings. The property shall be reported in ever...

...(A) A domestic fraternal benefit society may, by a reinsurance agreement, cede any individual risk or risks in whole or in part to an insurer, other than another fraternal benefit society, having the power to make such reinsurance and authorized to do business in this state, or if not so authorized, one which is approved by the superintendent of insurance; however, no society may reinsure substantially all of i...

...(A) A domestic fraternal benefit society may consolidate or merge with any other society by complying with the provisions of this section. (B) The society shall file all of the following with the superintendent of insurance: (1) A certified copy of the written contract containing in full the terms and conditions of the consolidation or merger; (2) A sworn statement by the president and secretary or corresponding o...

...Any domestic fraternal benefit society may be converted and licensed as a mutual life insurance company by compliance with all the applicable requirements of Chapter 3913. of the Revised Code, if the plan of conversion has been approved by the superintendent of insurance. If the society's supreme governing body is constituted as an assembly, the plan shall be prepared in writing by the board of directors and shall se...

...(A) A fraternal benefit society may provide any of the following contractual benefits in any form: (1) Death benefits; (2) Endowment benefits; (3) Annuity benefits; (4) Temporary or permanent disability benefits; (5) Hospital, medical, or nursing benefits; (6) Monument or tombstone benefits to the memory of deceased members; (7) Any other benefit that may be provided by a life insurer and that is not inconsist...

...(A) The owner of a benefit contract may at any time change the beneficiary in accordance with the laws or rules of the fraternal benefit society unless the owner waives this right by specifically requesting in writing that the beneficiary designation be irrevocable. A society may, through its laws or rules, limit the scope of beneficiary designations and shall provide that no revocable beneficiary shall have or obtai...

...No money or other benefit, charity, relief, or aid to be paid, provided, or rendered by any fraternal benefit society, shall be liable to attachment, garnishment, or other process, or shall be seized, taken, appropriated, or applied by any legal or equitable process or operation of law to pay any debt or liability of a member or beneficiary, or any other person who may have a right, either before or after payment by ...

... (A) Each fraternal benefit society authorized to do business in this state shall issue to each owner of a benefit contract a certificate specifying the amount of benefits provided under the contract. The certificate, together with any riders or endorsements attached to the certificate, the laws of the society, the application for membership, the application for insurance and declaration of insurability, if any, sign...

...(A) A fraternal benefit society shall provide an applicant for contractual benefits a disclosure statement at the time of sale substantially as follows: "__________ (Name of the fraternal benefit society) IS LICENSED TO DO BUSINESS IN THE STATE OF OHIO. AS A ________ (not-for-profit, tax-exempt, self-governing, or membership organization), FRATERNAL BENEFIT SOCIETIES ARE NOT INCLUDED IN THE OHIO GUARANTY ASSO...

...(A) In the case of certificates that are delivered or issued for delivery in this state on or after January 1, 1997, but prior to January 1, 1998, the value of every paid-up nonforfeiture benefit and the amount of any cash surrender value, loan, or other option granted shall comply with the requirements that would have applied under the laws in effect on December 31, 1996. (B) In the case of certificates that are de...

... (A) Except as provided in division (B) of this section, a fraternal benefit society shall invest its funds only in such investments as are authorized by section 3907.14 of the Revised Code for the investment of assets of life insurers and subject to the limitations thereon. Any foreign or alien society permitted or seeking to do business in this state that invests its funds in accordance with the laws of the s...

...(A) A fraternal benefit society shall hold, invest, and disburse all assets for the use and benefit of the society. No member or beneficiary shall have or acquire individual rights to the assets, or be entitled to any apportionment on the surrender of any part of the assets, except as provided in the benefit contract. (B) A society may create, maintain, invest, disburse, and apply any special fund or funds ne...

...Except as provided in this chapter, fraternal benefit societies shall be governed by this chapter and are exempt from all other provisions of the insurance laws of this state, not only in governmental relations with the state, but for every other purpose. No law shall apply to societies unless they are expressly designated in the law.

...Every fraternal benefit society organized or licensed under this chapter is hereby declared to be a charitable and benevolent institution, and all of its funds are exempt from all state, county, district, municipal, and school taxes other than franchise taxes and taxes on real estate.

...(A) The standards of valuation for certificates that are delivered or issued for delivery in this state on or after January 1, 1997, but prior to January 1, 1998, shall be those standards that would have applied under the laws in effect on December 31, 1996. (B) The minimum standards of valuation for certificates of life insurance, annuity and pure endowment certificates, total and permanent disability benefit certi...

...(A) Each fraternal benefit society transacting business in this state shall annually file with the superintendent of insurance a true statement of its financial condition, transactions, and affairs for the preceding calendar year. The statement shall be filed on or before the first day of March. The statement shall be in general form and content as approved by the national association of insurance commissioners for f...

