Current through Reg. 50, No. 187; September 24, 2024
(1) Accident,
accidental injury, accidental means:
(a) The
definition shall employ "result" language and shall not include words which
establish an "accidental means" test or use words such as "external, violent,
visible wounds" or similar words of description or characterization.
(b) The definition shall not be more
restrictive than the following: "injury or injuries for which benefits are
provided means accidental bodily injuries sustained by the insured person which
are the direct cause independently of disease, bodily infirmity or other cause
of the loss and occur while the insurance is in force."
(c) Such definitions may provide that
injuries shall not include:
1. Injuries for
which benefits are provided under:
a. Any
workers' compensation, employers' liability or similar law; or
b. Florida Automobile Reparations Reform Act
(motor vehicle no-fault plan or similar law); or
2. Injuries occurring while the insured
person is engaged for wage or profit in any activity pertaining to any trade,
business, employment or occupation.
(2) "Categories of benefits" means the
following benefits:
(a) Mental health
coverage;
(b) Substance abuse
coverage;
(c) Prescription drug
coverage;
(d) Dental coverage;
and,
(e) Vision
coverage.
(3)
Convalescent nursing home or extended care facility. The term "convalescent
nursing home" or "extended care facility" (skilled nursing facility) may be
defined in relation to its status, facilities and available services.
(a) A definition shall not be more
restrictive than one requiring that it:
1. Be
operated pursuant to law;
2. Be
approved for payment of Medicare benefits or be qualified to receive such
approval, if so requested;
3. Be
primarily engaged in providing, in addition to room and board accommodations,
skilled nursing care under the supervision of a duly licensed
physician;
4. Provide continuous 24
hour a day nursing service by or under the supervision of a registered graduate
professional nurse (R.N.); and,
5.
Maintain a daily medical record of each patient.
(b) A the definition may provide that the
term shall not include:
1. Any home, facility
or part thereof used primarily for rest;
2. Any home or facility for the aged or for
the care of drug addicts or alcoholics; or
3. Any home or facility primarily used for
the care and treatment of mental diseases or disorders or custodial or
educational care.
(4) "Earned first year premium" is the amount
of gross premium to be paid by an insured for the twelve months of coverage,
measured from the effective date of coverage and which is earned during the
period of time being measured.
(5)
Hospital. The term "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 or the American Osteopathic Hospital
Association.
(a) The definition shall not be
more restrictive than one requiring that the hospital:
1. Be an institution licensed as a hospital
and operated pursuant to law;
2. Be
primarily and continuously engaged in providing or operating, either on its
premises or in facilities controlled by the hospital, under the supervision of
a staff of duly licensed physicians, medical, diagnostic and major surgery
facilities for the medical care and treatment of sick or injured persons on an
inpatient basis for which a charge is made; and,
3. Provide 24 hour nursing service by or
under the supervision of registered graduate professional nurses
(R.N.'s).
(b) The
definition may state that the term shall not be inclusive of:
1. Any military or veteran's hospital or
soldier's home or any hospital contracted for or operated by any national
government or agency thereof for the treatment of members or ex-members of the
armed forces;
2. Convalescent
homes, convalescent, rest, or nursing facilities; or
3.
a.
Facilities for the aged, drug addicts, or alcoholics;
b. Facilities primarily affording custodial,
educational, or rehabilitory care; or
c. Those primarily affording care for mental
and nervous disorders.
(6) "Medical advice, diagnosis, care or
treatment" means advice, diagnosis, care or treatment recommended by, or
received from an individual licensed or similarly authorized to provide such
services under state law and operating within the scope of practice authorized
by state law.
(7) "Medical care or
condition" means amounts paid for any of the following:
(a) The diagnosis, cure, mitigation or
prevention of disease, or amounts paid for the purpose of affecting any
structure or function of the body.
(b) Transportation primarily for and
essential to medical care referred to in paragraph (7)(a).
(c) Insurance covering medical care referred
to in paragraphs (7)(a) and (b).
(8) Mental or Nervous Disorders. A definition
of "mental or nervous disorder" as used in a policy shall not be more
restrictive than:
(a) Neurosis;
(b) Psychoneurosis;
(c) Psychopathy;
(d) Psychosis; or
(e) Mental or emotional disease or disorder
of any kind.
(9) Nurse.
