Insurance Regulation - Chapter 836
Division 20ADVERTISEMENTS OF HEALTH INSURANCE
836-020-0200Purpose and also Authority
The purpose of this rule is to ascertain truthful and enough disclocertain of all product and appropriate indevelopment in the proclaiming of health insurance. This objective is intfinished to be completed by the facility of minimum standards and guidelines of conduct for such heralding. This preeminence is promulgated under the provisions of ORS 731.244, 742.009 and also 746.075.
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(1) This ascendancy uses to all wellness insurance advertisements intfinished for presentation, distribution, or circulation in this state.
(2) Eexceptionally insurer shall establish and also keep a system of control over the content, develop, and method of presentation, distribution, and circulation of all such advertisements of its plans. All such advertisements, regardmuch less of by whom written, created, designed, presented, dispersed, or disseminated, shall be the duty of the insurer whose policies are advertised.
(1) Definitions given in the Insurance Code and also in this dominion govern the building of this rule.
(2) "Advertisement" includes:
(a) Written, oral, and pictorial material provided in straight mail, newsfiles, magazines, radio scripts, TV scripts, billboards, and other similar mediums for reaching the public;
(b) Written, oral, and pictorial product intended for individual presentation to the public, including, but not limited to, circulars, leafallows, booklets, depictions, illustrations; and
(c) Written, dental, and photographic material ready for any various other use by insurance producers or other representatives of an insurer.
(3) "Policy" contains any kind of certificate of insurance or statement of coverage.
(4) "Insurer" has fraternal advantage cultures and health and wellness treatment company contractors.
(5) "Health Insurance" does not incorporate incidental coverages issued via or supplemental to licapability insurance, or covereras consisted of within the Insurance Code definition of life insurance.
(6) "Exception" implies any kind of policy provision through which coverage for a mentioned risk is entirely eliminated. An "exception" is a statement of a threat not assumed under the plan.
(7) "Reduction" implies any type of policy provision which reduces the amount of the plan advantage. Under the terms of a "reduction", a hazard of loss is assumed however payment upon the event of such loss is limited to some amount or period that is less than would certainly otherwise be the situation had actually the reduction provision not been offered.
(8) "Limitation" indicates any policy provision which restricts coverage under the plan, other than an "exception" or a "reduction".
836-020-0215Method of Disclosure of Required Information
All indevelopment compelled to be disclosed by this preeminence shall be collection out conspicuously, and also in cshed conjunction via the statements to which the information relates or under proper captions of enough importance that the information is not lessened, rendered obscure, presented in an ambiguous fashion or so intermingled with the content of the advertisement as to be confusing or misleading.
836-020-0220Form and also Content of Advertisements
(1) The develop and also content of an advertisement shall be sufficiently finish and also clear to protect against deception or the capacity or tendency to mislead or deceive. Whether an advertisement has a capacity or tendency to mislead or deceive will be identified by the Insurance Commissioner from the all at once impression that the advertisement might fairly be supposed to produce upon a perkid of average education and learning or intelligence within the segment of the public to which it is directed.
(2) Advertisements shall be truthful and also not misleading in fact or in implication. Words or phrases, the interpretation of which is clear just by implication or by familiarity through insurance terminology, shall not be supplied.
