Okla. Stat. tit. 36, § 36-1250.5

settlement practice.

Any of the following acts by an insurer, if committed in

violation of Section 1250.3 of this title, constitutes an unfair

claim settlement practice exclusive of paragraph 16 of this section

which shall be applicable solely to health benefit plans:

1. Failing to fully disclose to first-party claimants,

benefits, coverages, or other provisions of any insurance policy or

insurance contract when the benefits, coverages or other provisions

are pertinent to a claim;

2. Knowingly misrepresenting to claimants pertinent facts or

policy provisions relating to coverages at issue;

3. Failing to adopt and implement reasonable standards for

prompt investigations of claims arising under its insurance policies

or insurance contracts;

4. Not attempting in good faith to effectuate prompt, fair and

equitable settlement of claims submitted in which liability has

become reasonably clear;

5. Failing to comply with the provisions of Section 1219 of

this title;

6. Denying a claim for failure to exhibit the property without

proof of demand and unfounded refusal by a claimant to do so;

7. Except where there is a time limit specified in the policy,

making statements, written or otherwise, which require a claimant to

give written notice of loss or proof of loss within a specified time

limit and which seek to relieve the company of its obligations if

the time limit is not complied with unless the failure to comply

with the time limit prejudices the rights of an insurer. Any policy

that specifies a time limit covering damage to a roof due to wind or

hail must allow the filing of claims after the first anniversary but

no later than twenty-four (24) months after the date of the loss, if

the damage is not evident without inspection;

8. Requesting a claimant to sign a release that extends beyond

the subject matter that gave rise to the claim payment;

9. Issuing checks, drafts or electronic payment in partial

settlement of a loss or claim under a specified coverage which

contain language releasing an insurer or its insured from its total

liability;

10. Denying payment to a claimant on the grounds that services,

procedures, or supplies provided by a treating physician, hospital,

or person or entity licensed or otherwise authorized to provide

health care services were not medically necessary unless the health

insurer or administrator, as defined in Section 1442 of this title,

first obtains an opinion from any provider of health care licensed

by law and preceded by a medical examination or claim review, to the

effect that the services, procedures or supplies for which payment

is being denied were not medically necessary. In the event that

Oklahoma Statutes - Title 36. Insurance Page 309

claims for mental health or substance use disorder treatments and

services are under review, the reviewing health care provider shall

have appropriate, qualified, and specialized credentials with

respect to the services and treatments. Upon written request of a

claimant, treating physician, hospital, or authorized person or

entity, the opinion shall be set forth in a written report, prepared

and signed by the reviewing physician. The report shall detail

which specific services, procedures, or supplies were not medically

necessary, in the opinion of the reviewing physician, and an

explanation of that conclusion. A copy of each report of a

reviewing physician shall be mailed by the health insurer, or

administrator, postage prepaid, to the claimant, treating physician,

hospital, or authorized person or entity requesting same within

fifteen (15) days after receipt of the written request. As used in

this paragraph, “physician” means a person holding a valid license

to practice medicine and surgery, osteopathic medicine, podiatric

medicine, dentistry, chiropractic, or optometry, pursuant to the

state licensing provisions of Title 59 of the Oklahoma Statutes;
hospital, or authorized person or entity requesting same within

fifteen (15) days after receipt of the written request. As used in

this paragraph, “physician” means a person holding a valid license

to practice medicine and surgery, osteopathic medicine, podiatric

medicine, dentistry, chiropractic, or optometry, pursuant to the

state licensing provisions of Title 59 of the Oklahoma Statutes;

11. Compensating a reviewing physician, as defined in paragraph

10 of this section, on the basis of a percentage of the amount by

which a claim is reduced for payment;

12. Violating the provisions of the Health Care Fraud

Prevention Act;

13. Compelling, without just cause, policyholders to institute

suits to recover amounts due under its insurance policies or

insurance contracts by offering substantially less than the amounts

ultimately recovered in suits brought by them, when the

policyholders have made claims for amounts reasonably similar to the

amounts ultimately recovered;

14. Failing to maintain a complete record of all complaints

which it has received during the preceding three (3) years or since

the date of its last financial examination conducted or accepted by

the Commissioner, whichever time is longer. This record shall

indicate the total number of complaints, their classification by

line of insurance, the nature of each complaint, the disposition of

each complaint, and the time it took to process each complaint. For

the purposes of this paragraph, “complaint” means any written

communication primarily expressing a grievance;

15. Requesting a refund of all or a portion of a payment of a

claim made to a claimant more than six (6) months or a health care

provider more than twelve (12) months after the payment is made.

This paragraph shall not apply:

a. if the payment was made because of fraud committed by

the claimant or health care provider, or

b. if the claimant or health care provider has otherwise

agreed to make a refund to the insurer for overpayment

of a claim;

Oklahoma Statutes - Title 36. Insurance Page 310

16. Failing to pay, or requesting a refund of a payment, for

health care services covered under the policy if a health benefit

plan, or its agent, has provided a preauthorization or

precertification and verification of eligibility for those health

care services. This paragraph shall not apply if:

a. the claim or payment was made because of fraud

committed by the claimant or health care provider,

b. the subscriber had a preexisting exclusion under the

policy related to the service provided, or

c. the subscriber or employer failed to pay the

applicable premium and all grace periods and

extensions of coverage have expired;

17. Denying or refusing to accept an application for life

insurance, or refusing to renew, cancel, restrict or otherwise

terminate a policy of life insurance, or charge a different rate

based upon the lawful travel destination of an applicant or insured

as provided in Section 4024 of this title; or

18. As a health insurer that provides pharmacy benefits or a

pharmacy benefits manager that administers pharmacy benefits for a

health plan, failing to include any amount paid by an enrollee or on

behalf of an enrollee by another person when calculating the

enrollee’s total contribution to an out-of-pocket maximum,

deductible, copayment, coinsurance or other cost-sharing

requirement.

However, if, under federal law, application of this paragraph

would result in health savings account ineligibility under Section

223 of the federal Internal Revenue Code, as amended, this

requirement shall apply only for health savings accounts with

qualified high-deductible health plans with respect to the

deductible of such a plan after the enrollee has satisfied the

minimum deductible, except with respect to items or services that

are preventive care pursuant to Section 223(c)(2)(C) of the federal
ity under Section

223 of the federal Internal Revenue Code, as amended, this

requirement shall apply only for health savings accounts with

qualified high-deductible health plans with respect to the

deductible of such a plan after the enrollee has satisfied the

minimum deductible, except with respect to items or services that

are preventive care pursuant to Section 223(c)(2)(C) of the federal

Internal Revenue Code, as amended, in which case the requirements of

this paragraph shall apply regardless of whether the minimum

deductible has been satisfied.