Chapter 743 — Chapter 743

ORS 743.380 Claim report and payment. (1) All claims under policies of credit life or credit health insurance, or both, shall be promptly reported to the insurer or its designated claim representative and the insurer shall maintain adequate claim files. All claims shall be settled as soon as possible and in accordance with the terms of the policy

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ORS 743.402 Exceptions to individual health insurance policy requirements. ORS 743.405 to 743.498 and 743A.160 do not apply to or affect

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ORS 743.405 General requirements for health insurance policies. An individual health insurance policy must meet the following requirements

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ORS 743.406 Required provisions in group health insurance policies. A group health insurance policy shall contain in substance the following provisions

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ORS 743.408 Mandatory provisions. Except as provided in ORS 742.021, a health insurance policy shall contain the provisions set forth in ORS 743.411 to 743.444. The provisions shall be preceded individually by the caption appearing in the sections or, at the option of the insurer, by the appropriate individual or group captions or subcaptions as the Director of the Department of Consumer and Business Services may approve. [1967 c.359 §428; 2011 c.9 §92]

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ORS 743.411 Entire contract; changes. A health insurance policy shall contain a provision as follows: “ENTIRE CONTRACT; CHANGES: This policy, including the indorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the insurer and unless such approval be indorsed hereon or attached hereto. No insurance producer has authority to change this policy or to waive any of its provisions.” [1967 c.359 §429; 2003 c.364 §107]

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ORS 743.412 [1977 c.632 §2; 1981 c.319 §1; 2001 c.900 §230; renumbered 743A.160 in 2007]

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ORS 743.414 Time limit on certain defenses; incontestability. (1) A health insurance policy shall contain a provision as follows: “TIME LIMIT ON CERTAIN DEFENSES: After two years from the date of issue of this policy no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or to deny a claim for loss incurred or disability, as defined in the policy, commencing after the expiration of that period.”

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ORS 743.416 Due date for first premium payment. An insurer offering an individual health benefit plan may establish a due date for payment of the first premium for the plan no earlier than 15 days after the date that the coverage begins or 15 days after the insurer sends the initial invoice to the insured, whichever is later. [2021 c.205 §3]

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ORS 743.417 Grace period for subsequent premium payments; cancellation and nonrenewal. (1) A policy of health insurance issued to an individual residing in this state shall specify a minimum grace period following the premium due date for the payment of each premium falling due after the first premium, during which grace period the policy shall continue in force. Unless a longer grace period is provided by federal law, the grace period must be at least

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ORS 743.420 Reinstatement. (1) A health insurance policy, other than a health benefit plan as defined in ORS 743B.005, shall contain a provision as follows: “REINSTATEMENT: If any renewal premium is not paid within the grace period, a subsequent acceptance of premium by the insurer or by any insurance producer duly authorized by the insurer to accept such premium, without requiring in connection therewith an application for reinstatement, shall reinstate the policy; provided, however, that if the insurer or such insurance producer requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy will be reinstated upon approval of such application by the insurer or, lacking such approval, upon the 45th day following the date of such conditional receipt unless the insurer has previously notified the insured in writing of its disapproval of such application. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than 10 days after such date. In all other respects the insured and insurer shall have the same rights thereunder as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions indorsed hereon or attached hereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than 60 days prior to the date of reinstatement.”

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ORS 743.423 Notice of claim. (1) A health insurance policy shall contain a provision as follows: “NOTICE OF CLAIM: Written notice of claim must be given to the insurer within 20 days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or the beneficiary to the insurer at ___ (insert the location of such office as the insurer may designate for the purpose), or to any authorized agent of the insurer, with information sufficient to identify the insured, shall be deemed notice to the insurer.”

