{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-1250.5","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-1250.5","heading":"Acts by an insurer constituting an unfair claim","body":"settlement practice.\n\nAny of the following acts by an insurer, if committed in\n\nviolation of Section 1250.3 of this title, constitutes an unfair\n\nclaim settlement practice exclusive of paragraph 16 of this section\n\nwhich shall be applicable solely to health benefit plans:\n\n1. Failing to fully disclose to first-party claimants,\n\nbenefits, coverages, or other provisions of any insurance policy or\n\ninsurance contract when the benefits, coverages or other provisions\n\nare pertinent to a claim;\n\n2. Knowingly misrepresenting to claimants pertinent facts or\n\npolicy provisions relating to coverages at issue;\n\n3. Failing to adopt and implement reasonable standards for\n\nprompt investigations of claims arising under its insurance policies\n\nor insurance contracts;\n\n4. Not attempting in good faith to effectuate prompt, fair and\n\nequitable settlement of claims submitted in which liability has\n\nbecome reasonably clear;\n\n5. Failing to comply with the provisions of Section 1219 of\n\nthis title;\n\n6. Denying a claim for failure to exhibit the property without\n\nproof of demand and unfounded refusal by a claimant to do so;\n\n7. Except where there is a time limit specified in the policy,\n\nmaking statements, written or otherwise, which require a claimant to\n\ngive written notice of loss or proof of loss within a specified time\n\nlimit and which seek to relieve the company of its obligations if\n\nthe time limit is not complied with unless the failure to comply\n\nwith the time limit prejudices the rights of an insurer. Any policy\n\nthat specifies a time limit covering damage to a roof due to wind or\n\nhail must allow the filing of claims after the first anniversary but\n\nno later than twenty-four (24) months after the date of the loss, if\n\nthe damage is not evident without inspection;\n\n8. Requesting a claimant to sign a release that extends beyond\n\nthe subject matter that gave rise to the claim payment;\n\n9. Issuing checks, drafts or electronic payment in partial\n\nsettlement of a loss or claim under a specified coverage which\n\ncontain language releasing an insurer or its insured from its total\n\nliability;\n\n10. Denying payment to a claimant on the grounds that services,\n\nprocedures, or supplies provided by a treating physician, hospital,\n\nor person or entity licensed or otherwise authorized to provide\n\nhealth care services were not medically necessary unless the health\n\ninsurer or administrator, as defined in Section 1442 of this title,\n\nfirst obtains an opinion from any provider of health care licensed\n\nby law and preceded by a medical examination or claim review, to the\n\neffect that the services, procedures or supplies for which payment\n\nis being denied were not medically necessary. In the event that\n\nclaims for mental health or substance use disorder treatments and\n\nservices are under review, the reviewing health care provider shall\n\nhave appropriate, qualified, and specialized credentials with\n\nrespect to the services and treatments. Upon written request of a\n\nclaimant, treating physician, hospital, or authorized person or\n\nentity, the opinion shall be set forth in a written report, prepared\n\nand signed by the reviewing physician. The report shall detail\n\nwhich specific services, procedures, or supplies were not medically\n\nnecessary, in the opinion of the reviewing physician, and an\n\nexplanation of that conclusion. A copy of each report of a\n\nreviewing physician shall be mailed by the health insurer, or\n\nadministrator, postage prepaid, to the claimant, treating physician,\n\nhospital, or authorized person or entity requesting same within\n\nfifteen (15) days after receipt of the written request. As used in\n\nthis paragraph, “physician” means a person holding a valid license\n\nto practice medicine and surgery, osteopathic medicine, podiatric\n\nmedicine, dentistry, chiropractic, or optometry, pursuant to the\n\nstate licensing provisions of Title 59 of the Oklahoma Statutes;\nhospital, or authorized person or entity requesting same within\n\nfifteen (15) days after receipt of the written request. As used in\n\nthis paragraph, “physician” means a person holding a valid license\n\nto practice medicine and surgery, osteopathic medicine, podiatric\n\nmedicine, dentistry, chiropractic, or optometry, pursuant to the\n\nstate licensing provisions of