Sec. 3923.05. Except as provided in section 3923.07 of the | 8 |
Revised Code, no policy of sickness and accident insurance | 9 |
delivered, issued for delivery, or used in this state shall | 10 |
contain provisions respecting the matters set forth in this | 11 |
section unless such provisions are in the words in which the same | 12 |
appear in this section. Any such provisions in any such policy | 13 |
shall be preceded by the appropriate caption appearing in this | 14 |
section or, at the option of the insurer, by such appropriate | 15 |
individual or group captions or subcaptions as the superintendent | 16 |
of insurance may approve. | 17 |
(A) A provision as follows: Change of occupation. If the | 18 |
insured be injured or contract sickness after having changed his | 19 |
the
insured's
occupation to one classified by the insurer as more | 20 |
hazardous
than that stated in this policy or while doing for | 21 |
compensation
anything pertaining to an occupation so classified, | 22 |
the insurer
will pay only such portion of the indemnities provided | 23 |
in this
policy as the premium paid would have purchased at the | 24 |
rates and
within the limits fixed by the insurer for such more | 25 |
hazardous
occupation. If the insured changes histhe insured's | 26 |
occupation
to one
classified by the insurer as less hazardous than | 27 |
that stated in
this policy, the insurer, upon receipt of proof of | 28 |
such change of
occupation, will reduce the premium rate | 29 |
accordingly, and will
return the excess pro rata unearned premium | 30 |
from the date of
change of occupation or from the policy | 31 |
anniversary date
immediately preceding receipt of such proof, | 32 |
whichever is the
more recent. In applying this provision, the | 33 |
classification for
occupational risk and the premium rates shall | 34 |
be such as have
been last filed by the insurer prior to the | 35 |
occurrence of the
loss for which the insurer is liable or prior to | 36 |
the date of
proof of change in occupation with the state official | 37 |
having
supervision of insurance in the state where the insured | 38 |
resided
at the time this policy was issued; but if such filing was | 39 |
not
required, then the classification of occupational risk and the | 40 |
premium rates shall be those last made effective by the insurer
in | 41 |
such state prior to the occurrence of the loss or prior to the | 42 |
date of proof of change in occupation. | 43 |
(1) Other insurance in this insurer. If an accident or | 49 |
sickness or accident and sickness policy or policies previously | 50 |
issued by the insurer to the insured be in force concurrently | 51 |
herewith, making the aggregate indemnity for ............... in | 52 |
excess of ......... dollars, the excess insurance shall be void | 53 |
and all premiums paid for such excess shall be returned to the | 54 |
insured or to histhe insured's estate. | 55 |
(2) In lieu of the foregoing provision in division (C)(1)
of | 61 |
this section, a provision as follows: Other insurance in this | 62 |
insurer. Insurance effective at any time on the insured under a | 63 |
like policy or policies in this insurer is limited to the one
such | 64 |
policy elected by the insured, histhe insured's
beneficiary or | 65 |
histhe insured's estate, as the case may be, and
the insurer will | 66 |
return all
premiums paid for all other such policies. | 67 |
(D) A provision as follows: Insurance with other
insurers. If | 68 |
there be other valid coverage, not with this
insurer, providing | 69 |
benefits for the same loss on a provision of
service basis or on | 70 |
an expense incurred basis and of which this
insurer has not been | 71 |
given written notice prior to the occurrence
or commencement of | 72 |
loss, the only liability under any expense
incurred coverage of | 73 |
this policy shall be for such proportion of
the loss as the amount | 74 |
which would otherwise have been payable
hereunder plus the total | 75 |
of the like amounts under all such other
valid coverages for the | 76 |
same loss of which this insurer had
notice bears to the total like | 77 |
amounts under all valid coverages
for such loss, and for the | 78 |
return of such portion of the premiums
paid as shall exceed the | 79 |
pro-rata portion for the amount so
determined. For the purpose of | 80 |
applying this provision when
other coverage is on a provision of | 81 |
service basis, the "like
amount" of such other coverage shall be | 82 |
taken as the amount which
the services rendered would have cost in | 83 |
the absence of such
coverage. | 84 |
The insurer may at its option include in the provision in | 90 |
division (D) of this section a definition of "other valid | 91 |
coverage" approved as to form by the superintendent. Such | 92 |
definition shall be limited in subject matter to coverage
provided | 93 |
by organizations subject to regulation by insurance law
or by | 94 |
insurance authorities of this or any other state of the
United | 95 |
States or any province of the Dominion of Canada, and by
hospital | 96 |
or medical service organizations, and to any other
coverage the | 97 |
inclusion of which may be approved by the
superintendent. In the | 98 |
absence of such definition in the
provision in division (D) of | 99 |
this section, "other valid coverage"
as used in such provision | 100 |
shall not include group insurance,
automobile medical payments | 101 |
insurance, or coverage provided by
hospital or medical service | 102 |
organizations or by union welfare
plans or employer or employee | 103 |
benefit organizations. | 104 |
For the purpose of applying the provision in division (D)
of | 105 |
this section with respect to any insured, any amount of
benefit | 106 |
provided for such insured pursuant to any compulsory
benefit | 107 |
statute, including any workers' compensation or
employer's | 108 |
liability statute, whether provided by governmental
agency or | 109 |
otherwise, shall in all cases be deemed to be "other
valid | 110 |
coverage" of which the insurer has had notice. | 111 |
(E) A provision as follows: Insurance with other
insurers. If | 115 |
there be other valid coverage, not with this
insurer, providing | 116 |
benefits for the same loss on other than an
expense incurred basis | 117 |
and of which the insurer has not been
given written notice prior | 118 |
to the occurrence or commencement of
loss, the only liability for | 119 |
such benefits under this policy
shall be for such proportion of | 120 |
