Free Individual Accident and Health Provisions Study Guide
Oregon Life, Accident & Health exam — Individual Accident and Health Provisions.
Oregon puts the uniform individual health policy provisions into ORS 743.405 to 743.498. Most deadlines follow the familiar pattern, but Oregon has its own grace periods, a cancellation provision with 30 days' notice, statutory reasons for refusing renewal, and no intoxicants or narcotics provision. Only the illegal occupation provision exists among the "conduct" exclusions. What each provision does in general is covered in the national Individual Accident and Health Provisions guide.
Right to return (ORS 743.492)
- The buyer of an individual health policy (other than a single-premium nonrenewable policy) may return it within 10 days of delivery, to the insurer or the producer who sold it, for a refund.
- A returned policy is void from the beginning.
Required provisions
| Provision | Oregon rule |
|---|---|
| Entire contract (743.411) | Only an executive officer may change the policy or waive a provision, with approval endorsed on or attached to the policy |
| Time limit on certain defenses (743.414) | After 2 years in force, only fraudulent misstatements can void the policy or deny a claim |
| Grace period (743.417) | 30 days for an individual health benefit plan, or longer if federal law requires. 10 days for other health policies, such as disability income. |
| Reinstatement (743.420) | Sickness covered only if it begins more than 10 days after reinstatement. Automatic reinstatement on the 45th day after a conditional receipt, absent written disapproval. Premium can't be applied more than 60 days before reinstatement. |
| Notice of claim (743.423) | Within 20 days, or as soon as reasonably possible. For long-duration disability, notice of continuance may be required every 6 months. |
| Claim forms (743.426) | If not furnished within 15 days, the claimant may submit proof in any written form |
| Proof of loss (743.429) | Within 90 days. Late proof is accepted if reasonable, but no later than 1 year after it was due, absent legal incapacity. |
| Time of payment (743.432) | Periodic benefits at least monthly, with the balance on due proof |
| Payment of claims (743.435) | To the insured; death benefits to the beneficiary. Optional facility of payment up to $1,000. |
| Physical exam and autopsy (743.438) | At the insurer's expense |
| Legal actions (743.441) | No suit until 60 days after proof of loss; none after 3 years from when proof is required |
| Change of beneficiary (743.444) | Reserved to the insured. The beneficiary's consent isn't needed unless the designation is irrevocable. |
Renewal, nonrenewal and cancellation
Nonrenewal notice (743.417(3))
- If the insurer reserves the right to refuse renewal, it must give written notice stating the reason at least 30 days before the premium due date.
Cancellation provision (743.471)
- An insurer cancellation, other than for nonpayment, can't take effect earlier than the 30th day after notice.
- When the insurer cancels, earned premium is figured pro rata.
- When the insured cancels, it is figured on the insurer's short-rate table.
Permitted reasons to cancel or refuse renewal (743.472)
- Fraud or material misstatement.
- Excess insurance with the same insurer.
- Nonpayment of premium.
- Reasons set by rule.
- Nonrenewal of all policies of the same type and form.
Renewability labels (743.495, 743.498)
- Guaranteed renewable, used without qualification, means the insured can keep the policy for life, and the insurer may change premiums only by class.
- Noncancelable also bars premium changes.
- A policy that isn't guaranteed renewable must state prominently on its first page that the insurer may refuse to renew only for a reason permitted by law.
Optional provisions
- Change of occupation (743.450): moving to a less hazardous job reduces the rate and refunds excess unearned premium pro rata. Moving to a riskier job adjusts benefits.
- Misstatement of age (743.453): benefits are what the premium would buy at the true age.
- Relation of earnings to insurance (743.465): total monthly loss-of-time benefits can't be reduced below the lesser of the policy's monthly benefits or $200.
- Conformity with state statutes (743.474): conflicting provisions are amended to meet state law.
- Illegal occupation (743.477): 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.
- No intoxicants or narcotics provision: Oregon's statute doesn't include one, so an Oregon policy can't use it.
Form and application rules
- Policy text must be printed in type no smaller than 12-point (ORS 743.405).
- No one may alter a written application without the applicant's consent, except for the insurer's administrative notes clearly not attributed to the applicant (743.039).
Common exam traps
- Grace periods: 30 days for individual health benefit plans and 10 days for other individual health policies. Oregon doesn't use the 7/10/31 pattern.
- No intoxicants or narcotics exclusion in Oregon. Illegal occupation is the only one.
- Insurer cancellation: at least 30 days after notice, pro rata. Insured cancellation is short rate.
- Nonrenewal notice must give the reason, 30 days ahead.
- Right to return: 10 days, void from the beginning.
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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.
