SECTION 365:40-5-51. Definitions

  The following words or terms, when used in this Part, shall have the following meaning, unless the context clearly indicates otherwise:

"Allowable expense" means, unless otherwise mandated by law, any necessary, reasonable, and customary item of expense at least a portion of which is covered under at least one of the Plans covering the person for whom claim is made except where a statute requires a different definition. However, items of expense under coverage such as dental care, vision care, prescription drug or hearing aid programs may be excluded from the definition of allowable expense. A plan which provides benefits only for any such items of expense may limit its definition of allowable expense to like items of expense. When a Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered shall be deemed to be both an Allowable Expense and a benefit paid. The difference between the cost of a private hospital room and the cost of a semi-private hospital room shall not be deemed to be an "Allowable Expense," except for the period of time during which the patient's confinement to a private hospital room is deemed medically necessary in terms of generally accepted medical practice.

"Plan" includes the following:

(A)   Group and nongroup insurance contracts and subscriber contracts;

(B)   Uninsured arrangements of group or group-type coverage;

(C)   Group and nongroup coverage through closed panel plans;

(D)   Group-type contracts;

(E)   The medical care components of long-term care contracts, such as skilled nursing care;

(F)   The medical benefits coverage in automobile "no fault" and traditional automobile "fault" type contracts;

(G)   Medicare or other governmental benefits, as permitted by law, except as provided in a state plan under Medicaid. That part of the definition of plan may be limited to the hospital, medical and surgical benefits of the governmental program; and

(H)   Group and nongroup insurance contracts and subscriber contracts that pay or reimburse for the cost of dental care.

"Plan"does not include:

(A)   Hospital indemnity coverage benefits or other fixed indemnity coverage;

(B)   Accident only coverage;

(C)   Specified disease or specified accident coverage;

(D)   Limited benefit health coverage;

(E)   School accident-type coverages that cover students for accidents only, including athletic injuries, either on a twenty-four-hour basis or on a "to and from school" basis;

(F)   Benefits provided in long-term care insurance policies for non-medical services, for example, personal care, adult day care, homemaker services, assistance with activities of daily living, respite care and custodial care or for contracts that pay a fixed daily benefit without regard to expenses incurred or the receipt of services;

(G)   Medicare supplement policies;

(H)   A state plan under Medicaid; or

(I)   A governmental plan, which, by law, provides benefits that are in excess of those of any private insurance plan or other non-governmental plan.

"This plan" means that portion of the policy which provides the benefits that are subject to this subchapter.

[Source: Added at 21 Ok Reg 77, eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff 7-14-04; Amended at 32 Ok Reg 1976, eff 9-15-15]