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ORS 743.426 Claim forms. A health insurance policy shall contain a provision as follows: “CLAIM FORMS: The insurer, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proof of loss. If such forms are not furnished within 15 days after the giving of such notice, the claimant shall be deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made.” [1967 c.359 §434]

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ORS 743.429 Proofs of loss. A health insurance policy shall contain a provision as follows: “PROOFS OF LOSS: Written proof of loss must be furnished to the insurer at its office in case of claim for loss for which this policy provides any periodic payment contingent upon continuing loss within 90 days after the termination of the period for which the insurer is liable and in case of claim for any other loss within 90 days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate or reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required.” [1967 c.359 §435]

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ORS 743.432 Time of payment of claims. A health insurance policy shall contain a provision as follows: “TIME OF PAYMENT OF CLAIMS: Indemnities payable under this policy for any loss other than loss for which this policy provides any periodic payment will be paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment will be paid ______ (insert period for payment which must not be less frequently than monthly) and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof.” [1967 c.359 §436]

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ORS 743.435 Payment of claims. (1) A health insurance policy shall contain a provision as follows: “PAYMENT OF CLAIMS: Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to the estate of the insured. Any other accrued indemnities unpaid at the insured’s death may, at the option of the insurer, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the insured.”

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ORS 743.438 Physical examinations and autopsy. A health insurance policy shall contain a provision as follows: “PHYSICAL EXAMINATIONS AND AUTOPSY: The insurer at its own expense shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law.” [1967 c.359 §438]

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ORS 743.441 Legal actions. A health insurance policy shall contain a provision as follows: “LEGAL ACTIONS: No action at law or in equity shall be brought to recover on this policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished.” [1967 c.359 §439]

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ORS 743.444 Change of beneficiary. (1) A health insurance policy shall contain a provision as follows: “CHANGE OF BENEFICIARY: Unless the insured makes an irrevocable designation of beneficiary, the right to change of beneficiary is reserved to the insured and the consent of the beneficiary or beneficiaries shall not be requisite to surrender or assignment of this policy or to any change of beneficiary or beneficiaries or to any other changes in this policy.”

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ORS 743.447 Optional provisions. Except as provided in ORS 742.021, provisions in a health insurance policy respecting the matters set forth in ORS 743.450 to 743.477 shall be in the words that appear in such sections. Any such provision contained in the policy shall be preceded individually by the appropriate caption appearing in such sections or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the Director of the Department of Consumer and Business Services may approve. [1967 c.359 §441; 2011 c.9 §93]

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ORS 743.450 Change of occupation. A health insurance policy may contain a provision as follows: “CHANGE OF OCCUPATION: If the insured be injured or contract sickness after having changed occupation to one classified by the insurer as more hazardous than that stated in this policy or while doing for compensation anything pertaining to an occupation so classified, the insurer will pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for such more hazardous occupation. If the insured changes occupation to one classified by the insurer as less hazardous than that stated in this policy, the insurer, upon receipt of proof of such change of occupation, will reduce the premium rate accordingly, and will return the excess pro rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent. In applying this provision, the classification of occupational risk and the premium rates shall be such as have been last filed by the insurer prior to the occurrence of the loss for which the insurer is liable or prior to date of proof of change in occupation with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued; but if such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the insurer in such state prior to the occurrence of the loss or prior to the date of proof of change in occupation.” [1967 c.359 §442]

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ORS 743.453 Misstatement of age. A health insurance policy may contain a provision as follows: “MISSTATEMENT OF AGE: If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age.” [1967 c.359 §443]

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ORS 743.456 Other insurance in same insurer. (1) A health insurance policy may contain a provision as follows: “OTHER INSURANCE IN THIS INSURER: If an accident or sickness or accident and sickness policy or policies previously issued by the insurer to the insured be in force concurrently herewith, making the aggregate indemnity for _____ (insert type of coverage or coverages) in excess of $___ (insert maximum limit of indemnity or indemnities), the excess insurance shall be void and all premiums paid for such excess shall be returned to the insured or to the estate of the insured.”

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ORS 743.459 Insurance with other insurers; expense incurred benefits. (1) A health insurance policy may contain a provision as follows: “INSURANCE WITH OTHER INSURERS: If there be other valid coverage, not with this insurer, providing benefits for the same loss on a provision of service basis or on an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability under any expense incurred coverage of this policy shall be for such proportion of the loss as the amount which would otherwise have been payable hereunder plus the total of the like amounts under all such other valid coverages for the same loss of which this insurer had notice bears to the total like amounts under all valid coverages for such loss, and for the return of such portion of the premiums paid as shall exceed the pro rata portion for the amount so determined. For the purpose of applying this provision when other coverage is on a provision of service basis, the ‘like amount’ of such other coverage shall be taken as the amount which the services rendered would have cost in the absence of such coverage.”

