{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-4502","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-4502","heading":"Provisions of group accident and health policies","body":"A. Each group accident and health policy shall contain in\n\nsubstance the following provisions:\n\n1. A provision that, in the absence of fraud, all statements\n\nmade by the policyholder or by any insured person shall be deemed\n\nrepresentations and not warranties, and that no statement made for\n\nthe purpose of effecting insurance shall avoid such insurance or\n\nreduce benefits unless contained in a written instrument signed by\n\nthe policyholder or the insured person, a copy of which has been\n\nfurnished to such policyholder or to such person or his or her\n\nbeneficiary;\n\n2. A provision that the insurer will furnish to the\n\npolicyholder, for delivery to each employee or member of the insured\n\ngroup, an individual certificate setting forth in summary form a\n\nstatement of the essential features of the insurance coverage of\n\nsuch employee or member and to whom benefits are payable. If\n\ndependents or family members are included in the coverage additional\n\ncertificates need not be issued for delivery to such dependents or\n\nfamily members; and\n\n3. A provision that to the group originally insured may be\n\nadded from time to time eligible new employees or members or\n\ndependents, as the case may be, in accordance with the terms of the\n\npolicy.\n\nB. Each group health policy certificate subject to the\n\nprovisions of the Federal Health Insurance Portability and\n\nAccountability Act, Public Law 104-191, (HIPAA) laws shall contain\n\nin substance the following provisions, which shall be in addition to\n\nthe provisions required by subsection A of this section.\n\n1. A provision that a health benefit plan shall not deny,\n\nexclude or limit benefits for a covered individual for losses\n\nincurred more than twelve (12) months following the effective date\n\nof the individual's coverage due to a preexisting condition;\n\n2. A provision that a health benefit plan shall not define a\n\npreexisting condition more restrictively than:\n\na. a condition for which medical advice, diagnosis, care\n\nor treatment was recommended or received during the\n\nsix (6) months immediately preceding the effective\n\ndate of coverage,\n\nb. pregnancy and genetic information shall not be\n\nconsidered preexisting conditions,\n\nc. a health benefit plan may exclude a preexisting\n\ncondition for late enrollees for a period not to\n\nexceed eighteen (18) months from the date the\n\nindividual enrolls for coverage,\n\nd. the period of any such preexisting condition exclusion\n\nshall be reduced by the aggregate of the periods of\n\ncreditable coverage as defined in the Federal HIPAA\n\nlaws,\n\ne. a period of creditable coverage shall not be counted\n\nif after such period and before the enrollment date,\n\nthere was a sixty-three-day period during all of which\n\nthe individual was not covered under any creditable\n\ncoverage,\n\nf. \"enrollment date\" means the date of enrollment of the\n\nindividual in the plan or coverage or, if earlier, the\n\nfirst day of the waiting period for such enrollment,\n\nand\n\ng. \"late enrollee\" means a participant or beneficiary who\n\nenrolls under the plan other than during the first\n\nperiod in which the individual is eligible to enroll\n\nunder the plan or a special enrollment period;\n\n3. A provision that individuals losing other coverage shall be\n\npermitted to enroll for coverage under the terms of the plan if each\n\nof the following conditions is met:\n\na. the employee or dependent was covered under a group\n\nhealth plan or had health insurance coverage at the\n\ntime coverage was previously offered to the employee\n\nor dependent,\n\nb. the employee stated in writing at such time that\n\ncoverage under a group health plan or health insurance\n\ncoverage was the reason for declining enrollment, but\n\nonly if the plan sponsor or issuer required such a\n\nstatement at such time and provided the employee with\n\nnotice of such requirement, and the consequences of\n\nsuch requirement, at such time,\ne employee stated in writing at such time that\n\ncoverage under a group health plan or health insurance\n\ncoverage was the reason for declining enrollment, but\n\nonly if the plan sponsor or issuer required such a\n\nstatement at such time and provided the employee with\n\nnotice of such requirement, and the consequences of\n\nsuch requirement, at such time,\n\nc. the employee's or dependent's coverage was under a\n\nCOBRA continuation provision and the coverage under\n\nsuch provision was exhausted; or was not under such a\n\nprovision and either the coverage was terminated as a\n\nresult of loss of eligibility for the coverage,\n\nincluding as a result of legal separation, divorce,\n\ndeath, termination of employment, or reduction in the\n\nnumber of hours of employment, or employer\n\ncontributions toward such coverage were terminated,\n\nand\n\nd. under the terms of the plan, the employee requests\n\nsuch enrollment not later than thirty (30) days after\n\nthe date of exhaustion of coverage;\n\n4. A provision that for any period that an individual is in a\n\nwaiting period for any coverage under a group health plan or for\n\ngroup health insurance coverage or is in an affiliation period, that\n\nperiod shall not be taken into account in determining the continuous\n\nperiod of creditable coverage. \"Affiliation period\" means a period\n\nwhich, under the terms of the health insurance coverage offered by a\n\nhealth maintenance organization, must expire before the health\n\ninsurance coverage becomes effective. The organization is not\n\nrequired to provide health care services or benefits during such\n\nperiod and no premium shall be charged to the participant or\n\nbeneficiary for any coverage during the period;\n\n5. A provision that preexisting condition exclusions will not\n\napply to newborns, who, as the last day of the thirty-day period\n\nbeginning with the date of birth, are covered