R590-286-4. Prohibited Provisions

(1) For the entire term of the contract, including any renewal or re-issuance, coverage may not exclude a loss due to a preexisting condition for a period greater than 12 months following the initial issuance of the contract. (2) Unless otherwise required by law, a contract may not limit or exclude coverage or benefits by type of illness, injury, treatment, or medical condition, except: (a) abortion; (b) acupuncture and acupressure; (c) administrative charges 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) applied behavioral analysis therapy; (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 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; (p) dietary products, except as required under Rule R590-194; (q) educational and nutritional training, except as required under Rule R590-200; (r) experimental or investigational service; (s) expenses before coverage begins or after coverage ends; (t) felony, riot, or insurrection, when it is determined the enrollee was a voluntary participant; (u) fitness training, exercise equipment, or membership fee to a spa or health club; (v)(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 enrollee who has a systemic disease, such as diabetes with peripheral neuropathy or circulatory insufficiency, if unskilled performance of the procedure would be hazardous; (w)(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)(w)(i); or (iii) a service required for the treatment of a complication from a procedure in Subsection (2)(w)(i); (x) gene therapy; (y) genetic testing; (z) hearing aid, including examination for the prescription or fitting; (aa) infertility services; (bb) injury as a result of a motor vehicle, to the extent the covered person is required to have no-fault coverage, up to the minimum coverage required by law whether or not coverage is in effect; (cc) mental health condition or substance use disorder services; (dd) nuclear release; (ee) preexisting condition, except: (i) as required under Sections 31A-22-605.1 and R590-286-5, and Subsection 31A-22-610(2); and (ii) for coverage of a congenital anomaly as required under Section 31A-22-610; (ff) pregnancy, except for a complication of pregnancy; (gg) refractive eye surgery; (hh) rehabilitation or habilitative therapy services, such as physical, speech, and occupational, except as required to correct an impairment caused by a covered injury or illness; (ii) respite care; (jj) rest cure; (kk) services while in the armed forces or an auxiliary unit; (ll) services performed by an enrollee's parent, spouse, sibling, or child, including a step or in-law relationship; (mm) services performed by an employee of a hospital, laboratory, or other institution; (nn) services that are not medically necessary; (oo) services for which no charge is normally made in the absence of insurance; (pp) sexual dysfunction procedure, equipment, or drug; (qq) shipping or handling, except as required by law; (rr) telephone or electronic consultation; (ss) territorial limitation outside the United States, except as required under Section 31A-22-627; (tt) terrorism, including an act of terrorism; (uu) transplant; (vv) transportation, except medically necessary ambulance services; (ww) war or act of war, whether declared or undeclared; (xx) except as provided in Subsection (2)(yy), a loss directly related to an enrollee's voluntary participation in an activity when the enrollee: (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; (yy) a loss established under Subsection (3)(a) that is directly related to the enrollee 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 (zz) any other exclusion that, in the opinion of the commissioner, is not inequitable, misleading, deceptive, obscure, unjust, unfair, or unfairly discriminatory to an enrollee. (3)(a) A violation of Subsection R590-286-4(2)(yy) shall be established: (i) in a criminal proceeding in which the enrollee is found guilty, enters a no contest plea or 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 of interest with: (A) the insurer; (B) an officer, director, or management employee of the insurer; (C) the enrollee; (D) the enrollee'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 R592-286-4(2)(yy) does not apply to an enrollee who is under 18 years of age. (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 the commissioner finds is unjust, unfair, or unfairly discriminatory to an enrollee.