Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 10 - HEALTH INSURANCE-GENERAL
Chapter 31.10.30 - Disability Benefit Claims Procedures
Section 31.10.30.02 - Definitions
Universal Citation: MD Code Reg 31.10.30.02
Current through Register Vol. 51, No. 19, September 20, 2024
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.
Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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