S. B. No. 54 As Introduced

As Introduced

127th General Assembly

Regular Session

2007-2008

S. B. No. 54

Senator Clancy

Cosponsor: Senator Schuler

A BILL

To amend section 3923.05 and to enact section 3923.80 1
of the Revised Code to prohibit certain insurers 2
from limiting or excluding coverage for injuries 3
occurring as a consequence of an insured's use of 4
alcohol or other drugs or both. 5

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

       Section 1. That section 3923.05 be amended and section 6
3923.80 be enacted to read as follows: 7

       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 ~~his~~the 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

       (B) A provision as follows: Misstatement of age. If the age 44
of the insured has been misstated, all amounts payable under this 45
policy shall be such as the premium paid would have purchased at 46
the correct age. 47

       (C) A provision as follows: 48

       (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 ~~his~~the insured's estate. 55

       The insurer shall insert the type of coverage or coverages in 56
the first blank space in the provision in division (C)(1) of this 57
section and the maximum limit of indemnity or indemnities in the 58
second blank space in the provision in division (C)(1) of this 59
section. 60

       (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, ~~his~~the insured's beneficiary or 65
~~his~~the 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

       If the provision in division (D) of this section is included 85
in a policy of sickness and accident insurance which also contains 86
the provision in division (E) of this section, the insurer shall 87
add to the caption of the provision in division (D) of this 88
section the following: Expense incurred benefits. 89

       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

       In applying the provision in division (D) of this section no 112
third party liability coverage shall be included as "other valid 113
coverage." 114

       (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

       If the provision in division (E) of this section is included 127
in a policy of sickness and accident insurance which also contains 128
the provision in division (D) of this section, the insurer shall 129
add to the caption of the provision in division (E) of this 130
section the following: Other benefits. 131

       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

       In applying the provision in division (E) of this section no 152
third party liability coverage shall be included as "other valid 153
coverage." 154

       (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 ~~his~~the 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 ~~exced~~exceed 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

       (G) A provision as follows: Unpaid premium. Upon the payment 201
of a claim under this policy, any premium then due and unpaid or 202
covered by any note or written order may be deducted therefrom. 203

       (H) A provision as follows: Conformity with state statutes. 204
Any provision of this policy which, on its effective date, is in 205
conflict with the statutes of the state in which the insured 206
resides on such date is hereby amended to conform to the minimum 207
requirements of such statutes. 208

       (I) A provision as follows: Illegal occupation. The insurer 209
shall not be liable for any loss to which a contributing cause was 210
the insured's commission of or attempt to commit a felony or to 211
which a contributing cause was the insured's being engaged in an 212
illegal occupation. 213

       ~~(J) A provision as follows: Intoxicants and narcotics. The~~ 214
~~insurer shall not be liable for any loss sustained or contracted~~ 215
~~in consequence of the insured's being intoxicated or under the~~ 216
~~influence of any narcotic unless administered on the advice of a~~ 217
~~physician.~~ 218

       Sec. 3923.80. (A) Notwithstanding section 3901.71 of the 219
Revised Code, no health benefit plan shall contain a provision 220
that limits or excludes an insured's coverage under the plan for a 221
loss the insured sustains that is the result of the insured's use 222
of alcohol or other drugs or both and the loss is otherwise 223
covered under the plan. 224

       (B) As used in this section: 225

       (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

       (3) "Insured" means a person covered by a health benefit plan 248
issued by a carrier. 249

       Section 2. That existing section 3923.05 of the Revised Code 250
is hereby repealed. 251

Section 1. That section 3923.05 be amended and section	6
3923.80 be enacted to read as follows:	7

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 ~~his~~the 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

(B) A provision as follows: Misstatement of age. If the age	44
of the insured has been misstated, all amounts payable under this	45
policy shall be such as the premium paid would have purchased at	46
the correct age.	47

(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 ~~his~~the insured's estate.	55

The insurer shall insert the type of coverage or coverages in	56
the first blank space in the provision in division (C)(1) of this	57
section and the maximum limit of indemnity or indemnities in the	58
second blank space in the provision in division (C)(1) of this	59
section.	60

(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, ~~his~~the insured's beneficiary or	65
~~his~~the 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

If the provision in division (D) of this section is included	85
in a policy of sickness and accident insurance which also contains	86
the provision in division (E) of this section, the insurer shall	87
add to the caption of the provision in division (D) of this	88
section the following: Expense incurred benefits.	89

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

In applying the provision in division (D) of this section no	112
third party liability coverage shall be included as "other valid	113
coverage."	114

(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

If the provision in division (E) of this section is included	127
in a policy of sickness and accident insurance which also contains	128
the provision in division (D) of this section, the insurer shall	129
add to the caption of the provision in division (E) of this	130
section the following: Other benefits.	131

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

In applying the provision in division (E) of this section no	152
third party liability coverage shall be included as "other valid	153
coverage."	154

(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 ~~his~~the 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 ~~exced~~exceed 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

(G) A provision as follows: Unpaid premium. Upon the payment	201
of a claim under this policy, any premium then due and unpaid or	202
covered by any note or written order may be deducted therefrom.	203

(H) A provision as follows: Conformity with state statutes.	204
Any provision of this policy which, on its effective date, is in	205
conflict with the statutes of the state in which the insured	206
resides on such date is hereby amended to conform to the minimum	207
requirements of such statutes.	208

(I) A provision as follows: Illegal occupation. The insurer	209
shall not be liable for any loss to which a contributing cause was	210
the insured's commission of or attempt to commit a felony or to	211
which a contributing cause was the insured's being engaged in an	212
illegal occupation.	213

~~(J) A provision as follows: Intoxicants and narcotics. The~~	214
~~insurer shall not be liable for any loss sustained or contracted~~	215
~~in consequence of the insured's being intoxicated or under the~~	216
~~influence of any narcotic unless administered on the advice of a~~	217
~~physician.~~	218

Sec. 3923.80. (A) Notwithstanding section 3901.71 of the	219
Revised Code, no health benefit plan shall contain a provision	220
that limits or excludes an insured's coverage under the plan for a	221
loss the insured sustains that is the result of the insured's use	222
of alcohol or other drugs or both and the loss is otherwise	223
covered under the plan.	224

(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

(3) "Insured" means a person covered by a health benefit plan	248
issued by a carrier.	249

Section 2. That existing section 3923.05 of the Revised Code	250
is hereby repealed.	251