Section R590-146-5 - Policy Definitions and TermsA policy or certificate may not be advertised, solicited, or issued for delivery in this state unless the policy or certificate contains definitions or terms that conform to Section R590-146-4 and this section.
(1) "Accident," "accidental injury," or "accidental means" shall be defined to use result language and may 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) The definition may not be more restrictive than "'injury or injuries for which benefits are provided' means accidental bodily injury sustained by the insured person which is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while insurance coverage is in force."(b) The definition may exclude injuries for which benefits are provided or available under any workers' compensation, employer's liability or similar law, or motor vehicle no-fault plan, unless prohibited by law.(2) "Benefit period" or "Medicare benefit period" may not be defined more restrictively than as defined in the Medicare program.(3) "Care provider" means a qualified or licensed home health aide or homemaker, personal care aide or nurse provided through a licensed home health care agency or referred by a licensed referral agency or licensed nurse registry.(4) "Convalescent nursing home," "extended care facility," or "skilled nursing facility" may not be defined more restrictively than as defined in the Medicare program.(5) "Health care expenses" means, for purposes of Section R590-146-14, expenses of health maintenance organizations associated with the delivery of health care services, which expenses are analogous to incurred losses of an issuer.(6) "Hospital" may be defined in relation to its status, facilities, and available services, or to reflect its accreditation by the Joint Commission on Accreditation of Hospitals, but not more restrictively than as defined in the Medicare program.(7) "Medicare eligible expenses" shall be defined to mean expenses of the kinds covered by Medicare Part A and B, to the extent recognized as reasonable and medically necessary by Medicare.(8) "Physician" may not be defined more restrictively than as defined in the Medicare program.(9) "Preexisting condition" may not be defined more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of coverage.(10)(a) "Sickness" may not be defined to be more restrictive than an illness or disease of an insured person which first manifests itself after the effective date of insurance and while insurance is in force.(b) "Sickness" may be further modified to exclude sicknesses or diseases for which benefits are provided under any workers' compensation, occupational disease, employer's liability, or similar law.Utah Admin. Code R590-146-5
Amended by Utah State Bulletin Number 2019-13, effective 6/7/2019Adopted by Utah State Bulletin Number 2024-16, effective 8/7/2024