under creditable\n\ncoverage;\n\n6. A provision that preexisting condition exclusions will not\n\napply to a child who is adopted or placed for adoption before\n\nattaining eighteen (18) years of age;\n\n7. A provision that dependents are eligible for a special\n\nenrollment period if the group health plan makes coverage available\n\nwith respect to a dependent of an individual, and the individual is\n\na participant under the plan, or has met any waiting period\n\napplicable to becoming a participant under the plan and is eligible\n\nto be enrolled under the plan but for a failure to enroll during a\n\nprevious enrollment period, and a person becomes such a dependent of\n\nthe individual through marriage, birth or adoption or placement for\n\nadoption. The special enrollment period shall apply to that person\n\nor, if not otherwise enrolled, the individual, the dependent of the\n\nindividual, and in the case of the birth or adoption of a child, the\n\nspouse of the individual may be enrolled as a dependent of the\n\nindividual if such spouse is otherwise eligible for coverage.\n\na. The dependent special enrollment period shall be a\n\nperiod of not less than thirty (30) days and shall\n\nbegin on the later of the date dependent coverage is\n\nmade available, or the date of the marriage, birth, or\n\nadoption or placement for adoption.\n\nb. There is no waiting period if an individual seeks to\n\nenroll a dependent during the first thirty (30) days\n\nof such a dependent special enrollment period.\n\nc. The coverage for the dependent shall become effective\n\nin the case of marriage, not later than the first day\n\nof the first month beginning after the date the\n\ncompleted request for enrollment is received, in the\n\ncase of a dependent's birth, as of the date of such\n\nbirth, in the case of a dependent's adoption or\n\nplacement for adoption, the date of such adoption or\n\nplacement for adoption;\n\n8. A provision that eligibility or continued eligibility of any\n\nindividual will not be based on any of the following health-status-\nth beginning after the date the\n\ncompleted request for enrollment is received, in the\n\ncase of a dependent's birth, as of the date of such\n\nbirth, in the case of a dependent's adoption or\n\nplacement for adoption, the date of such adoption or\n\nplacement for adoption;\n\n8. A provision that eligibility or continued eligibility of any\n\nindividual will not be based on any of the following health-status-\n\nrelated factors in relation to the individual or a dependent of the\n\nindividual: health status, medical condition, including both\n\nphysical and mental illnesses, claims experience, receipt of health\n\ncare, medical history, genetic information, evidence of\n\ninsurability, including conditions arising out of acts of domestic\n\nviolence or disability.\n\na. Carriers are not required to provide particular\n\nbenefits other than those provided under the terms of\n\nthe plan or coverage.\n\nb. Carriers may establish limitations or restrictions on\n\nthe amount, level, extent, and nature of the benefits\n\nor coverage for similarly situated individuals\n\nenrolled in the plan or coverage; and\n\n9. A provision that the group health plan is guaranteed\n\nrenewable, except as provided pursuant to the federal provisions\n\nfound in HIPAA, which are as follows:\n\na. nonpayment of premium,\n\nb. fraud,\n\nc. violation of participation and/or contribution rules,\n\nd. termination of coverage:\n\n(1) in any case in which an issuer decides to\n\ndiscontinue offering a particular type of group\n\nhealth insurance coverage offered in the large or\n\nsmall group market, coverage of such type may be\n\ndiscontinued by the issuer only if: the issuer\n\nprovides notice to each plan sponsor provided\n\ncoverage of this type in such market, and\n\nparticipants and beneficiaries covered under such\n\ncoverage, of such discontinuation at least ninety\n\n(90) days prior to the date of the\n\ndiscontinuation of such coverage and makes\n\navailable the option to purchase all or, in the\n\ncase of the large group market, any other health\n\ninsurance coverage currently being offered by the\n\nissuer to a group health plan in such market and\n\nin exercising the option to discontinue coverage\n\nof this type and in offering the option of\n\ncoverage pursuant to this provision, the issuer\n\nacts uniformly without regard to the claims\n\nexperience of those sponsors or any health-\n\nstatus-related factor relating to any\n\nparticipants or beneficiaries covered or new\n\nparticipants or beneficiaries who may become\n\neligible for such coverage,\n\n(2) in any case in which an issuer decides to\n\ndiscontinue offering a particular type of group\n\nhealth insurance coverage offered in the large or\n\nsmall group market, coverage of such type may be\n\ndiscontinued by the issuer only if: the issuer\n\nprovides notice to the Oklahoma Insurance\n\nDepartment and to each plan sponsor and\n\nparticipants and beneficiaries covered under such\n\ncoverage of such discontinuation at least one\n\nhundred eighty (180) days prior to the date of\n\nthe discontinuation of such coverage; and all\n\nhealth insurance issued or delivered for issuance\n\nin the state in such market or markets are\n\ndiscontinued and coverage under such health\n\ninsurance coverage in such market or markets is\n\nnot renewed, and\n\n(3) in the case of a discontinuation under division\n\n(2) of this subparagraph in a market, the issuer\n\nshall not provide for the issuance of any health\n\ninsurance coverage in the market and in this\n\nstate during the five-year period beginning on\n\nthe date of the discontinuation of the last\n\nhealth insurance coverage not so renewed,\n\ne. movement outside the service area, and\n\nf. association membership ceases.","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":"707ab612d9644185f5b533f4c283a4de318f326a20b9d55f41c4ac56bc78f6c4","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-4501","next":"us-ok/okla.-stat.-tit.-36-36-4502.1"},"notice":"GroundRules: Original legal text. Not legal advice."}