Title 59 of the Oklahoma Statutes;\n\n11. Compensating a reviewing physician, as defined in paragraph\n\n10 of this section, on the basis of a percentage of the amount by\n\nwhich a claim is reduced for payment;\n\n12. Violating the provisions of the Health Care Fraud\n\nPrevention Act;\n\n13. Compelling, without just cause, policyholders to institute\n\nsuits to recover amounts due under its insurance policies or\n\ninsurance contracts by offering substantially less than the amounts\n\nultimately recovered in suits brought by them, when the\n\npolicyholders have made claims for amounts reasonably similar to the\n\namounts ultimately recovered;\n\n14. Failing to maintain a complete record of all complaints\n\nwhich it has received during the preceding three (3) years or since\n\nthe date of its last financial examination conducted or accepted by\n\nthe Commissioner, whichever time is longer. This record shall\n\nindicate the total number of complaints, their classification by\n\nline of insurance, the nature of each complaint, the disposition of\n\neach complaint, and the time it took to process each complaint. For\n\nthe purposes of this paragraph, “complaint” means any written\n\ncommunication primarily expressing a grievance;\n\n15. Requesting a refund of all or a portion of a payment of a\n\nclaim made to a claimant more than six (6) months or a health care\n\nprovider more than twelve (12) months after the payment is made.\n\nThis paragraph shall not apply:\n\na. if the payment was made because of fraud committed by\n\nthe claimant or health care provider, or\n\nb. if the claimant or health care provider has otherwise\n\nagreed to make a refund to the insurer for overpayment\n\nof a claim;\n\n16. Failing to pay, or requesting a refund of a payment, for\n\nhealth care services covered under the policy if a health benefit\n\nplan, or its agent, has provided a preauthorization or\n\nprecertification and verification of eligibility for those health\n\ncare services. This paragraph shall not apply if:\n\na. the claim or payment was made because of fraud\n\ncommitted by the claimant or health care provider,\n\nb. the subscriber had a preexisting exclusion under the\n\npolicy related to the service provided, or\n\nc. the subscriber or employer failed to pay the\n\napplicable premium and all grace periods and\n\nextensions of coverage have expired;\n\n17. Denying or refusing to accept an application for life\n\ninsurance, or refusing to renew, cancel, restrict or otherwise\n\nterminate a policy of life insurance, or charge a different rate\n\nbased upon the lawful travel destination of an applicant or insured\n\nas provided in Section 4024 of this title; or\n\n18. As a health insurer that provides pharmacy benefits or a\n\npharmacy benefits manager that administers pharmacy benefits for a\n\nhealth plan, failing to include any amount paid by an enrollee or on\n\nbehalf of an enrollee by another person when calculating the\n\nenrollee’s total contribution to an out-of-pocket maximum,\n\ndeductible, copayment, coinsurance or other cost-sharing\n\nrequirement.\n\nHowever, if, under federal law, application of this paragraph\n\nwould result in health savings account ineligibility under Section\n\n223 of the federal Internal Revenue Code, as amended, this\n\nrequirement shall apply only for health savings accounts with\n\nqualified high-deductible health plans with respect to the\n\ndeductible of such a plan after the enrollee has satisfied the\n\nminimum deductible, except with respect to items or services that\n\nare preventive care pursuant to Section 223(c)(2)(C) of the federal\nity under Section\n\n223 of the federal Internal Revenue Code, as amended, this\n\nrequirement shall apply only for health savings accounts with\n\nqualified high-deductible health plans with respect to the\n\ndeductible of such a plan after the enrollee has satisfied the\n\nminimum deductible, except with respect to items or services that\n\nare preventive care pursuant to Section 223(c)(2)(C) of the federal\n\nInternal Revenue Code, as amended, in which case the requirements of\n\nthis paragraph shall apply regardless of whether the minimum\n\ndeductible has been satisfied.","path":["OK Code","Title 36"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os36.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"8e972a035c6d0bd07e26bd4e850c96339721eaacb0b86294fdfa16f1c362639f","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-1250.4","next":"us-ok/okla.-stat.-tit.-36-36-1250.6"},"notice":"GroundRules: Original legal text. Not legal advice."}