Idaho Admin. Code r. 18.04.13.011

Current through September 2, 2024

Section 18.04.13.011 - POLICY DEFINITIONS

An insurance policy subject to this chapter will not apply 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 sustained by the insured person that is the direct cause of the condition for which benefits are provided, independent of disease or bodily infirmity or any other cause, and that occurs while the insurance is in force.

b. It may exclude injuries for which benefits are provided:

i. Under workers' compensation, employers' liability, or similar law; or

ii. Under a motor vehicle no-fault plan, unless the motor vehicle no-fault plan provides for coordination of benefits; or

iii. For 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. Includes "extended care 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 approved for payment of Medicare benefits or be qualified to receive approval for payment of Medicare benefits, if so requested;

iii. Be primarily engaged in providing, 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; and

v. Maintain a daily medical record of each patient.

b. Such home or facility definition may exclude:

i. A home, facility or part of a home or facility used primarily for rest;

ii. A home or facility for the aged or for the care of drug addicts or alcoholics; or

iii. A home or facility primarily used for the care and treatment of mental or nervous disorders, or for custodial or educational care.

03.Home Health Care Agency. An agency approved under Medicare, or that is licensed to provide home health care under applicable state law.

04.Hospice. 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; and

c. Directed by a physician.

05.Hospital. Is defined in relation to its status, facilities and available services or to reflect its accreditation by the Joint Commission on Accreditation of Healthcare Organizations, Accreditation of Rehabilitation Facilities or by Medicare.

a. The term "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 inpatient basis for which a charge is made; and

iii. Provide twenty-four (24) hour nursing service by or under the supervision of registered nurses.

b. The term "hospital" may exclude, unless the facility otherwise meets the requirements:

i. Convalescent homes or, convalescent, rest, or nursing facilities;

ii. Facilities affording primarily the care and treatment of mental or nervous disorders, or for custodial educational, or rehabilitative care;

iii. Facilities for the aged, drug addicts, or alcoholics; or

iv. 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 or Nervous Disorders. Neurosis, psychoneurosis, psychosis, or mental or emotional disease or disorder of any kind.

07.Pre-existing Condition.

a. A condition or disease that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment during the six (6) months immediately preceding the effective date of coverage;

b. A condition or disease for which medical advice, diagnosis, care or treatment was recommended or received during the six (6) months immediately preceding the effective date of coverage; or

c. A pregnancy existing on the effective date of coverage.

08.Sickness or Illness. A sickness or disease of an insured person that first manifests itself after the effective date of insurance and while the insurance is in force. It may be further modified to exclude sickness or disease for which benefits are provided under a worker's compensation, occupational disease, employers' liability or similar law.

09.Total Disability. An individual not engaged in any employment or occupation for which the individual 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.

a. It may be defined in relation to the inability of the person to perform duties but will not 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"; or

ii. Engage in a training or rehabilitation program.

b. An insurer may require 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 provider other than the insured or a member of the insured's immediate family.

Idaho Admin. Code r. 18.04.13.011

Effective March 31, 2022