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ORS 743.462 Insurance with other insurers; other than expense incurred benefits. (1) A health insurance policy may contain a provision as follows: “INSURANCE WITH OTHER INSURERS: If there be other valid coverage, not with this insurer, providing benefits for the same loss on other than an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability for such benefits under this policy shall be for such proportion of the indemnities otherwise provided hereunder for such loss as the like indemnities of which the insurer had notice (including the indemnities under this policy) bear to the total amount of all like indemnities for such loss, and for the return of such portion of the premium paid as shall exceed the pro rata portion for the indemnities thus determined.”

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ORS 743.465 Relation of earnings to insurance. (1) A health insurance policy may contain a provision as follows: “RELATION OF EARNINGS TO INSURANCE: If the total monthly amount of loss of time benefits promised for the same loss under all valid loss of time coverage upon the insured, whether payable on a weekly or monthly basis, shall exceed the monthly earnings of the insured at the time disability commenced or the average monthly earnings of the insured for the period of two years immediately preceding a disability for which claim is made, whichever is the greater, the insurer will be liable only for such proportionate amount of such benefits under this policy as the amount of such monthly earnings or such average monthly earnings of the insured bears to the total amount of monthly benefits for the same loss under all such coverage upon the insured at the time such disability commences and for the return of such part of the premiums paid during such two years as shall exceed the pro rata amount of the premiums for the benefits actually paid hereunder; but this shall not operate to reduce the total monthly amount of benefits payable under all such coverage upon the insured below the sum of $200 or the sum of the monthly benefits specified in such coverages, whichever is the lesser, nor shall it operate to reduce benefits other than those payable for loss of time.”

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ORS 743.468 Unpaid premium. A health insurance policy may contain a provision as follows: “UNPAID PREMIUM: Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom.” [1967 c.359 §448]

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ORS 743.471 Cancellation. A health insurance policy may contain a provision as follows: “CANCELLATION: The insurer may cancel this policy by written notice delivered to the insured, or mailed to the last address of the insured as shown by the records of the insurer. The notice must state the reason for cancellation and the date on which the cancellation shall be effective. Except as provided under the ‘GRACE PERIOD’ provision of this policy for nonpayment of premium, cancellation shall not become effective earlier than the 30th day after the date of the notice. After the policy has been continued beyond its original term, the insured may cancel this policy at any time by written notice delivered or mailed to the insurer, effective upon receipt or on such later date as may be specified in such notice. In the event of cancellation, the insurer will return promptly the unearned portion of any premium paid. If the insured cancels, the earned premium shall be computed by the use of the short rate table last filed with the state official having supervision of insurance in the state where the insured resided when the policy was issued. If the insurer cancels, the earned premium shall be computed pro rata. Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation.” [1967 c.359 §449; 1989 c.784 §20]

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ORS 743.472 Permissible reasons for cancellation or refusal to renew. An insurer selling individual health insurance policies may cancel or refuse to renew an individual health insurance policy only if the insurer makes a determination to cancel or not to renew all policies of the same type and form as the individual policy, or if the ground for cancellation or nonrenewal is any of the following and is stated as a provision of the policy

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ORS 743.474 Conformity with state statutes. A health insurance policy may contain a provision as follows: “CONFORMITY WITH STATE STATUTES: Any provision of this policy which, on its effective date, is in conflict with the statutes of the state in which the insured resides on such date hereby is amended to conform to the minimum requirements of such statutes.” [1967 c.359 §450]

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ORS 743.477 Illegal occupation. A health insurance policy may contain a provision as follows: “ILLEGAL OCCUPATION: The insurer shall not be liable for any loss to which a contributing cause was the insured’s commission of or attempt to commit a felony or to which a contributing cause was the insured’s being engaged in an illegal occupation.” [1967 c.359 §451]

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ORS 743.480 [1967 c.359 §452; 1979 c.744 §64; 2007 c.128 §1; renumbered 743A.164 in 2007]

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ORS 743.483 Arrangement of provisions. The provisions of a health insurance policy that are the subject of ORS 743.408 to 743.477, or any corresponding provisions that are used in lieu thereof in accordance with the Insurance Code, shall be printed in the consecutive order of such sections or, at the option of the insurer, any such provision may appear as a unit in any part of the policy, with other provisions to which it may be logically related, provided the resulting policy shall not be in whole or in part unintelligible, uncertain, ambiguous, abstruse or likely to mislead a person to whom the policy is offered, delivered or issued. [1967 c.359 §453; 2009 c.11 §95; 2011 c.9 §94]

