New York Codes, Rules and Regulations
Title 11 - INSURANCE
Chapter III - Policy and Certificate Provisions
Subchapter A - Life, Accident and Health Insurance
Part 52 - Minimum Standards For Form, Content And Sale Of Health Insurance, Including Standards Of Full And Fair Disclosure
Section 52.2 - Definitions

Universal Citation: 11 NY Comp Codes Rules and Regs § 52.2

Current through Register Vol. 46, No. 39, September 25, 2024

As used in this Part, the following words and phrases are defined as follows:

(a) Accident and health insurance means insurance written under sections 1113 (a)(3) and 4505 of the Insurance Law.

(b) Article 43 corporation means a corporation organized under article 43 of the Insurance Law.

(d) Charges means the amount billed by the provider for services rendered, including the reimbursement made by article 43 corporations pursuant to the provisions of section 2807 of the Public Health Law.

(e) Complications of pregnancy means:

(1) conditions requiring hospital stays (when the pregnancy is not terminated) whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion and similar medical and surgical conditions of comparable severity, and shall not include false labor, occasional spotting, physician-prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, preeclampsia and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy; and

(2) nonelective caesarean section, ectopic pregnancy which is terminated and spontaneous termination of pregnancy, which occurs during a period of gestation in which a viable birth is not possible.

(f) Continuous hospital confinement means consecutive days of in-hospital service received as an inpatient, or successive confinements when discharge from and readmission to the hospital occur within a period of time not more than 90 days or three times the maximum number of days of in-hospital coverage provided under the policy to a maximum of 180 days, or, as an alternative with respect to group insurance, successive confinements due to the same or related causes unless between such confinements a covered person has been actively at work, if an employee, or engaged in normal activity if not an employee, for a period of not more than 90 days. A confinement for an accident shall not be combined with another confinement for an illness in determining continuous hospital confinement.

(g) Expected future loss ratio means the ratio, at time of rate filing, of the present value of future benefits to the present value of future premiums, under assumptions accepted by the superintendent. Expected dividends may be used in the calculation, within the limits prescribed in this Part.

(h) Expected lifetime loss ratio means the ratio, at time of rate filing, of the present value of past plus future benefits to the present value of past plus future premiums, under assumptions accepted by the superintendent. Expected dividends may be used in the calculation, within the limits prescribed in this Part.

(i) Extra-hazardous activities means aviation and related activities, such as sky diving and parachuting, and participation as a professional in athletics or sports.

(j) Forms means policies, contracts, certificates, riders, endorsements, applications, and any form signed by the applicant which requests information to be used in determining acceptance or rejection of the applicant for insurance.

(k) Franchise insurance means that form of accident and health insurance, distributed on a mass merchandising basis and administered by group methods, provided, with or without evidence of insurability, and under which the insured's right to renew his policy, with or without other permissible renewal conditions, may be contingent upon the continuing of such employment, membership, or supplier participation, by:

(1) individual policies which are made available to persons under a plan sponsored by:

(i) an employer;

(ii) an association consisting of persons having the same or similar occupation or profession;

(iii) a union;

(iv) two or more employers under common control; or

(v) an association of civil service employees; or

(2) individual policies which are made available to individuals supplying or delivering materials to a central point of collection.

(l) Group insurance means insurance written under the provisions of section 4235 or 4305 of the Insurance Law.

(m) Hospital means a short-term, acute, general hospital, which:

(1) is primarily engaged in providing, by or under the continuous supervision of physicians, to inpatients, diagnostic services and therapeutic services for diagnosis, treatment and care of injured or sick persons;

(2) has organized departments of medicine and major surgery;

(3) has a requirement that every patient must be under the care of a physician or dentist;

(4) provides 24-hour nursing service by or under the supervision of a registered professional nurse (R.N.);

(5) if located in New York State, has in effect a hospitalization review plan applicable to all patients which meets at least the standards set forth in section 1861(k) of United States Public Law 89-97 (42 USCA 1395x [k]);

(6) is duly licensed by the agency responsible for licensing such hospitals; and

(7) is not, other than incidentally, a place of rest, a place primarily for the treatment of tuberculosis, a place for the aged, a place for drug addicts, alcoholics, or a place for convalescent, custodial, educational or rehabilitory care.

(n) Individual insurance means insurance written under the provisions of section 3216, 4304 or 4505 of the Insurance Law.

(o) Insurer means a commercial insurance carrier, fraternal benefit society and an article 43 corporation.

(p) Medicare means title XVIII of the Social Security Act of 1965, as amended.

(q) MedicarekChoice plan means a plan of coverage for health benefits under part C of title XVIII of the Social Security Act as added by the Balanced Budget Act of 1997 (Public Law 105-33) as then constituted or later amended (42 U.S.C. section 1395w-21 et seq.).

(r) Member hospital means any hospital with whom an article 43 corporation has an agreement with respect to the rendering of services to its subscribers.

(s) Metropolitan area means that area within the corporate limits of the counties of Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, Rockland and Westchester.

(t) Participating physician means any duly licensed physician with whom an article 43 corporation has an agreement with respect to the rendering of services to its subscribers.

(u) Policy means the totality of the contractual relationship between an insurer and insured, and includes subscriber contracts issued by article 43 corporations.

(v) Preexisting condition means, except as to insurance defined in sections 52.11, 52.12, 52.13 and 52.14 of this Part, and except as to policies which are subject to sections 52.18(a)(5) and 52.20 of this Part, the existence of symptoms which would ordinarily cause a prudent person to seek diagnosis, care or treatment within a two-year period preceding the effective date of the coverage of the insured person, or a condition for which medical advice or treatment was recommended by a physician or received from a physician within a two-year period preceding the effective date of coverage of the insured person.

(w) State of New York Certified Surgical Fee Schedule means a schedule setting forth fees for surgery, expressed on a relative value scale as certified by the Commissioner of Health and promulgated by the Superintendent of Insurance.

(x) Health maintenance organization or HMO means an organization or line of business of an Insurance Law, article 43 corporation which has received a certificate of authority from the Commissioner of Health pursuant to article 44 of the Public Health Law, or, an article 43 corporation which is qualified within the meaning of section 1310(c) of title XIII of the Public Health Service Act (42 U.S.C. 300e-9 [c]).

(y) Religious employer means an entity for which each of the following is true:

(1) The inculcation of religious values is the purpose of the entity.

(2) The entity primarily employs persons who share the religious tenets of the entity.

(3) The entity serves primarily persons who share the religious tenets of the entity.

(4) The entity is a nonprofit organization as described in Section 6033(a)(2)(A)i or iii, of the Internal Revenue Code of 1986, as amended.

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