Current through Register Vol. 39, No. 6, September 16, 2024
(a) Unless
otherwise required by federal law or regulation, no policy issued or issued for
delivery in this State shall use the terms set forth below, unless the terms
are defined in the policy and the definitions satisfy the following
requirements:
(1) "Activities of daily
living" means at least bathing, continence, dressing, eating, toileting, and
transferring.
(2) "Acute condition"
means that the individual is medically unstable and requires frequent
monitoring by a medical doctor or registered nurse.
(3) "Bathing" means washing oneself by sponge
bath, or in a tub or shower, including the task of getting into and out of the
tub or shower.
(4) "Cognitive
impairment" means a deficiency in a person's short or long-term memory;
orientation as to person, place, and time; deductive or abstract reasoning; or
judgment as it relates to safety awareness.
(5) "Continence" means the ability to
maintain control of bowel and bladder function; or, when unable to maintain
control of bowel or bladder function, the ability to perform associated
personal hygiene (including caring for catheter or colostomy bag).
(6) "Dressing" means putting on and taking
off all items of clothing and any necessary braces, fasteners, or artificial
limbs.
(7) "Eating" means feeding
oneself by getting food into the body from a receptacle (such as a plate, cup,
or table); or by feeding tube or intravenously.
(8) "Hands-on-assistance" means physical
assistance (minimal, moderate, or maximal) without which the individual would
not be able to perform the activity of daily living.
(9) "Medicare" means the "Health Insurance
for the Aged Act", Title XVIII of the Social Security Amendments of 1965, as
amended.
(10) "Mental of nervous
disorder" shall not be defined to include mroe than neurosis, psychoneurosis,
psychopathy, psychosis, or mental or emotional disease or disorder.
(11) "Personal care" means the provision of
hands-on services to assist an individual with activities of daily
living.
(12) "Toileting" means
getting to and from the toilet, getting on and off the toilet, and performing
associated personal hygiene.
(13)
"Transferring" means moving into our out of a bed, chair, or
wheelchair.
(14) "Skilled nursing
care," "intermediate care," "personal care," home care," and other services
shall be defined in relation to the level of skill required, the nature of the
care, and the setting in which care must be delivered.
(b) The definitions contained in
G.S.
58-55-20 and
G.S.
58-55-35(a) are incorporated
by reference into this Section.
(c)
A policy may condition the payment of benefits on a determination of the
insured's ability to perform activities of daily living and on cognitive
impairment as long as those conditions are defined in the policy. Assessments
of activities of daily living and cognitive impairment shall be performed by
licensed or certified professionals, such as medical doctors, nurses, or social
workers. Policies shall include a description of the procedures for appealing
and resolving benefit determinations.