the indemnities otherwise
provided hereunder for such loss as the | 121 |
like indemnities of which
the insurer had notice (including the | 122 |
indemnities under this
policy) bear to the total amount of all | 123 |
like indemnities for such
loss, and for the return of such portion | 124 |
of the premium paid as
shall exceed the pro-rata portion for the | 125 |
indemnities thus
determined. | 126 |
The insurer may at its option include in the provision in | 132 |
division (E) of this section a definition of "other valid | 133 |
coverage" approved as to form by the superintendent. Such | 134 |
definition shall be limited in subject matter to coverage
provided | 135 |
by organizations subject to regulation by insurance law
or by | 136 |
insurance authorities of this or any other state of the
United | 137 |
States or any province of the Dominion of Canada, and to
any other | 138 |
coverage the inclusion of which may be approved by the | 139 |
superintendent. In the absence of such definition in the
provision | 140 |
in division (E) of this section, "other valid coverage"
as used in | 141 |
such provision shall not include group insurance, or
benefits | 142 |
provided by union welfare plans or by employer or
employee benefit | 143 |
organizations. | 144 |
For the purpose of applying the provision in division (E)
of | 145 |
this section with respect to any insured, any amount of
benefit | 146 |
provided for such insured pursuant to any compulsory
benefit | 147 |
statute, including any workers' compensation or
employer's | 148 |
liability statute, whether provided by a governmental
agency or | 149 |
otherwise, shall in all cases be deemed to be "other
valid | 150 |
coverage" of which the insurer has had notice. | 151 |
(F) A provision as follows: Relation of earnings to | 155 |
insurance. If the total monthly amount of loss of time benefits | 156 |
promised for the same loss under all valid loss of time coverage | 157 |
upon the insured, whether payable on a weekly or monthly basis, | 158 |
shall exceed the monthly earnings of the insured at the time | 159 |
disability commenced or histhe insured's average monthly
earnings | 160 |
for the
period of two years immediately preceding a disability for | 161 |
which
claim is made, whichever is the greater, the insurer will be | 162 |
liable only for such proportionate amount of such benefits under | 163 |
this policy as the amount of such monthly earnings or such
average | 164 |
monthly earnings of the insured bears to the total amount
of | 165 |
monthly benefits for the same loss under all such coverage
upon | 166 |
the insured at the time such disability commences and for
the | 167 |
return of such part of the premiums paid during such two
years as | 168 |
shall excedexceed the pro-rata amount of the premiums
for the | 169 |
benefits actually paid hereunder; this shall not operate
to reduce | 170 |
the total monthly amount of benefits payable under all
such | 171 |
coverage upon the insured below the sum of two hundred
dollars or | 172 |
the sum of the monthly benefits specified in such
coverages, | 173 |
whichever is the lesser, nor shall this operate to
reduce benefits | 174 |
other than those payable for loss of time. | 175 |
The provision in division (F) of this section may be placed | 176 |
only in a policy of sickness and accident insurance which the | 177 |
insured has a right to continue in force subject to its terms by | 178 |
the timely payment of premiums until at least age fifty or in a | 179 |
policy of sickness and accident insurance issued after the
insured | 180 |
has attained age forty-four and which the insured has the
right to | 181 |
continue in force subject to its terms by the timely
payment of | 182 |
premiums for at least five years from its date of
issue. | 183 |
The insurer may at its option include in the provision in | 184 |
division (F) of this section a definition of "valid loss of time | 185 |
coverage" approved as to form by the superintendent. Such | 186 |
definition shall be limited in subject matter to coverage
provided | 187 |
by governmental agencies or by organizations subject to
regulation | 188 |
by insurance law or by insurance authorities of this
or any other | 189 |
state of the United States or any province of the
Dominion of | 190 |
Canada or to any other coverage the inclusion of
which may be | 191 |
approved by the superintendent or any combination of
such | 192 |
coverages. In the absence of such definition in the
provision in | 193 |
division (F) of this section "valid loss of time
coverage" as used | 194 |
in such provision shall not include any
coverage provided for such | 195 |
insured pursuant to any compulsory
benefit statute, including any | 196 |
workers' compensation or
employer's liability statute, whether | 197 |
provided by a governmental
agency or otherwise, or benefits | 198 |
provided by union welfare plans
or by employer or employee benefit | 199 |
organizations. | 200 |
(1) "Carrier" means any sickness and accident insurance | 226 |
company or health insuring corporation authorized to issue health | 227 |
benefit plans in this state, a public employee benefit plan, or a | 228 |
multiple employer welfare arrangement, as defined in the "Employee | 229 |
Retirement Income Security Act of 1974," 88 Stat. 832, 29 U.S.C. | 230 |
1002, except for any arrangement which is fully insured as defined | 231 |
in that act at 29 U.S.C. 1144 (b)(6)(d). | 232 |
(2) "Health benefit plan" means any hospital or medical | 233 |
expense policy or certificate or any health plan provided by a | 234 |
carrier, that is delivered, issued for delivery, renewed, or used | 235 |
in this state on or after the date occurring six months after the | 236 |
effective date of this act. "Health benefit plan" does not include | 237 |
policies covering only accident, credit, dental, disability | 238 |
income, long-term care, hospital indemnity, medicare supplement, | 239 |
specified disease, or vision care; coverage under a one-time, | 240 |
limited duration policy of not longer than six months; coverage | 241 |
issued as a supplement to liability insurance; insurance arising | 242 |
out of a workers' compensation or similar law; automobile | 243 |
medical-payment insurance; or insurance under which benefits are | 244 |
payable with or without regard to fault and which is statutorily | 245 |
required to be contained in any liability insurance policy or | 246 |
equivalent self-insurance. | 247 |