Most policyholders are unaware of their rights and entitlements when dealing with
their insurance company during the claims process. The majority of states, including
Oklahoma, have codified the “Unfair Claims Settlement Practice Act.” The UCSPA identifies
those specific acts by an insurer, which if committed, constitute an unfair claim
settlement practice. Those actions are as follows:
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:
Failing to fully disclose to first party claimants, benefits, coverages or other
provisions of any insurance policy or insurance contract when such benefits, coverages
or other provisions are pertinent to a claim;
Knowingly misrepresenting to claimants pertinent facts or policy provisions relating
to coverages at issue;
Failing to adopt and implement reasonable standards for prompt investigations of
claims arising under its insurance policies or insurance contracts;
Not attempting in good faith to effectuate prompt, fair and equitable settlement
of claims submitted in which liability has become clear;
Failing to comply with the provisions of Section 1219 of this title;
Denying a claim for failure to exhibit the property without proof of demand and
unfounded refusal by a claimant to do so;
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 such a time limit is not complied with unless the failure to comply
with such time limit prejudices an insurer’s rights;
Requesting a claimant to sign a release that extends beyond the subject matter that
gave rise to the claim payment;
Issuing checks or drafts in partial settlement of a loss or claim under a specified
coverage which contain language which releases an insurer or its insured from its
total liability.
Denying payment to a claimant on the grounds that services, procedures, or supplies
provided by a treating physician or hospital 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. Upon
written request of a claimant, treating physician or hospital, such opinion shall
be set forth in a written report, prepared and signed by the reviewing physician.
The report shall detail with specific services, procedures, or supplies where 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 or hospital requesting same within fifteen (15) days after receipt of
such written request. As used in this paragraph, “physician” means a person holding
a valid license to practice medicine and surgery, osteopathic medicine, podiatric
medicine, denistry, chiropractic or optometry, pursuant to the state licensing provisions
of Title 59 of the Oklahoma Statutes.
Compensating a reviewing physician, as defined in paragraph 10 of this subsection,
on the basis of a percentage of the amount by which a claim is reduced for payment;
Violating the provisions of the Health Care Fraud Prevention Act;
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;
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;
Requesting a refund of all or a portion of a payment of a claim made to a claimant
or health care provider more than twenty-four (24) months after the payment is made.
This paragraph shall not apply:
if the payment was made because of fraud committed by the claimant or health care
provider, or
if the claimant or health care provider has otherwise agreed to make a refund to
the insurer for overpayment of a claim; or
Failing to pay, or requesting a refund of a payment, for health care services covered
under the policy of 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:
the claim or payment was made because of fraud committed by the claimant or health
care provider,
the subscriber had a pre-existing exclusion under the policy related to the service
provided, or
the subscriber or employer failed to pay the applicable premium and all grace periods
and extensions of coverage have expired.