Current through August 31, 2023
Except as provided in this chapter, an insurance policy or
certificate to which this chapter applies will not include definitions more
restrictive than the following: (3-31-22)
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. (3-31-22)
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. (3-31-22)
b. It may exclude injuries for which benefits
are provided: (3-31-22)
i. Under workers'
compensation, employers' liability, or similar law; or (3-31-22)
ii. Under a motor vehicle no-fault plan,
unless the motor vehicle no-fault plan provides for coordination of benefits;
or (3-31-22)
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.
(3-31-22)
02.
Convalescent Nursing Home. "Convalescent nursing home," "extended
care facility," or "skilled nursing facility" is to be defined in relation to
its status, facility and available services. (3-31-22)
a. Such home or facility is to: (3-31-22)
i. Be operated pursuant to law;
(3-31-22)
ii. Be approved for
payment of Medicare benefits or be qualified to receive approval for payment of
Medicare benefits, if so requested; (3-31-22)
iii. Be primarily engaged in providing, in
addition to room and board accommodations, skilled nursing care under the
supervision of a duly licensed physician; (3-31-22)
iv. Provide continuous twenty-four (24) hours
per day nursing service by or under the supervision of a registered nurse; and
(3-31-22)
v. Maintain a daily
medical record of each patient. (3-31-22)
b. The definition of the home or facility may
provide that the term will not be inclusive of: (3-31-22)
i. A home, facility or part of a home or
facility used primarily for rest; (3-31-22)
ii. A home or facility for the aged or for
the care of drug addicts or alcoholics; or (3-31-22)
iii. A home or facility primarily used for
the care and treatment of mental diseases or disorders, or for custodial or
educational care. (3-31-22)
03.
Home Health Care Agency.
"Home health care agency" means an agency approved under Medicare, or that is
licensed to provide home health care under applicable state law, or that meets
all of the following requirements: (3-31-22)
a. It is primarily engaged in providing home
health care services; (3-31-22)
b.
Its policies are established by a group of professional personnel (including at
least one (1) physician and one (1) registered nurse); (3-31-22)
c. A physician or a registered nurse provides
supervision of home health care services; (3-31-22)
d. It maintains clinical records on all
patients; and (3-31-22)
e. It has a
full-time administrator. (3-31-22)
04.
Hospice. "Hospice" means a
facility licensed, certified or registered in accordance with state law that
provides a formal program of care that is: (3-31-22)
a. For terminally ill patients whose life
expectancy is less than six (6) months; (3-31-22)
b. Provided on an inpatient or outpatient
basis; and (3-31-22)
c. Directed by
a physician. (3-31-22)
05.
Hospital. "Hospital" is to
be 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. (3-31-22)
a. The hospital may:
(3-31-22)
i. Be an institution licensed to
operate as a hospital pursuant to law; (3-31-22)
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 in-patient basis
for which a charge is made; and (3-31-22)
iii. Provide twenty-four (24) hour nursing
service by or under the supervision of registered nurses.
(3-31-22)
b. The term
will not be inclusive of the following, unless the facility otherwise meets the
qualifications set forth at Paragraph 011.05.a. of this Section: (3-31-22)
i. Convalescent homes or, convalescent, rest,
or nursing facilities; (3-31-22)
ii. Facilities affording primarily custodial,
educational, or rehabilitory care; (3-31-22)
iii. Facilities for the aged, drug addicts,
or alcoholics; or (3-31-22)
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.
(3-31-22)
06.
Mental Disorders or Nervous Disorders. "Mental disorders" or
"nervous disorders" includes neurosis, psychoneurosis, psychosis, or mental or
emotional disease or disorder of any kind. (3-31-22)
07.
Nurse. "Nurse" may be
restricted to a type of nurse, such as registered nurse, a licensed practical
nurse, or a licensed vocational nurse. If the words "nurse," "trained nurse" or
"registered nurse" are used without specific instruction, then the use of these
terms necessitates the insurer to recognize the services of any individual who
qualifies under the terminology in accordance with the applicable statutes or
administrative rules of the licensing or registry board of the state of Idaho.
(3-31-22)
08.
One Period of
Confinement. "One (1) period of confinement" means consecutive days of
in-hospital service received as an in-patient, or successive confinements when
discharge from and readmission to the hospital occurs within a period of time
not more than ninety (90) days or three (3) times the maximum number of days of
in-hospital coverage provided by the policy to a maximum of one hundred eighty
(180) days. (3-31-22)
09.
Partial Disability. "Partial disability" is in relation to the
individual's inability to perform one or more but not all of the "major,"
"important" or "essential" duties of employment or occupation, or may be
related to a percentage of time worked or to a specified number of hours or to
compensation. (3-31-22)
10.
Preexisting Condition. "Preexisting condition" is: (3-31-22)
a. A condition 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;
(3-31-22)
b. A condition 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
(3-31-22)
c. A pregnancy existing
on the effective date of coverage. (3-31-22)
11.
Provider. "Provider" means a
person or entity that, as necessary, is licensed to provide health care or
related services. (3-31-22)
12.
Residual Disability. "Residual disability" is in relation to the
individual's reduction in earnings and may be related either to the inability
to perform some part of the "major," "important," or "essential duties" of
employment or occupation, or to the inability to perform all usual business
duties for as long as is usually necessary. A policy that provides for residual
disability benefits may impose a qualification period, during which the insured
needs to be continuously totally disabled before residual disability benefits
are payable. The qualification period for residual benefits may be longer than
the elimination period for total disability. In lieu of the term "residual
disability," the insurer may use "proportionate disability" or other term of
similar import that in the opinion of the Director adequately and fairly
describes the benefit. (3-31-22)
13.
Sickness or Illness.
"Sickness or illness" means sickness or disease of an insured person that
presents itself after the effective date of insurance and while the insurance
is in force. It may exclude sickness or disease for which benefits are provided
under a worker's compensation, occupational disease, employers' liability or
similar law." (3-31-22)
14.
Total Disability. "Total disability" is in accordance with the
following limitations: (3-31-22)
a. 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. (3-31-22)
b. Total disability may be defined in
relation to the inability of the person to perform duties but is not to be
based solely upon an individual's inability to: (3-31-22)
i. Perform "any occupation whatsoever," "any
occupational duty," or "any and every duty of his occupation"; or
(3-31-22)
ii. Engage in a training
or rehabilitation program. (3-31-22)
c. An insurer may stipulate 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
stipulate care by a physician other than the insured or a member of the
insured's immediate family. (3-31-22)
