Req. No. 6969 Page 1 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
STATE OF OKLAHOMA
1st Session of the 58th Legislature (2021)
HOUSE BILL 2678 By: Marti
AS INTRODUCED
An Act relating to insurance; amending 36 O.S. 2011,
Section 1250.5, as amended by Section 1, Chapter 105,
O.S.L. 2012 (36 O.S. Supp. 2020 , Section 1250.5),
which relates to the Unfair Claim s Settlement
Practices Act; expanding actions that constitute
unfair claims settlement practice s; and providing an
effective date.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 36 O.S. 2011, Section 1250.5, as
amended by Section 1, Chapter 105, O.S.L. 2012 (36 O.S. Supp. 2019,
Section 1250.5), is amended to read as follows:
Section 1250.5 Any of the following acts by an insurer, if
committed in violation of Section 1250.3 of this title, constitutes
an unfair claim settlement practice exclusive of paragraph 16 of
this section which shall be applicable solely to health benefit
plans:
1. Failing to fully disclose to first party claimants,
benefits, coverages, or other provisions of any insurance policy or
Req. No. 6969 Page 2 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
insurance contract when the benefits, coverages or other provisions
are pertinent to a claim;
2. Knowingly misrepresenting to claimants pertinent facts or
policy provisions relating to cove rages at issue;
3. Failing to adopt and implement reasonable standards for
prompt investigations of claims arising under its insurance policies
or insurance contracts;
4. Not attempting in good faith to effectuate prompt, fair and
equitable settlement of claims submitted in which liability has
become reasonably clear;
5. Failing to comply with the provisions of Section 1219 of
this title;
6. Denying a claim for failure to exhibit the property without
proof of demand and unfounded refusal by a claimant t o do so;
7. Except where there is a time limit specified in the policy,
making statements, written or otherwise, which require a claimant to
give written notice of loss or proof of loss within a specified time
limit and which seek to relieve the company o f its obligations if
the time limit is not complied with unless the failure to comply
with the time limit prejudices the rights of an insurer;
8. Requesting a claimant to sign a release that extends beyond
the subject matter that gave rise to the claim pa yment;
Req. No. 6969 Page 3 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
9. Issuing checks or drafts in partial settlement of a loss or
claim under a specified coverage which contain language releasing an
insurer or its insured from its total liability;
10. Denying payment to a claimant on the grounds that services,
procedures, or supplies provided by a treating physician or a
hospital were not medically necessary unless the health insurer or
administrator, as defined in Section 1442 of this title, first
obtains an opinion from any provider of health care licensed by la w
and preceded by a medical examination or claim review, to the effect
that the services, procedures or supplies for which payment is being
denied were not medically necessary. Upon written request of a
claimant, treating physician, or hospital, the opini on shall be set
forth in a written report, prepared and signed by the reviewing
physician. The report shall detail which specific services,
procedures, or supplies were not medically necessary, in the opinion
of the reviewing physician, and an explanation of that conclusion.
A copy of each report of a reviewing physician shall be mailed by
the health insurer, or administrator, postage prepaid, to the
claimant, treating physician or hospital requesting same within
fifteen (15) days after receipt of the wri tten request. As used in
this paragraph, "physician" means a person holding a valid license
to practice medicine and surgery, osteopathic medicine, podiatric
medicine, dentistry, chiropractic, or optometry, pursuant to the
state licensing provisions of Ti tle 59 of the Oklahoma Statutes;
Req. No. 6969 Page 4 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
11. Compensating a reviewing physician, as defined in paragraph
10 of this subsection section, on the basis of a percentage of the
amount by which a claim is reduced for payment;
12. Violating the provisions of the Health Care Fraud
Prevention Act;
13. Compelling, without just cause, policyholders to institute
suits to recover amounts due under its insurance policies or
insurance contracts by offering substantially less than the amounts
ultimately recovered in suits broug ht by them, when the
policyholders have made claims for amounts reasonably similar to the
amounts ultimately recovered;
14. Failing to maintain a complete record of all complaints
which it has received during the preceding three (3) years or since
the date of its last financial examination conducted or accepted by
the Commissioner, whichever time is longer. This record shall
indicate the total number of complaints, their classification by
line of insurance, the nature of each complaint, the disposition of
each complaint, and the time it took to process each complaint. For
the purposes of this paragraph, "complaint" means any written
communication primarily expressing a grievance;
15. Requesting a refund of all or a portion of a payment of a
claim made to a claimant or health care provider more than twenty -
four (24) months after the payment is made. This paragraph shall
not apply:
Req. No. 6969 Page 5 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
a. if the payment was made because of fraud committed by
the claimant or health care provider, or
b. if the claimant or health care provider has otherwise
agreed to make a refund to the insurer for overpayment
of a claim;
16. Failing to pay, or requesting a refund of a payment, for
health care services covered under the policy if a health benefit
plan, or its agent, has provided a preauthorization or
precertification and verification of eligibility for those health
care services. This paragraph shall not apply if:
a. the claim or payment was made because of fraud
committed by the claimant or health care provider,
b. the subscriber had a preexisting exclusion under the
policy related to the service provided, or
c. the subscriber or employer failed to pay the
applicable premium and all grace periods and
extensions of coverage have expired; or
17. Denying or refusing to accept an a pplication for life
insurance, or refusing to renew, cancel, restrict or otherwise
terminate a policy of life insurance, or charge a different rate
based upon the lawful travel destination of an applicant or insured
as provided in Section 4024 of this titl e; or
18. As a health insurer that provides pharmacy benefits or a
pharmacy benefits manager that administers pharmacy benefits for a
Req. No. 6969 Page 6 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
health plan, failing to include any amount paid for an enrollee or
on behalf of an enrollee by another person when calcul ating the
enrollee's total contribution to an out -of-pocket maximum,
deductible, copayment, coinsurance or other cost -sharing
requirement.
SECTION 2. This act shall become effective November 1, 2021 .
58-1-6969 AMM 12/17/20