OAR 836-052-0124
Policy Definitions and Terms

A policy or certificate may not be advertised, solicited or issued for delivering in this state as a Medicare supplement policy or certificate unless the policy or certificate contains definitions or terms that conform to the following requirements:

(1)

“Accident,” “accidental injury” or “accidental means” shall be defined to employ “result” language and shall not include words that establish an accidental means test or use words such as “external, violent, visible wounds” or similar words of description or characterization. The following provisions also apply to definition of the terms under this section:

(a)

The definition shall not be more restrictive than the following: “’Injury or injuries for which benefits are provided’ means accidental bodily injury sustained by the insured person that is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while insurance coverage is in force”;

(b)

The definition may provide that injuries shall not include injuries for which benefits are provided or available under any worker’s compensation, employer’s liability or similar law or motor vehicle no-fault plan, unless prohibited by law.

(2)

“Benefit period” or “Medicare benefit period” shall not be defined more restrictively than as defined in the Medicare program.

(3)

“Convalescent nursing home,” “extended care facility” or “skilled nursing facility” shall not be defined more restrictively than as defined in the Medicare program.

(4)

“Health care expenses” means, for OAR 836-052-0145 (Loss Ratio Standards and Refund or Credit of Premium), expenses of health maintenance organizations associated with the delivery of health care services which expenses are analogous to incurred losses of insurers.

(5)

“Hospital” may be defined in relation to its status, facilities and available services or to reflect its accreditation by the Joint Commission on Accreditation of Hospitals but not more restrictively than as defined in the Medicare program.

(6)

“Medicare” shall be defined in the policy and certificate. “Medicare” may be substantially defined as “The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as then constituted or later amended,” or “Title I, Part I of Public Law 89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof,” or words of similar import.

(7)

“Medicare eligible expenses” shall mean expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare.

(8)

“Physician” shall not be defined more restrictively than as defined in the Medicare program.

(9)

“Sickness” shall not be defined to be more restrictive than the following: “Sickness means illness or disease of an insured person that manifests itself after the effective date of insurance and while the insurance is in force.” The definition may be further modified to exclude sicknesses or diseases for which benefits are provided under any worker’s compensation, occupational disease, employer’s liability or similar law.

Source: Rule 836-052-0124 — Policy Definitions and Terms, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-052-0124.

836‑052‑0103
Purpose 836‑052‑0107
Authority 836‑052‑0114
Applicability and Scope 836‑052‑0119
Definitions 836‑052‑0124
Policy Definitions and Terms 836‑052‑0129
Policy Provisions 836‑052‑0132
Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date of Coverage on or After June 1, 2010 836‑052‑0133
Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010 836‑052‑0134
Minimum Benefit Standards for Policies or Certificates Issued for Delivery Prior to July 1, 1992 836‑052‑0136
Standard Medicare Supplement Benefit Plans for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010 836‑052‑0138
Open Enrollment 836‑052‑0139
Medicare Select Policies and Certificates 836‑052‑0140
Standards for Claims Payment 836‑052‑0141
Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates with an Effective Date of Coverage on or After June 1, 2010 836‑052‑0142
Guaranteed Issue for Eligible Persons 836‑052‑0143
Annual Opportunity to Select Another Medicare Supplement Policy or Certificate 836‑052‑0144
Standard Medicare Supplement Benefit Plans for 2020 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery to Individuals Newly Eligible for Medicare on or after January 1, 2020. 836‑052‑0145
Loss Ratio Standards and Refund or Credit of Premium 836‑052‑0151
Filing and Approval of Policies and Certificates and Premium Rates 836‑052‑0156
Permitted Compensation Arrangements 836‑052‑0160
Required Disclosure Provisions 836‑052‑0165
Requirements for Application Forms, Replacement Coverage 836‑052‑0170
Filing Requirements for Advertising 836‑052‑0175
Standards for Marketing 836‑052‑0180
Appropriateness of Recommended Purchase and Excessive Insurance 836‑052‑0185
Reporting of Multiple Policies 836‑052‑0190
Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary Periods in Replacement Policies and Certificates 836‑052‑0192
Prohibition Against Use of Genetic Information and Requests for Genetic Testing 836‑052‑0194
Separability 836‑052‑0225
Durational Limits for Health Maintenance Organizations 836‑052‑0230
Provider Services Limits for Insurers and Health Care Contractors 836‑052‑0500
Statutory Authority 836‑052‑0508
Definitions 836‑052‑0516
Policy Definitions 836‑052‑0526
Policy Practices and Provisions 836‑052‑0531
Long Term Care Insurance Partnership Program 836‑052‑0546
Required Policy Provisions 836‑052‑0556
Required Disclosure of Rating Practices to Consumers 836‑052‑0566
Initial Rate Filing Requirements 836‑052‑0576
Prohibition Against Post-Claims Underwriting, Applications 836‑052‑0586
Minimum Standards for Home Health and Community Care Benefits in Long-Term Care Insurance Policies 836‑052‑0596
Standards for Covered Services 836‑052‑0606
Use and Definition of “Home” or Similar Wording 836‑052‑0616
Requirement to Offer Inflation Protection 836‑052‑0626
Requirements for Application Forms and Replacement Coverage 836‑052‑0636
Reporting Requirements 836‑052‑0637
Annual Rate Certification Requirements 836‑052‑0639
Training for Insurance Producers 836‑052‑0646
Benefits Provided Through Advancement of Life Insurance Proceeds 836‑052‑0656
Reserve Standards 836‑052‑0666
Loss Ratio 836‑052‑0676
Premium Rate Schedule Increases 836‑052‑0680
Premium Rate Schedule Increases for Policies Subject to Loss Ratio Limits Related to Original Filings 836‑052‑0686
Filing Requirements for Out-of-State Group Policies 836‑052‑0696
Filing Requirements for Advertising 836‑052‑0706
Standards for Marketing 836‑052‑0716
Disclosure Statement 836‑052‑0726
Suitability 836‑052‑0736
Prohibition Against Preexisting Conditions, Waiting Periods and Probationary Periods in Replacement Policies and Certificates 836‑052‑0738
Availability of New Services or Providers 836‑052‑0740
Right to Reduce Coverage and Lower Premiums 836‑052‑0746
Nonforfeiture Benefit Requirement 836‑052‑0756
Standards for Benefit Triggers 836‑052‑0766
Additional Standards for Benefit Triggers for Qualified Long-Term Care Insurance Contracts 836‑052‑0768
Appealing An Insurer’s Determination That The Benefit Trigger Is Not Met 836‑052‑0770
Prompt Payment of Clean Claims 836‑052‑0776
Standard Format Outline of Coverage 836‑052‑0786
Requirement to Deliver Shopper’s Guide 836‑052‑0790
Disclosure of Benefits Paid 836‑052‑0800
Purpose 836‑052‑0810
Replacement Upon Termination 836‑052‑0840
Termination of Coverage 836‑052‑0850
Multiple Employer Trusts 836‑052‑0860
Form of Notice to Group Policyholder 836‑052‑1000
Prosthetic and Orthotic Devices
Last Updated

Jun. 8, 2021

Rule 836-052-0124’s source at or​.us