(a) The definition or description of "nurse"
may be restricted to a type of nurse, such as:
1. Registered graduate professional nurse
(R.N.);
2. Licensed practical nurse
(L.P.N.); or
3. Licensed vocational
nurse (L.V.N.).
(b) If
the words "nurse", "trained nurse" or "registered nurse" are used without
specific instruction, then the use of such terms requires the insurer to
recognize the services of any individual who qualifies under such terminology
in accordance with the applicable statutes or administrative rules of the
licensing or registry board of this state.
(10) "Offer" means to actively
market.
(11) One Period of
Confinement.
(a) "One period of confinement"
as used in subsections
69O-154.106(1) and
(2), F.A.C., means one or more separate or
combined periods of confinement in a hospital, for the same or related causes,
unless separated by an interval of not more than six consecutive months between
the end of one such period and the beginning of the succeeding
period.
(b) When succeeding
confinements for the same or related causes are separated by a six-month
interval, the following confinement will be considered a new period of
confinement, and any applicable benefit provisions will be
restored.
(12) Partial
Disability. "Partial disability" may be defined in relation to:
(a) One's inability to perform some part or
all of the "major," "important," or "essential" duties of his employment or
occupation; or
(b) A "percentage"
of time worked;
(c) A "specified
number of hours";
(d)
"Compensation."
(13)
Physician.
(a) The definition or description
of "physician" may be restricted to a type of physician to the extent allowed
by law.
(b)
1. The insurer may also include terms such as
"duly qualified physician" or "duly licensed physician."
2. The use of such terms requires an insurer
to recognize and to accept, to the extent of its obligation under the contract,
all providers of medical care and treatment when they are within the scope of
the providers' licensed authority, and are provided pursuant to Section
627.419,
F.S.
(14)
(a) "Placement, or being placed, for
adoption" means the assumption and retention of a legal obligation for total or
partial support of a child by a person with whom the child has been placed in
anticipation of the child's adoption.
(b) The child's placement for adoption with
the person terminates upon the termination of the legal
obligation.
(15) "Service
area" means the geographic area approved by the Agency for Health Care
Administration within which an insurer is authorized pursuant to Section
627.6472, F.S., to offer a
health insurance policy, or within which an HMO is authorized pursuant to
Section 641.495, F.S., to provide or
arrange for comprehensive health care services.
(16) Sickness.
(a) The definition of "sickness" shall not be
more restrictive than the following: Sickness means illness or disease of an
insured person which first manifests itself after the effective date of
insurance and while the insurance is in force.
(b)
1. A
definition of "sickness" which anticipates the exclusion of coverage of
preexisting conditions, subject to the limitations in Section
627.607, F.S., shall not use the
phrase "the cause of which originates" or any similar phrase.
2. Such definitions may provide for a
probationary period which will not exceed 30 days except as stated in paragraph
69O-154.105(6)(a),
F.A.C.
(c) The definition
may be further modified to exclude sickness or disease for which benefits are
provided under any workers' compensation, occupational disease, employers'
liability or similar law.
(17) Total Disability.
(a) A general definition of "total
disability" must not be more restrictive than one requiring the individual to
be totally disabled from engaging in any employment or occupation for which the
individual is or may become qualified by reason of education, training, or
experience, and 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
the inability may not be based solely upon an individual's ability to:
1. Perform "any occupation whatsoever" or
"any occupational duty"; or
2.
Engage in any training or rehabilitation program;
3. An insurer may specify the requirement of
the complete inability of the person to perform substantially all of the
material duties pertaining to his regular occupation, or words of similar
import.
(c)
1. The definition may reasonably require
regular care and attendance by a physician, other than the insured or a member
of insured's immediate family.
2.
The definition may require that the total disability be "continuous" or
"uninterrupted" for a specified period of time or to a specified age which
shall be consistent with the type of coverage afforded.
(d) If the insured's total disability shall
continue to the specified age or for the specified period and shall then and
thereafter continue, the definition of "total disability" may predicate
continuance of benefits on the insured's inability to perform any work or
occupation for which he is reasonably trained or qualified by education or
experience.
Rulemaking Authority 624.308, 627.643, 641.36 FS. Law
Implemented 624.307(1), 627.642, 627.643
FS.
New 1-1-75, Formerly 4-37.04, 4-37.004, Amended 9-19-00,
Formerly 4-154.104, Amended 2-19-20.
