R590-126-4. Prohibited Contract Provisions

(1)(a) A contract may not establish a probationary period when coverage is not provided, except under Subsection (1)(b), (1)(c), or (1)(d). (b) A contract may specify a probationary period not to exceed six months for a loss resulting from: (i) adenoids; (ii) appendix; (iii) disorder of a reproductive organ; (iv) hernia; (v) tonsils; or (vi) varicose veins. (c) Coverage shall be provided for a disease, condition, or procedure in Subsection (1)(b) if the disease, condition, or procedure is treated on an emergency basis. (d) A probationary period for a specified disease insurance contract may not exceed 30 days. (e) An accident insurance contract may not include a probationary period. (2) Unless otherwise required by law, a contract may not limit or exclude coverage or benefits by type of illness, accident, injury, treatment, or medical condition, except: (a) abortion; (b) acupuncture or acupressure; (c) administrative charge for completing an insurance form, duplication service, interest, finance charge, or other administrative charge, unless otherwise required by law; (d) administrative exam or service; (e) allergy test or treatment; (f) aviation, to a non-fare-paying passenger; (g) axillary hyperhidrosis; (h) benefits paid for under: (i) employer's liability or occupational disease law; (ii) Medicare or another governmental program, except Medicaid; or (iii) state or federal workers' compensation; (i) charge for a missed appointment; (j) chiropractic care; (k) complementary or alternative medicine; (l) corrective lens, including an examination for the prescription or fitting, except lens implant following cataract surgery; (m) cosmetic surgery, including reversal, revision, repair, complication, or treatment related to a non-covered cosmetic surgery, except reconstructive surgery: (i) when the service is incidental to or follows surgery resulting from trauma, infection, or other disease of the involved part; or (ii) due to a congenital disease or anomaly of a covered dependent child that resulted in a functional defect; (n) custodial care; (o) dental care or treatment, except a dental contract; (p) dietary products; (q) educational or nutritional training, except as required under Rule R590-200; (r) experimental or investigational service; (s) felony, riot, or insurrection, when it is determined the insured was a voluntary participant; (t) fitness training, exercise equipment, or a membership to a spa or health club; (u)(i) foot care for a corn, a callus, a flat foot, a fallen arch, a weak foot, chronic foot strain, or symptomatic complaints of a foot, including an orthotic; and (ii) the cutting or removal of a corn, a callus, or a nail may not be excluded when provided to an insured who has a systemic disease, such as diabetes with peripheral neuropathy or circulatory insufficiency if unskilled performance of the procedure would be hazardous; (v)(i) gastric or intestinal bypass service, including lap banding, gastric stapling, or a similar procedure to facilitate weight loss; (ii) the reversal or revision of a procedure in Subsection (2)(v)(i); or (iii) a service required for the treatment of a complication from a procedure in Subsection (2)(v)(i); (w) gender reassignment; (x) gene therapy; (y) genetic testing; (z) hearing aid, including examination for the prescription or fitting; (aa) incarceration, limited to income replacement insurance; (bb) infertility service; (cc) injury as a result of a motor vehicle, to the extent the insured is required to have no-fault coverage, up to the minimum coverage required by law, whether or not such coverage is in effect; (dd) mental health condition or substance use disorder services; (ee) nuclear release; (ff) preexisting condition, except as required under Section 31A-22-605.1 and Subsection 31A-22-610(2); (gg) pregnancy, except for a complication of pregnancy; (hh) refractive eye surgery; (ii) rehabilitation therapy service, such as physical, speech, and occupational, unless required to correct an impairment caused by a covered accident, injury, or illness; (jj) respite care; (kk) rest cure; (ll) routine physical examination; (mm) services performed by an insured's parent, spouse, sibling, or child, including a step or in-law relationship; (nn) services performed by an employee of a hospital, laboratory, or other institution; (oo) services for which no charge is normally made in the absence of insurance; (pp) services while in the armed forces or an auxiliary unit; (qq) sexual dysfunction procedure, equipment, or drug; (rr) shipping or handling; (ss) suicide, sane or insane, attempted suicide, or intentionally self-inflicted injury; (tt) telephone or electronic consultation; (uu) territorial limitation outside the United States, except as required under Section 31A-22-627; (vv) terrorism, including an act of terrorism; (ww) transplant; (xx) transportation; (yy) treatment provided in a government hospital, except for fixed indemnity insurance; (zz) war or act of war, whether declared or undeclared; (aaa) except under Subsection (2)(bbb), a loss directly related to the insured's voluntary participation in an activity when the insured: (i) is found guilty of an illegal activity in a criminal proceeding, including a plea of guilty, a no contest plea, and a plea in abeyance; or (ii) is found liable for the activity in a civil proceeding; (bbb) a loss established under Subsection (3) that is directly related to the insured violating: (i) Section 41-6a-502, if the loss occurred in Utah; or (ii) a law in a state other than Utah that prohibits operating a motor vehicle while exceeding the legal limit of concentration of alcohol, drugs, or a combination of both, in the blood, if the loss occurred in the other state; or (ccc) any other exclusion that, in the opinion of the commissioner, is not inequitable, misleading, deceptive, obscure, unjust, unfair, or unfairly discriminatory to an insured. (3)(a) A violation under Subsection (2)(bbb) shall be established: (i) in a criminal proceeding in which the insured is found guilty, enters a no contest plea, a plea in abeyance, or enters into a diversion agreement; or (ii) by a request for an independent review when the findings support a decision to deny coverage based on the exclusion. (b)(i) For purposes of Subsection (3)(a)(ii), an independent review means a process that: (A) is conducted by an independent entity designated by the insurer; (B) renders an independent and impartial decision on a decision to deny coverage based on the exclusion; and (C) is paid for by the insurer. (ii) The independent review entity may not have a material professional, familial, or financial conflict with: (A) the insurer; (B) an officer, director, or management employee of the insurer; (C) the insured; (D) the insured's health care provider; (E) the health care provider's medical group or independent practice association; or (F) a health care facility where services were provided. (c) The exclusion in Subsection (2)(bbb) does not apply to an insured who is under age 18. (4)(a) An insurer may use a waiver to exclude, limit, or reduce coverage or benefits for a specifically named or described preexisting condition, physical condition, or extra hazardous activity. (b) A signed acceptance by the insured is required if a waiver is required as a condition of issuance, renewal, or reinstatement. (5) A contract provision precluded in this section may not be construed as a limitation on the commissioner's authority to prohibit a contract provision that, in the opinion of the commissioner, is unjust, unfair, or unfairly discriminatory to an insured.