Free Individual Accident and Health Provisions Study Guide
Oklahoma Accident & Health exam — Individual Accident and Health Provisions.
Oklahoma puts the uniform individual accident and health policy provisions into statute at 36 O.S. 4405, along with its own rules on renewability labels, applications, and the optional provisions an insurer may use. Most of the numbers follow the familiar NAIC pattern. The state questions ask for Oklahoma's version: grace periods by premium mode, reinstatement timing, claim deadlines, the $1,000 facility-of-payment limit, and the separate illegal occupation and narcotics provisions. What each provision does in general is explained in the national Individual Accident and Health Provisions guide.
Required provisions (36 O.S. 4405(A))
| Provision | Oklahoma rule |
|---|---|
| Entire contract; changes | Only an executive officer may approve a change, by endorsement. Agents can't change or waive provisions. |
| Time limit on certain defenses | After 2 years from issue, only fraudulent misstatements in the application can void the policy or deny a claim. A loss beginning after 2 years can't be denied as preexisting unless the condition was excluded by name or specific description. |
| Grace period | 7 days weekly, 10 days monthly, 31 days otherwise (for example, annual) |
| Reinstatement | Covers accidental injury sustained after reinstatement and sickness beginning more than 10 days after reinstatement. |
| Notice of claim | Within 20 days of the loss, or as soon as reasonably possible |
| Claim forms | Furnished within 15 days; otherwise the claimant may send written proof without them |
| Proof of loss | Within 90 days. Late proof is accepted if it wasn't reasonably possible, but no later than 1 year after it was due, absent legal incapacity. |
| Time of payment of claims | Promptly on receipt of proof. Periodic benefits are paid at least monthly. |
| Payment of claims | To the insured. A death benefit goes to the beneficiary, or the estate if none is named. Optional facility of payment: up to $1,000 to a relative. |
| Physical exam and autopsy | At the insurer's expense |
| Legal actions | No suit until 60 days after proof of loss, and none after 3 years from the time proof is required |
| Change of beneficiary | Unless the designation is irrevocable, the insured alone may change it |
Grace period and reinstatement details (4405(A)(3)-(4))
- Nonrenewal notice: if the insurer reserves the right to refuse renewal, the grace period doesn't apply when the insurer delivered or mailed notice of nonrenewal at least 30 days before the premium due date.
- Automatic reinstatement: if the insurer accepts a late premium with a conditional receipt and doesn't act on the reinstatement application, the policy is reinstated on the 45th day after the receipt.
- Back premium: a premium accepted for reinstatement can be applied to a period of no more than 60 days before the reinstatement date.
Disability claims (4405(A)(5)(b))
- For a policy that may pay loss-of-time benefits for at least 2 years, the insurer may require notice that the disability continues at least once every 6 months.
Optional provisions (36 O.S. 4405(B))
- Change of occupation:
- Moving to a less hazardous occupation lowers the rate and brings a refund of the excess premium.
- Moving to a more hazardous one adjusts benefits to what the premium would buy.
- Misstatement of age: benefits are adjusted to what the premium would buy at the correct age.
- Relation of earnings to insurance: benefits beyond earnings can be reduced. Total monthly benefits can't be cut below the lesser of the specified benefits or $200 (4405(B)(6)).
- Unpaid premium: any premium due and unpaid may be deducted from a claim payment.
- Conformity with state statutes: a provision that conflicts with the law of the insured's state on the effective date is amended to meet the minimum.
- Illegal occupation: the insurer may deny a loss to which the insured's commission of or attempt to commit a felony, or engaging in an illegal occupation, contributed (4405(B)(9)).
- Narcotics: no liability for a loss sustained while the insured is under the influence of a narcotic, unless it was administered on a physician's advice (4405(B)(10)). Oklahoma lists this as its own provision, separate from illegal occupation.
- Continuity of coverage: a covered spouse whose coverage would end for a reason other than nonpayment may continue or convert it without evidence of insurability (4405(B)(11)).
Renewability labels (36 O.S. 4405(C))
- Noncancellable: the insurer can't cancel the policy or raise the premium.
- Guaranteed renewable: the insurer must renew but may change rates by class.
- To use either label, the insured must be able to keep the policy in force by paying premiums until at least age 50. If the policy was issued after age 44, the period is at least 5 years from issue.
Applications and claims handling
Applications (36 O.S. 4407)
- The insured isn't bound by application statements unless a copy of the application is attached to the policy.
- No one but the applicant may alter a written application, apart from administrative notes, without the applicant's written consent.
- A false statement bars recovery only if it materially affected the acceptance of the risk or the hazard assumed.
Claims handling (36 O.S. 4408)
- Sending claim forms or investigating a claim doesn't waive the insurer's defenses.
Employer as beneficiary (36 O.S. 4405(G))
- An employer may be named beneficiary only for a key employee.
Common exam traps
- Grace periods by mode: 7 days weekly, 10 days monthly, 31 days otherwise.
- Claim deadlines: notice in 20 days, forms in 15 days, proof in 90 days, with a 1-year outer limit for late proof.
- Legal actions: wait 60 days; sue within 3 years.
- Reinstatement: sickness coverage starts after 10 days. Automatic reinstatement on day 45.
- Facility of payment: $1,000.
- Narcotics is separate from the illegal occupation provision. A physician-prescribed narcotic doesn't trigger it.
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Practice questions are study aids generated for exam preparation and are not actual exam questions. Content is provided for educational purposes and is not legal advice. Verify current statutes, rules, and exam specifications with the Insurance Department and the exam administrator before relying on it.
