Definitions

Section 2007 Section 2007.50  Definitions Except as provided hereafter, no individual accident or health insurance policy delivered or issued for delivery to any person in this State shall contain definitions respecting the matters set forth in this Part unless the definitions comply with the requirements of this Section. "ACA" means the Patient Protection and Affordable Care Act (42 USC 18001 et seq.). "Accident and Accidental Injury" shall be defined to employ "result" language and shall not include words that establish an accidental means test or use words such as "external", "violent", "visible" or similar words of description or characterization.  The definition shall not be more restrictive than the following:  "Injury or injuries, for which benefits are provided, means accidental bodily injuries sustained by the insured person which are the direct cause of loss, independent of disease cause of loss, independent of disease or bodily infirmity and occurring while the insurance is in force." AGENCY NOTE:  The fact that the injury combined with other factors to produce the loss does not necessarily relieve the insurer of liability.  Each claim must be judged on the basis of its particular facts and in light of the court decisions, to determine whether the injury is to be considered as the cause of the loss. The definition may provide that injuries shall not include injuries for which benefits are provided under any workers' compensation, employer's liability or similar law, motor vehicle no-fault plan, unless prohibited by law, or injuries occurring while the insured person is engaged in any activity pertaining to any trade, business, employment or occupation for wage or profit. "Convalescent Nursing Home, Extended Care Facility, or Skilled Nursing Facility" shall be defined in relation to its status, facilities and available services. A definition of the home or facility shall not be more restrictive than one requiring that it: be operated pursuant to law; be approved for payment of Medicare benefits or be qualified to receive approval, if so requested; be primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under the supervision of a duly licensed physician; provide continuous 24 hours a day nursing service by or under the supervision of a registered graduate professional nurse (R.N.); and maintains a daily medical record of each patient. The definition of a home or facility may provide that the term shall not be inclusive of: any home, facility or part thereof used primarily for rest; a home or facility for the aged or for the care of drug addicts or alcoholics; or a home or facility primarily used for the care and treatment of mental diseases or disorders, or custodial or educational care. "Excepted Benefits", for purposes of this Part, means benefits under one or more (or any combination thereof) of the following: Benefits not subject to requirements: Coverage only for accident or disability income insurance, or any combination thereof; Coverage issued as a supplement to liability insurance; Liability insurance, including general liability insurance and automobile liability insurance; Workers' compensation or similar insurance; Automobile medical payment insurance; Credit-only insurance; Coverage for on-site medical clinics; or Other similar insurance coverage under which benefits for medical care are secondary or incidental to other insurance benefits. Benefits not subject to requirements if offered separately: Limited scope dental or vision benefits; and Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof. Benefits not subject to requirements if offered as independent, noncoordinated benefits: Coverage only for a specified disease or illness; or Hospital indemnity or other fixed indemnity insurance paid as a fixed dollar amount per day or other period, per event or service or upon benefits paid upon a basis other than period of time, regardless of the amount of expenses incurred. Benefits not subject to requirements if offered as separate insurance policy Medicare supplemental health insurance (as defined under section 1882(g)(1) of the Social Security Act (42 USC 1395ss(g)(1))), coverage supplemental to the coverage provided under 10 USC 55, and similar supplemental coverage provided to coverage under a group health plan.  (26 USC 9832) "Grandfathered Health Plan" means any group health plan or health insurance coverage in which an individual was enrolled on the date of the enactment of the ACA and shall have the same meaning as set forth in section 18011 of the Public Health and Welfare Act (42 USC 18011). "Home Health Care Agency" shall not be defined more restrictively than a public agency or private organization that provides skilled nursing services and meets the following requirements: It is primarily engaged in providing home health care services; Its policies are established by a group of professional personnel (including at least one physician and one registered nurse (R.N.)); Supervision of home health care services is provided by a physician or a registered nurse (R.N.); It maintains clinical records on all patients; and It has a full time administrator. "Home Health Care" shall not be defined more restrictively than skilled nursing care or services provided to a person at a residence according to a plan of treatment for illness or infirmity prescribed by a physician.  These services shall include, but are not limited to, the following: Part time and intermittent skilled nursing services − Services given to a patient at least once every 60 days or as frequently as a few hours per day, several days per week. Therapeutic Services: Physical Therapy; Occupational Therapy; Speech and Hearing Therapy; Medical social services, medical supplies, drugs and medicines prescribed by a physician and related pharmaceutical services and laboratory services to the extent the charges or costs would have been covered under the policy if the insured person had remained in the hospital. "Hospital" may be defined in relation to its status, facilities and available services or to reflect its accreditation by the Joint Commission. The definition of the term "hospital" shall not be more restrictive than one requiring that the hospital: be an institution operated pursuant to the law; and be primarily and continuously engaged in providing or operating medical and diagnostic facilities, with major surgical facilities either on its premises or