Skip to main content

15.10 Individual Accident & Health Insurance Policy General Provisions

Standard Provisions​

In addition to the provisions covered in earlier chapters, all individual accident and health insurance policies issued in Ohio are required to contain the following provisions.

Entire Contract​

The policy constitutes the complete agreement between the insurer and the insured. Any change to the policy is valid only if it is approved by the insurer and incorporated into the policy through an endorsement or attached amendment.

An insurance agent does not have the authority to alter the policy or waive any of the policy’s provisions.

Any statement made by the applicant may be used to deny a claim or in a legal proceeding only if the statement is included as part of the insurance contract.

Time Limit on Certain Defenses (Incontestability)​

Once a policy has remained in force for 2 years, misstatements in the application cannot be used to void the policy or deny a claim unless the misstatements were fraudulent.

A claim for a loss occurring 2 years or more after the policy’s issue date cannot be denied or reduced due to a pre-existing condition. Additionally, a chronic disease or chronic physical condition may only be excluded from coverage if it is specifically named or clearly described in the policy.

Grace Period​

Required grace periods are as follows:

  • At least 7 days for policies with weekly premium payments
  • At least 10 days for policies with monthly premium payments
  • At least 31 days for all other types of policies

Nonrenewal​

If an insurer chooses not to renew a policy, other than an accident-only policy, the insurer must provide the insured with a notice of nonrenewal at least 5 days before the premium due date. An insurer may not refuse to renew a policy prior to its first anniversary date or between policy anniversary dates.

Reinstatement​

If a renewal premium is not paid, the insurer or producer may subsequently accept the overdue premium without requiring a new application, resulting in reinstatement of the policy.

If the insurer requires a reinstatement application and provides a conditional receipt upon payment of the premium, the policy will be reinstated either when the insurer approves the application or automatically on the 45th day after the date of the conditional receipt, unless the insurer has already notified the insured in writing that the application was disapproved.

Coverage for accidental injury becomes effective immediately upon reinstatement, while coverage for sickness is subject to a 10-day waiting period before benefits become payable.

Any premium accepted as part of a reinstatement may be applied to a period for which premiums were unpaid, but it cannot be applied to any period more than 60 days before the reinstatement date.

Claim Procedures​

Written notice of a claim must be provided to the insurer within 20 days after a covered loss occurs or begins, or as soon thereafter as reasonably possible.

Claim Forms​

After receiving notice of a claim, the insurer must provide the claimant with the forms required to submit proof of loss within 15 days.

Proof of Loss​

Proof of loss must be submitted within 90 days after the date of the loss. Failure to provide proof within this period will not invalidate or reduce a claim if it was not reasonably possible to furnish proof on time, provided the proof is submitted as soon as reasonably possible thereafter. However, except in cases involving a lack of legal capacity, proof of loss may not be submitted more than 1 year after the date it was otherwise required.

Time of Payment of Claims​

Indemnity benefits must be paid within 30 days after the insurer receives proof of loss, except for benefits payable on a periodic basis, which may be paid monthly.

Payment of Claims​

Benefits payable for loss of life will be paid to the named beneficiary. If no beneficiary has been designated, the benefits will be paid to the insured’s estate.

Physical Examination and Autopsy​

At its own expense, the insurer has the right to examine the insured as often as reasonably necessary while a claim is pending. In the event of death, the insurer may also require an autopsy where permitted by law.

After submitting proof of loss, the insured may not bring legal action against the insurer until 60 days have passed, and no legal action may be initiated after 3 years from the time proof of loss was required.

Change of Beneficiary​

Unless the insured has made an irrevocable beneficiary designation, the insured retains the right to change the beneficiary, assign the policy, or surrender the policy without obtaining the beneficiary’s consent.

Cancellation by Insured​

The insured may cancel the policy at any time by providing written notice to the insurer, either by delivery or by mail. Cancellation becomes effective upon the insurer’s receipt of the notice or on any later date specified in the notice.

If the policy is canceled, the insurer must promptly refund any unearned premium to the insured.

An insurer is not permitted to cancel an accident and health insurance policy.

Optional Standard Provisions​

In addition to the optional provisions discussed in earlier chapters, an individual accident and health insurance policy may also include any of the following optional provisions:

  • Change of Occupation: If the insured becomes injured or ill after changing occupations while still insured under the classification of the former occupation, the insurer will pay only the amount of benefits that the premium paid would have purchased based on the rates applicable to the insured’s new occupation.
  • Misstatement of Age: If the insured’s age has been misstated, the benefits payable under the policy will be adjusted to the amount that the premium paid would have purchased at the insured’s correct age.
  • Other Insurance in This Insurer: If benefits payable under multiple policies issued by the same insurer exceed the amount of the actual insurance claim, the excess coverage will be considered void, and the insurer must refund the excess premiums paid.
  • Insurance With Other Insurers (Expense-Incurred Basis): If the insured has coverage with another insurer that also provides benefits for the same loss on an expense-incurred basis, and the insurer was not notified of the additional coverage, the insurer is liable only for its proportional share of the covered expenses.
  • Insurance With Other Insurers (Other Than Expense-Incurred Basis): If the insured has additional coverage with another insurer providing benefits for the same loss on a basis other than expense-incurred coverage, and the insurer was not informed of the additional insurance, the insurer is responsible only for its proportional share of the indemnity payable under the claim.

Other General Provisions​

Right to Examine (Free Look)​

A policyowner has the right to return an individual sickness and accident insurance policy within 10 days after receiving it. The policy may be returned to either the insurer or the insurer’s agent, and the policyowner is not required to provide a reason for the return.

The policy may state that coverage remains effective during the period before the policy is returned and that a prorated premium may be charged for that period of coverage. Any such charge must be calculated strictly on a per-day basis.

A notice explaining the policyholder’s right to return the policy must be displayed prominently on, or attached to, the first page of the policy. The notice must also explain how and where the policy may be returned.

The Free Look provision does not apply to single-premium, nonrenewable policies.

Subrogation​

The rights of a subrogee, or any individual asserting a subrogation claim against a third party in a tort action, are subject to the following conditions:

  • If the injured party recovers less than the full value of the tort claim because of comparative negligence, reduction due to another party’s liability, or inability to collect the full amount of the claim, the subrogee’s recovery must be reduced in the same proportion as the injured party’s recovery.
  • If a disagreement arises regarding how the recovery from the tort action should be distributed, either party may bring a legal action to resolve the dispute.