...Fraternal benefit societies that are authorized to transact business in this state on December 31, 1996, may continue such business until April 1, 1997. The authority of those societies and all societies licensed on or after January 1, 1997, may be renewed annually, but in all cases shall terminate on the first day of the succeeding April. However, a license so issued shall continue in full force and effect until a ...

... (A)(1) Each domestic fraternal benefit society and each applicant for a certificate of incorporation as a domestic fraternal benefit society shall be subject to examination by the superintendent of insurance in accordance with section 3901.07 of the Revised Code. Section 3901.07 of the Revised Code shall govern every aspect of the examination, including the circumstances under and frequency with which it is conducte...

...No foreign or alien fraternal benefit society shall transact business in this state without a license issued by the superintendent of insurance. Any such society may be licensed to transact business in this state upon filing all of the following with the superintendent: (A) A duly certified copy of its articles of incorporation; (B) A copy of its bylaws certified by its secretary or corresponding officer; (C...

... If the superintendent of insurance finds, upon investigation, that a domestic fraternal benefit society has exceeded its powers, has failed to comply with any provision of this chapter, is not fulfilling its contracts in good faith, has a membership of less than four hundred after an existence of one year or more, or is conducting business fraudulently or in a manner hazardous to its members, creditors, the pu...

... If the superintendent of insurance finds, upon investigation, that a foreign or alien fraternal benefit society transacting or applying to transact business in this state has exceeded its powers, has failed to comply with any provision of this chapter, is not fulfilling its contracts in good faith, or is conducting its business fraudulently or in a manner hazardous to its members or creditors or the public, th...

... (A) Liquidation proceedings for a domestic fraternal benefit society shall be conducted consistent with the purposes of section 3903.02 of the Revised Code in a manner designed to conserve assets, limit liquidation expenses, and avoid any assessment of shares of a deficiency. (B)(1) The liquidator shall attempt to transfer policies or certificates of the liquidating fraternal benefit society by way of assignment, ...

...(A) Agents of fraternal benefit societies shall be licensed in the manner provided for agents of insurance companies in Chapter 3905. of the Revised Code, and shall be required to complete continuing education as set forth in section 3905.481 of the Revised Code starting with the twenty-four-month period commencing on the first day of January of 1999. However, no written or other examination shall be required o...

... On receipt of a notice pursuant to section 3123.43 of the Revised Code, the superintendent of insurance shall comply with sections 3123.41 to 3123.50 of the Revised Code and any applicable rules adopted under section 3123.63 of the Revised Code with respect to a license issued pursuant to this chapter.

...Sections 3901.19 to 3901.26 of the Revised Code, and any other provision of Title XXXIX of the Revised Code that prohibits life or sickness and accident insurers from engaging in any unfair and deceptive act or practice in the business of insurance, continue on and after January 1, 1997, to apply to every fraternal benefit society authorized to do business in this state. However, nothing in any of those sections or ...

...(A) Any fraternal benefit society authorized to transact business in this state shall have and maintain an agent upon whom may be served any process, notice, or demand required or permitted by law to be served upon a society. The agent required under this section may be a natural person residing in this state or a corporation holding a license under the laws of this state that is authorized by its articles of...

...(A) No person shall cause or permit to be made, issued, or circulated in any form any of the following: (1) Any misrepresentation or false or misleading statement concerning the terms, benefits, or advantages of any fraternal insurance contract now issued or to be issued in this state, or the financial condition of any fraternal benefit society; (2) Any false or misleading estimate or statement concerning the divid...

...(A) Nothing in this chapter shall be construed as applying to or otherwise affecting any of the following: (1) Grand or subordinate lodges of societies, orders, or associations doing business in this state that provide benefits exclusively through local or subordinate lodges; (2) Orders, societies, or associations that admit to membership only persons engaged in one or more crafts or hazardous occupations, in the s...

...All decisions and findings of the superintendent of insurance made under the provisions of this chapter are subject to review by the proper proceedings in any court of competent jurisdiction in this state.

...(A) Whoever violates division (A) of section 3921.36 of the Revised Code or knowingly receives any compensation or commission by or in consequence of such violation, is guilty of a misdemeanor of the first degree, and shall in addition be liable for a civil penalty in the amount of three times the sum received by the violator as compensation or commission, which penalty may be sued for and recovered by any person or ...

... As used in this chapter: (A) "Adverse benefit determination" means a decision by a health plan issuer: (1) To deny, reduce, or terminate a requested health care service or payment in whole or in part, including all of the following: (a) A determination that the health care service does not meet the health plan issuer's requirements for medical necessity, appropriateness, health care setting, level of care, ...

... (A) A covered person may make a request for an external review of an adverse benefit determination. (B) All requests for external review shall be made in writing, including by electronic means, by the covered person to the health plan issuer within one hundred eighty days of the date of the final adverse benefit determination. However, in the case of an expedited external review under section 3922.09 of the ...