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ORS 743.486 Scope of term “insured” in statutory policy provisions. As used in ORS 743.402 to 743.498, the word “insured” shall not be construed as preventing a person other than the insured with a proper insurable interest from making application for and owning a policy covering the insured or from being entitled under such a policy to any indemnities, benefits and rights provided therein. [1967 c.359 §454; 2011 c.9 §95]

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ORS 743.489 Extension of coverage beyond policy period; effect of misstatement of age. If any health insurance policy contains a provision establishing, as an age limit or otherwise, a date after which the coverage provided by the policy will not be effective, and if such date falls within a period for which premium is accepted by the insurer or if the insurer accepts a premium after such date, the coverage provided by the policy shall continue in force subject to any right of cancellation until the end of the period for which premium has been accepted. In the event the age of the insured has been misstated and if, according to the correct age of the insured, the coverage provided by the policy would not have become effective, or would have ceased prior to the acceptance of such premium or premiums, then the liability of the insurer shall be limited to the refund, upon request, of all premiums paid for the period not covered by the policy. [Formerly 741.170]

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ORS 743.492 Policy return and premium refund provision. Every health insurance policy except single premium nonrenewable policies shall have printed on its face or attached thereto a notice stating in substance that the person to whom the policy is issued shall be permitted to return the policy within 10 days of its delivery to the purchaser and to have the premium paid refunded if, after examination of the policy, the purchaser is not satisfied with it for any reason. If a policyholder or purchaser pursuant to such notice returns the policy to the insurer at its home or branch office or to the insurance producer through whom it was purchased, it shall be void from the beginning and the parties shall be in the same position as if no policy had been issued. [Formerly 741.180; 2003 c.364 §109]

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ORS 743.495 Use of terms “noncancelable” or “guaranteed renewable”; synonymous terms. (1) No health insurance policy shall contain the following unqualified terms except as provided in this subsection

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ORS 743.498 Statement in policy of cancelability or renewability. (1) A health insurance policy which is noncancelable or guaranteed renewable as those terms are used in ORS 743.495, except that the insured’s right is for a limited period of more than one year rather than for life, shall contain the applicable one of the following statements, or such other statement which, in the opinion of the Director of the Department of Consumer and Business Services, is equally clear or more definite as to the subject matter

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ORS 743.499 [2011 c.500 §4a; 2012 c.24 §1; renumbered 743B.330 in 2015]

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ORS 743.516 [1967 c.359 §459; repealed by 1999 c.987 §28]

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ORS 743.519 [1967 c.359 §460; 1971 c.231 §25; repealed by 1999 c.987 §28]

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ORS 743.520 [1971 c.231 §4; repealed by 1999 c.987 §28]

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ORS 743.521 (1)(a) A professional employer organization may offer group health insurance to its clients’ covered employees

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ORS 743.522 (1) As used in this section and ORS 743.521

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ORS 743.523 Certain sales practices prohibited. (1) No person selling group health insurance is authorized to sell membership in an association, including a labor union, for the purpose of qualifying an applicant who is an individual for group health insurance

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ORS 743.524 Eligibility of association to be group health policyholder; rules. (1) An insurer may not offer a policy of group health insurance to an association as the policyholder or offer coverage under such a policy, whether issued in this or another state, unless the Director of the Department of Consumer and Business Services determines that the association satisfies the requirements of an association under ORS 731.098 (2)

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ORS 743.525 [1967 c.359 §462; repealed by 1981 c.752 §17]

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ORS 743.526 Determination of whether trustees are policyholders; consequences; rules. (1) An insurer may not offer a policy of group health insurance described in ORS 731.098 (3) that insures persons in this state or offer coverage under such a policy, whether the policy is to be issued in this or another state, unless the Director of the Department of Consumer and Business Services determines that the requirements of this section and ORS 731.098 (3) are satisfied

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ORS 743.527 [1979 c.797 §2; 1981 c.395 §1; renumbered 743B.340 in 2015]

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ORS 743.528 [1967 c.359 §463; 1981 c.752 §13; 1997 c.716 §23; 2013 c.681 §57; renumbered 743.406 in 2015]

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