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OAC 365:10


request of the insured.

"2010 Standardized Medicare supplement benefit plan," "2010 Standardized benefit plan" or "2010 plan" means a group or individual policy of Medicare supplement insurance issued on or after June 1, 2010.

"Policy Form" means the form on which the policy is delivered or issued for delivery by the issuer.

"Secretary" means the Secretary of the United States Department of Health and Human Services.

[Source: Added at 9 Ok Reg 2499, eff 6-26-92; Amended at 14 Ok Reg 2292, eff 7-1-97; Amended at 15 Ok Reg 3569, eff 5-29-98 (emergency); Amended at 16 Ok Reg 1088, eff 4-26-99; Amended at 22 Ok Reg 1954, eff 7-14-05; Amended at 26 Ok Reg 1529, eff 7-01-2009.]

365:10-5-124. Policy definitions and terms No policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy or certificate unless such policy or certificate contains definitions or terms which conform to the requirements of this section.

(1) "Accident," "Accidental Injury," or "Accidental Means" shall be defined to employ "result" language and shall not include words which establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characterization.

    • (A)

      The definition shall not be more restrictive than the following: "Injury or injuries for which benefits are provided means accidental bodily injury sustained by the insured person which is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while insurance coverage is in force."

    • (B)

      Such definition may provide that injuries shall not include injuries for which benefits are provided or available under any workers' compensation, employer's liability or similar law, or motor vehicle no-fault plan, unless prohibited by law.

  • (2)

    "Benefit Period" or "Medicare Benefit Period" shall not be defined more restrictively

than as defined in the Medicare program. (3) "Convalescent Nursing Home," "Extended Care Facility," or "Skilled Nursing Facility" shall not be defined more restrictively than as defined in the Medicare program. (4) "Health Care Expenses" means, for purposes of Section 365:10-5-131, expenses of health maintenance organizations associated with the delivery of health care services, which expenses are analogous to incurred losses of insurers. (5) "Hospital" may be defined in relation to its status, facilities and available services or to reflect its accreditation by the Joint Commission on Accreditation of Hospitals, but not more restrictively than as defined in the

Medicare program. (6) "Medicare" shall be defined in the policy and certificate.

Medicare may be

substantially defined as "The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended," or "Title I, Part I of Public Law 89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof," or words of similar import. (7) "Medicare Eligible Expenses" shall mean expenses of the kinds covered by Medicare

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