Section Ins 6205.02 - Definitions(a) "Activities of daily living (ADL)" means activities related to personal care, such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, continence, and eating.(b) "Adverse benefit determination" means a denial, reduction, termination of, or a failure to provide or make payment, in whole or in part, for a benefit, including any such denial, reduction, termination of, or failure to provide or make payment that is based on a determination of a participant's or claimant's eligibility to participate in a plan and including a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.(c) "Bathing" means washing oneself by sponge bath or in either a tub or shower, including the task of getting into or out of the tub or shower.(d) "Beneficiary" means the person or persons designated as such in the application.(e) "Benefit period" means the length of time for which a disabled insured receives periodic income benefit amounts under the policy.(f) "Catastrophic disability benefit" means a supplemental benefit in addition to any other disability benefit amounts. The benefit shall be triggered by an inability of the insured to perform, due to injury or sickness, a maximum of 2 ADLs. The benefit shall also be triggered by the cognitive impairment of the insured.(g) "Cognitive impairment" means a deficiency in the insured's short or long-term memory, orientation as to person, place, and time, deductive or abstract reasoning, or judgment as it relates to safety awareness.(h) "Concurrent disability" means one continuous period of disability that is caused or is continued by more than one injury or sickness.(i) "Conditionally renewable" means that renewal of the policy is based on certain conditions.(j) "Contagious disease(s)" means a condition that the Division of Communicable Disease Control of the Centers for Disease Control and Prevention works to promptly identify, prevent, and control. This includes infectious diseases that pose a threat to public health, including emerging and reemerging infectious diseases, vaccine preventable agents, bacterial toxins, bioterrorism, and pandemics.(k) "Continence" means the ability to maintain control of bowel and bladder function or, when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene, including caring for catheter or colostomy bag.(l) "Cost of living index" means an index used to measure the rate of change over time of the cost of living, such as the Consumer Price Index for Urban Wage Earners and Clerical Workers published by the United States Department of Labor.(m) "Death benefits" means the benefit to be paid due to the death of the insured resulting from an injury or sickness.(n) "Disability" means that due to injury or sickness, the insured meets the definition of partial disability, residual disability, or total disability, or the insured meets other disability benefit triggers specified in the policy or certificate. (o) "Disability income protection coverage" means a policy or certificate that provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from either sickness or injury.(p) "Dressing" means putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs.(q) "Earnings" means the amount of income received by an insured.(r) "Eating" means feeding oneself by getting food into the body from a receptacle, such as a plate, cup, table, or by a feeding tube or intravenously.(s) "Elimination period" means the length of time an insured shall wait from the commencement of disability for the insured as defined in the policy before periodic income benefit amounts are paid under the policy.(t) "Hands-on assistance" means physical assistance without which an insured or spouse, as applicable, would not be able to perform an ADL.(u) "Integration" means income from other sources, as permitted under these rules, that is factored into the calculation of income to determine the amount of disability benefits paid under the policy or certificate. Integration does not mean coordination of benefits.(v) "Occupation" means a position or professional calling for which a person receives or is eligible to receive remuneration.(w) "Partial disability" means that due to an injury or sickness, the insured is unable to perform one or more, but not all, of the substantial and material duties of an occupation for which he or she is qualified by reason of education, training, or experience or the inability to perform all of the substantial and material duties of an occupation for which he or she is qualified by reason of education, training, or experience for as long as usually required. The term shall also include residual disability. (x) "Presumptive disability" means total and permanent loss of any one of the following 6 body functions which shall be sufficient to trigger any benefits based upon presumptive disability: (2) Hearing in both ears;(6) Use of one arm and one leg.(y) "Pre-disability earnings" means the measurement of earnings of an insured just before disability began in order to provide an accurate and fair measure of earnings of an insured just before disability began.(z) "Recurrent disability" means a disability that occurs within a specified period of time immediately following a prior period of disability and which is due to the same or related cause applicable to the prior period of disability. (aa) "Rehabilitation" means a program of receiving services that is geared toward aiding an insured to better perform his or her occupation or any occupation for which he or she is qualified by reason of education, training, or experience.(ab) "Relevant to a claimant's claim" means, when used in reference to a document, record, or other information, that the document, record, or other information: (1) Was relied upon in making the benefit determination;(2) Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination;(3) Demonstrates compliance with the administrative processes and safeguards required in making the benefit determination; or(4) Constitutes a statement of policy or guidance with respect to the carrier's policy concerning the denied treatment option or benefit for the claimant's diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination. (ac) "Substantial and material duties" means the important tasks, functions, and operations generally required for an occupation that cannot be reasonably omitted or modified. This term shall be permitted to include an insured's ability to work on a regular work schedule for a specified number of hours.(ad) "Substantial assistance" means assistance or stand-by help required to perform ADLs.(ae) "Toileting" means getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.(af) "Total disability": (1) A general definition of total disability shall not be more restrictive than one requiring that 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; (2) Total disability shall be permitted to be defined in relation to the inability of the person to perform duties but shall not be based solely upon an individual's inability to: a. Perform "any occupation whatsoever", "any occupational duty", "any and every duty of his or her occupation", or other phrases of similar import;b. Engage in a training or rehabilitation program; orc. Perform activities of daily living (ADLs); (3) An insurer shall be permitted to 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; and(4) An insurer shall be permitted to require care by a physician other than the insured or a member of the insured's immediate family.(ag) "Transferring" means moving into or out of a bed, chair, or wheelchair.N.H. Admin. Code § Ins 6205.02
Derived from Volume XLI Number 49, Filed December 9, 2021, Proposed by #13297, Effective 11/24/2021, Expires 11/24/2031