State RegulationsOH specificDifficulty 2/5
A Cincinnati insured has back trouble that began before her individual sickness policy took effect. The policy was issued more than 2 years ago and does not exclude back conditions by name. Her insurer denies a back claim, citing the preexisting condition. Is the denial valid under Ohio law?
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
ORC 3923.04(B) provides that after the policy has been in force 2 years, no claim may be reduced or denied because a disease or condition that existed before the effective date existed, unless the policy excluded that condition by name or specific description. Because this policy never named back conditions as excluded, the denial fails.
Why the other options are wrong
- A) Wrong because ORC 3923.04(B) does not create a blanket exclusion; after 2 years only conditions excluded by name or specific description can support a denial.
- C) Wrong because the insured's knowledge does not matter after the 2-year period; the statute protects claims from denial based on unexcluded preexisting conditions.
- D) Wrong because preexisting conditions can be excluded during the contestable period and, for chronic conditions, by name or specific description at any time under ORC 3923.04(B).
Memory hook
After 2 years, name it or pay it.