... (A) All health plan issuers shall implement an internal appeal process under which a covered person may appeal an adverse benefit determination. This process must be in compliance with the "Patient Protection and Affordable Care Act of 2010," Pub. L. 111-148, 124 Stat. 119, as amended, and the associated regulations, as well as any other applicable state laws or rules or federal regulations. (B) Review of a...

... (A) Except as provided in division (E) of this section, a health plan issuer is not required to grant a request for a standard external review made under section 3922.08 or 3922.10 of the Revised Code until the covered person has exhausted the health plan issuer's internal appeal process. (B) An internal appeal process shall be considered exhausted if a covered person has requested an internal appeal and has ...

... (A) A health plan issuer shall afford the opportunity for an external review by an independent review organization for an adverse benefit determination if the determination involved a medical judgment or if the decision was based on any medical information, pursuant to the following sections: (1) Section 3922.08 of the Revised Code for a standard review; (2) Section 3922.09 of the Revised Code for an expedi...

...Except for when an expedited request is made under section 3922.09 or 3922.10 of the Revised Code, an independent review organization shall forward upon receipt a copy of any information received from a covered person pursuant to division (D)(1) of section 3922.05 of the Revised Code, as well as any other information received from the covered person, to the health plan issuer. Upon receipt of that information...

... In addition to the information provided under division (D)(1)(b) of section 3922.05, division (B) of section 3922.08, division (C) of section 3922.09, and division (D) of section 3922.10 of the Revised Code, an assigned independent review organization, to the extent that such documents are available and appropriate, shall consider all of the following when conducting its review: (A) The covered person's medi...

... (A) The provisions of this section apply only to standard reviews, which are not expedited and do not involve an experimental or investigational treatment. (B) Within five days after the receipt of a request for an external review that is complete and valid, the health plan issuer shall provide to the assigned independent review organization all documents and information considered in making the adverse bene...

... (A) A covered person may make a request for an expedited external review, except as provided in division (I) of this section: (1) After an adverse benefit determination, if both of the following apply: (a) The covered person's treating physician certifies that the adverse benefit determination involves a medical condition that could seriously jeopardize the life or health of the covered person, or would jeo...

... The provisions of this section apply only to external reviews that involve an experimental or investigational treatment. (A) A covered person may request an external review of an adverse benefit determination based on the conclusion that a requested health care service is experimental or investigational, except when the requested health care service is explicitly listed as an excluded benefit under the cover...

... (A) The superintendent of insurance shall establish and maintain a system for receiving and reviewing requests for external review for adverse benefit determinations where the determination by the health plan issuer was based on a contractual issue and did not involve a medical judgment or a determination based on any medical information, except for emergency services, as specified in division (C) of section 3922.05...

... (A) An external review decision is binding on the health plan issuer except to the extent the health plan issuer has other remedies available under applicable state law, or unless the superintendent of insurance determines that, due to the facts and circumstances of an external review, a second external review is required. (B) An external review decision is binding on the covered person except to the extent ...

... The superintendent shall accredit independent review organizations as prescribed by this section. (A) The superintendent shall develop an application form to accredit and renew accreditation of an independent review organization. (B) An independent review organization seeking to be accredited by the superintendent, or to renew its accreditation, shall submit the application form and include with the form al...

... (A) To be accredited by the superintendent of insurance to conduct external reviews under section 3922.13 of the Revised Code, in addition to the requirements provided in section 3922.13 of the Revised Code and any associated rules adopted by the superintendent, an independent review organization shall do all of the following: (1) Develop and maintain written policies and procedures that govern all aspects of both...

... All clinical reviewers assigned by an independent review organization to conduct external reviews shall have the same license as the health care provider of the service in question, and shall be physicians or other appropriate health care providers who meet all of the following minimum qualifications: (A) Be an expert in the treatment of the medical condition that is the subject of the external review; (B) ...

... (A) Nothing in this chapter shall be construed to create a cause of action against any of the following: (1) An employer that provides health care benefits to employees through a health plan issuer; (2) A clinical reviewer or independent review organization that participates in an external review under this chapter; (3) A health plan issuer that provides coverage for benefits pursuant to this chapter. (B) ...

... (A)(1) An independent review organization assigned pursuant to sections 3922.08, 3922.09, or 3922.10 of the Revised Code to conduct an external review shall maintain written records in accordance with the associated rules established by the superintendent, in the aggregate by state, and by the health plan issuer, on all external reviews requested and conducted during a calendar year. Each independent review...

...The health plan issuer against which a request for a standard external review or an expedited external review is filed shall pay the cost of the external review, including the cost of any external review that is required at the direction of the superintendent. If the superintendent determines that, due to the facts and circumstances of an external review, a second external review is required, the health plan issuer ...

... (A) Each health plan issuer shall include a description of its external review procedures, including the superintendent's contractual review, in, or attached to, the policy, certificate, membership booklet, or outline of coverage, or other evidence of coverage it provides to covered persons. This disclosure shall be in a form prescribed by the superintendent in any associated rules, policies, or procedures. ...