South Dakota Administrative Rules
Title 20 - PUBLIC SAFETY
Article 20:06 - INSURANCE
Chapter 20:06:52 - Discretionary clauses
Section 20:06:52:01 - Definitions

Universal Citation: SD Admin Rules 20:06:52:01

Current through Register Vol. 50, page 114, March 25, 2024

Terms used in this chapter mean:

(1) "Appeal," any review or appeal before an administrative agency, arbitrator, court or mediator;

(2) "Discretionary clause," a provision in a policy that purports to bind the claimant to, or grant deference in, proceedings subsequent to the insurer's decision, denial, or interpretation on terms, coverage, or eligibility for benefits, including a policy provision that provides any of the following:

(a) A policyholder or other claimant may not appeal a denial of a claim;

(b) The insurer's decision to deny policy coverage is binding upon a policyholder or other claimant or is otherwise entitled to deference upon appeal or review;

(c) On appeal or review the insurer's decision-making power as to policy coverage is binding or otherwise entitled to deference;

(d) The insurer's interpretation of the terms of a policy is binding upon a policyholder or other claimant or is otherwise entitled to deference;

(e) On appeal the insurer's interpretation of the terms of a policy is binding or is otherwise entitled to deference;

(f) A standard of review on appeal that gives deference in the original claim decision, or gives rise to such standard of review;

(g) A standard of review on appeal other than a de novo review, or gives rise to a standard of review other than de novo;

(h) The insurer has discretion to determine whether a claim is compensable or to interpret the provisions of the policy or certificate;

(3) "Policy," any plan, certificate, contract, policy, and agreement that provides for health insurance as defined by SDCL 58-9-3 or otherwise provides health or disability benefits.

General Authority: SDCL 58-2-39, 58-17-87, 58-18-79, 58-18-79(14), 58-29D-34.

Law Implemented: SDCL 58-17-87, 58-18-79, 58-29D-23, 58-29D-31(2)(6), 58-33-67.

Disclaimer: These regulations may not be the most recent version. South Dakota 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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