in facilities available to the hospital on a prearranged basis, under the supervision of a staff of duly licensed physicians, for the medical care and treatment of sick or injured persons on an in-patient basis for which a charge is made; and provide 24 hours nursing service by or under the supervision of registered graduate professional nurses (R.N.s). The definition of the term "hospital" may state that such term shall not be inclusive of: convalescent, rest or nursing homes or facilities; facilities primarily affording custodial or educational care or care or treatment for persons suffering from mental diseases or disorders; facilities for the aged, mentally ill, drug addicts or alcoholics (except for a unit of a hospital dedicated to the treatment of drug addicts or alcoholics or the mentally ill); or any military or veterans hospital or soldiers home or any hospital contracted for or operated by any national government or agency thereof for the treatment of members or ex-members of the armed forces, except for services rendered on an emergency basis where a legal liability exists for charges made to the individual for those services. "Medicare" shall be defined in any hospital, surgical or medical expense policy that relates its coverage to eligibility for Medicare or Medicare benefits.  Medicare may be substantially defined as "The Health Insurance for the Aged Act, Subchapter XVIII of the Social Security Amendments of 1965 as then constituted or later amended (42 USC 1395 et seq.)", 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 (42 USC 395 et seq.), as then constituted and any later amendments or substitutes thereof" or words of similar import. "Mental or Nervous Disorders" shall not be defined more restrictively than a definition including neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease, disorder or condition, including serious mental illness and substance use disorder or condition. "Nurses" may be defined so that the description of nurse is restricted to a type of nurse, such as a registered graduate professional nurse (R.N.), a licensed practical nurse (L.P.N.), or a licensed vocational nurse (L.V.N.). If the words "nurse", "trained nurse" or "registered nurse" are used without specific instruction, then the use of those terms requires the insurer to recognize the services of any individual who qualifies under that terminology in accordance with the applicable statutes or administrative rules of the state licensing or registry board. "One Period of Confinement or Continuous Hospital Confinement " means consecutive days of in-hospital service received as an in-patient, or successive confinements when discharge from and readmission to the hospital occurs within a period of time not more than 90 days or three times the maximum number of days of in-hospital coverage provided by the policy to a maximum of 180 days, whichever is greater. "Partial Disability" shall be defined in relation of the individual's inability to perform one or more, but not all, of the "major", "important", or "essential" duties of employment or occupation or may be related to a percentage of time worked, to a specified number of hours or to compensation. When a policy provides total disability benefits and partial disability benefits, only one elimination period may be required. "Physician" may be defined by including words such as "duly qualified physician" or "duly licensed physician".  The use of such terms requires an insurer to recognize and to accept, to the extent of its obligation under the contract, all providers of medical care and treatment when the services are within the scope of the provider's licensed authority and are provided pursuant to applicable laws dealing with physician licensure. "Residual Disability" shall be defined in relation to the individual's reduction in earnings and may be related either to the inability to perform some part of the "major," "important," or "essential" duties of employment or occupation, or to the inability to perform all usual business for as long as is usually required.  A policy that provides for residual disability benefits may require a qualification period, during which the insured must be continuously totally disabled before residual disability benefits are payable.  The qualification period for residual benefits may be longer than the elimination period for total disability.  In lieu of the term "residual disability", the insurer may use "proportionate disability" or other term of similar import that, in the opinion of the Director, adequately and fairly describes the benefit. "Sickness" shall not be defined to be more restrictive than the following:  "Sickness means sickness or disease of an insured person that first manifests itself after the effective date of insurance and while the insurance is in force."  A definition of sickness may provide for a probationary period that will not exceed 30 days from the effective date of the coverage of the insured person.  The definition may be further modified to exclude sickness or disease for which benefits are provided under any workers' compensation, occupational disease, employer's liability or similar law. "Total Disability" A general definition of total disability cannot be more restrictive than one requiring the individual to be totally disabled from engaging in any employment or occupation that he or she could, giving due consideration of his education, training or experience be reasonably expected to engage in and is not in fact engaged in any employment or occupation for wage or profit. Total disability may be defined in relation to the inability of the person to perform duties but may not be based solely upon an individual's inability to: Perform "any occupation whatsoever", "any occupational duty", or "any and every duty of his or her occupation"; Engage in any training or rehabilitation program. An insurer may specify the requirement of the complete inability of the person to perform all of the substantial and material duties of his or her regular occupation or words of similar import.  An insurer may require care by a physician other than the insured or a member of the insured's immediate family. When through a specific provision of a policy, disability coverage is provided to a retired person, the definition shall not require more than the insured be completely unable to engage in the normal activities of a retired person of like age and good health.