Regulation .02 Definitions.
Regulation .02 Definitions.LinkCopy Citation
A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
“Adverse appeal determination” means a decision made by an insurer on an appeal of an adverse benefit determination to uphold:
(a)
A denial, reduction, or termination of a disability benefit;
(b)
A failure to provide or make payment, in whole or in part, for a disability benefit; or
(c)
Any denial, reduction, termination, or failure to provide or make payment that is based on a determination of a covered individual's eligibility for coverage of a disability benefit.
(2)
“Adverse benefit determination” means a determination arising from a claim for disability benefits which results in:
(a)
A denial, reduction, or termination of a disability benefit;
(b)
A failure to provide or make payment, in whole or in part, for a disability benefit; or
(c)
Any denial, reduction, termination, or failure to provide or make payment that is based on a determination of a covered individual's eligibility for coverage of a disability benefit.
(3)
“Authorized representative” means a person, including a health care provider, authorized by the covered individual to act on behalf of the covered individual.
(4)
“Covered individual” means an individual covered under an insurance policy that provides a disability benefit.
(5)
Disability benefit.
(a)
“Disability benefit” means a benefit that is payable based on the disability of a covered individual.
(b)
“Disability benefit” does not include:
(i)
Benefits under a long-term care insurance policy;
(ii)
A benefit that is payable based solely on a dismemberment of a covered individual;
(iii)
Benefits in a life insurance policy that operate to safeguard the contract from lapse or to provide a special surrender value, special benefit, or annuity in the event of total and permanent disability; or
(iv)
Benefits in a health insurance policy that operate to safeguard the contract from lapse due to disability.