Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 42.00 - The Form And Contents Of Individual Accident And Sickness Insurance
Section 42.04 - Definitions

As used in 211 CMR 42.00, the following words shall mean:

Accident, Accidental Injury, Accidental Means must be defined to employ "result" language and may 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. Such definition may be modified or an exception or limitation may be included to provide that injuries shall not include injuries for which benefits are provided under any workmen's compensation, occupational disease, employer's liability or similar law.

Anticipated Loss Ratio means the present value at issue of the expected future benefits, excluding dividends, divided by the present value of the expected future annualized premiums, using a reasonable interest rate and reasonable assumptions as to the distribution of the policy form by age and by various options available.

Carrier means a commercial insurance company licensed to write accident and health insurance under M.G.L. c. 175, a fraternal benefit society licensed under M.G.L. c. 176, a non-profit hospital service corporation organized under M.G.L. c. 176A, a medical service corporation organized under M.G.L. c. 176B, a dental service corporation organized under M.G.L. c. 176E, and an optometric service corporation organized under M.G.L. c. 176F.

Class means underwriting and rating classifications used when a policy was originally issued.

Commissioner means the Commissioner of Insurance, appointed pursuant to M.G.L. c. 26, § 6, or his or her designee.

Elimination Period means the number of days during which services are provided to an insured person or during which the insured person is unable to work because of accident or sickness before the insurance policy begins to pay benefits.

Medicare means the program established under Title XVIII of the federal Social Security Act, "Health Insurance for the Aged Act", 42 USCS § 1395 et seq.

Policy means any policy, plan, certificate, contract, agreement, statement of coverage, rider or endorsement which provides insurance benefits whether as a service or on an indemnity reimbursement or prepaid basis.

Pre-existing Condition means a medical condition for which an insured person received medical advice or treatment during a period to be determined by the carrier prior to the effective date of coverage or because of which an individual had symptoms which would have led an ordinarily prudent person to seek medical advice or treatment for that medical condition, or a pregnancy existing on the effective date of coverage.

Sickness must be defined to be no more restrictive than a sickness or disease of an insured person that first manifests itself after the effective d ate of insurance and while the insurance is in force. The definition may be modified to exclude sickness or disease for which benefits are provided under any workmen's compensation, occupational disease, employer's liability, or similar law.