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836-020-0225Advertisements of Benefits Payable, Losses Covered, or Premiums Payable
(1) Deceptive Words, Phrases, or Illustrations Prohibited:
(a) No advertisement shall omit particular indevelopment or use particular words, phrases, statements, recommendations, or illustrations if the omission of such information or usage of such words, phrases, statements, referrals, or illustrations has actually the capacity, tendency, or result of misleading or deceiving prospective purchasers as to the nature or degree of any type of plan benefit payable, loss covered, or premium payable. The truth that the readily available policy is made obtainable to a prospective insured for inspection prior to consummation of sale, or that an market is made to remoney the premium if the purchaser is not satisfied, does not remedy misleading statements;
(b) No advertisement shall usage words or phrases such as “all,” “complete,” “finish,” “thorough,” “infinite,” “up to,” “as high as,” “this policy will certainly help pay your hospital and also surgical bills,” “this policy will certainly assist fill some of the gaps that Meditreatment and also your existing insurance leave out,” “this policy will certainly aid to rearea your income” (once supplied in reference to loss-of-time benefits), or comparable words or phrases, in a manner which exaggerates any type of benefit past the regards to the policy;
(c) No advertisement shall contain descriptions of a policy limitation, exemption, or reduction worded in a positive manner to suggest that it is a advantage. Instances of this are describing a waiting duration as a “benefit builder,” or stating that “even pre-existing problems are spanned after 2 years.” Words and also phrases offered in an advertisement to explain policy restrictions, exceptions, or reductions shall fairly and accurately define the negative functions of the limitation, exception, or reduction;
(d) No advertisement of a benefit for which payment is conditional upon confinement in a hospital or comparable facility shall use words or phrases such as “taxation totally free,” “added cash,” “added income,” “extra pay,” or considerably similar words or phrases in a manner which has the capacity, tendency, or impact of misleading prospective purchasers right into believing that the policy advertised will certainly in some way permit them to make a profit from being hospitalized. This ascendancy does not prohibit the usage of finish and also accurate terminology explaining the federal Internal Revenue Service rules applicable to the tax of assorted forms of health and wellness insurance benefits. It is provided that such rules carry out that premiums passist for and benefits obtained from hospital indemnity plans are subject to the exact same dominion as loss-of-time premiums and benefits, and also are not afforded the exact same favorable tax treatment as expense-incurred hospital, medical, and surgical benefit coverages;
(e) No advertisement of a hospital or similar facility confinement advantage shall advertise that the amount of the benefit is payable on a monthly or weekly basis when, in reality, the amount of the benefit payable is on a everyday pro rata basis relating to the number of days of confinement. When the plan includes a limit on the variety of days of coverage gave, the limit need to show up in the advertisement;
(f) No advertisement of a policy extending only one or more specified conditions shall imply coverage beyond the terms of the policy. Several identified terms shall not be supplied to describe any one condition so regarding imply larger coverage than is the fact;
(g) An advertisement for a policy offering benefits for stated illnesses only, such as cancer, or for stated mishaps just, such as automobile accidents, shall clearly and also conspicuously in prominent form state the limited nature of the policy;
(h) An advertisement of an insurance policy offered by straight mail shall not imply that, bereason “no insurance agent will speak to and no commission will certainly be passist to agents,” it is a “low expense setup,” or usage similar phrases. A statement that “no agent will call” is not of itself misleading.
(2) Limitations, Exceptions, and Reductions:
(a) When an advertisement describes a dollar amount of a benefit, a duration of time for which a benefit is payable, the price of the policy or of a details policy advantage, or the loss for which such advantage is payable, it shall likewise discshed the restrictions, exceptions, and reductions affecting the fundamental provisions of the plan without which disclocertain the advertisement would certainly have actually the capacity or tendency to mislead or deceive;
(b) When a plan contains a waiting elimicountry, probationary or comparable time period in between the efficient day of the plan and the efficient day of coverage under the plan, or a time period between the date a loss occurs and the date benefits begin to accrue for such loss, an advertisement to which the coming before paragraph is applicable shall discshed the presence of such periods;
(c) An advertisement shall not usage the words “only,” “simply,” “just,” “minimum,” or equivalent words or phrases to explain the applicability of any kind of exceptions and reductions. An instance is: “This plan is topic to the complying with minimum exceptions and reductions:.”
(3) Pre-Existing Conditions:
(a) An advertisement to which area (2) of this dominance is applicable shall disclose in negative terms the level to which any kind of loss is not extended if the reason of the loss is traceable to a condition existing before the effective day of the plan. No use of the term “pre-existing condition” shall be made without an correct meaning or description;
(b) When a plan does not cover losses resulting from pre-existing problems, no advertisement of the plan shall state or suggest that the applicant’s physical condition or medical history will certainly not impact the issuance of the policy or payment of case thereunder. This paragraph prohibits the usage of the expression “no medical examination required” and also phrases of equivalent import, but does not prohilittle explaining “automatic issue”;
(c) When an advertisement contains an application form to be completed by the applicant and also returned by mail for a direct response insurance coverage, the application form shall contain a question or statement, immediately coming before the blank room for the applicant’s signature, which shows the pre-existing problem provisions of the plan. The question or statement shall be substantially as follows:
(A) (Question) “Do you understand that this plan will not pay benefits during the initially ______ year(s) after the issue date for a disease or physical problem which you now have or have had actually in the past?”
(B) (Statement) “I understand also that this policy will not pay benefits for any kind of loss incurred during the initially year(s) after the worry day on account of an illness or physical condition which I currently have or have had actually in the previous.”