Section 18.04.08.011 - POLICY DEFINITIONS AND TERMSExcept as provided in this chapter, an insurance policy or certificate to which this chapter applies will not include definitions more restrictive than the following:
01.Accident. "Accident," "accidental injury," and "accidental" is to employ "result" language and does not include words that establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characterization. a. "Injury" or "injuries" means accidental bodily injury, independent of disease which occurs while the coverage is in force.b. It may exclude injuries for which benefits are provided under workers' compensation, employers' liability or similar law; or under a motor vehicle no-fault plan, unless not allowed by law; or injuries occurring while the insured person is engaged in any activity pertaining to a trade, business, employment or occupation for wage or profit.02.Convalescent Nursing Home. "Convalescent nursing home," "extended care facility," "assisted living facility", or "skilled nursing facility" is to be defined in relation to its status, facility and available services. a. Such home or facility is to: i. Be operated pursuant to law;ii. Be qualified to receive approval for payment of Medicare or medicaid benefits, if so requested;iii. Provide, in addition to room and board accommodations, skilled nursing care under the supervision of a duly licensed physician;iv. Provide continuous twenty-four (24) hours per day nursing service by or under the supervision of a registered nurse; andv. Maintain a daily medical record of each patient.b. The definition of the home or facility may exclude a home, facility or part of a home or facility used primarily: for rest, for the aged, for individuals with a substance use disorder or a mental disease or disorder, or for custodial or educational care.03.Home Health Care Agency. "Home health care agency" means an agency approved under Medicare, or that is licensed to provide home health care under applicable state law, or that: a. Is primarily engaged in providing home health care services;b. Has policies established by a group of professional personnel (including at least one (1) physician and one (1) registered nurse);c. Has a physician or a registered nurse supervising the home health care services;d. Maintains clinical records on all patients; ande. Has a full-time administrator.04.Hospice. "Hospice" means a facility licensed, certified or registered in accordance with state law that provides a formal program of care that is:a. For terminally ill patients whose life expectancy is less than six (6) months;b. Provided on an inpatient or outpatient basis; andc. Directed by a physician.05.Hospital. "Hospital" is to be defined in relation to its status, facilities and available services or to reflect its accreditation by the Joint Commission.a. The hospital may: i. Be an institution licensed to operate as a hospital pursuant to law;ii. Be primarily and continuously engaged in providing or operating, either on its premises or in facilities available to the hospital on a prearranged basis and under the supervision of a staff of licensed physicians, medical, diagnostic and major surgical facilities for the medical care and treatment of sick or injured persons on an in-patient basis for which a charge is made; andiii. Provide twenty-four (24) hour nursing service by or under the supervision of registered nurses.b. The term may exclude:i. Convalescent homes or, convalescent, rest, or nursing facilities;ii. Facilities affording primarily custodial, educational, or rehabilitory care;iii. Facilities for the aged, or individuals with a substance use disorder; oriv. A military or veterans' hospital, a soldiers' home or a hospital contracted for or operated by any national government or government agency for the treatment of members or ex-members of the armed forces, except for services rendered on an emergency basis where a legal liability for the patient exists for charges made to the individual for the services.06.Mental Disorders or Nervous Disorders. "Mental disorders" or "nervous disorders" means any condition or disorder defined by categories listed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or its successor.07.Nurse. "Nurse" may be restricted to a type of nurse, such as registered nurse. If the word "nurse," is used without specific instruction, then the use necessitates the insurer recognize the services of any individual who qualifies under the terminology in accordance with the applicable statutes or administrative rules of the licensing or registry board of the state.08.One Period of Confinement. "One (1) period of 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 ninety (90) days or three (3) times the maximum number of days of in-hospital coverage provided by the policy to a maximum of one hundred eighty (180) days.09.Partial Disability. "Partial disability" is in relation to 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 or to a specified number of hours or to compensation.10.Preexisting Condition. "Preexisting condition" is a condition for which medical advice or treatment was recommended by a provider or that would have caused an ordinarily prudent person to seek medical advice or treatment during the six (6) months immediately preceding the effective date of coverage.11.Provider. "Provider" means a person or entity that, as necessary, is licensed to provide health care or related services.12.Residual Disability. "Residual disability" is 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 duties for as long as is usually necessary. A policy that provides for residual disability benefits may impose a qualification period, during which the insured needs to 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.13.Sickness or Illness. "Sickness or illness" means sickness or disease of an insured person that presents itself after the effective date of insurance and while the insurance is in force. It may exclude sickness or disease for which benefits are provided under a worker's compensation, occupational disease, employers' liability or similar law."14.Total Disability. "Total disability" is in accordance with the following limitations: a. The individual who is totally disabled not be engaged in any employment or occupation for which he or she is or becomes qualified by reason of education, training or experience, and is not in fact engaged in any employment or occupation for wage or profit.b. Total disability may be defined in relation to the inability of the person to perform duties but is not to be based solely upon an individual's inability to: i. Perform "any occupation whatsoever," "any occupational duty," or "any and every duty of his occupation"; orii. Engage in a training or rehabilitation program.c. An insurer may stipulate 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 stipulate care by a physician other than the insured or a member of the insured's immediate family.Idaho Admin. Code r. 18.04.08.011