Utah Administrative Code
Topic - Insurance
Title R590 - Administration
Rule R590-192 - Unfair Accident and Health Insurance Claim Settlement Practice Rule
Section R590-192-3 - Definitions
Current through Bulletin 2024-06, March 15, 2024
Terms used in this rule are defined in Sections 31A-1-301, 31A-22-629, and 29 CFR 2560.503-1(m). Additional terms are defined as follows:
(1) "Authorized agent" means an individual, corporation, association, organization, partnership, or other legal entity authorized to represent an insurer with respect to a claim.
(2) "Claim file" means a record that can accurately and reliably reproduce the original material regarding a claim, its investigation, adjustment, and settlement.
(3) "Claimant" means an insured or an insured's legal representative, including an immediate family member designated by the insured.
(4) "Concurrent care" or "ongoing care" means an insurer approves an ongoing course of treatment over a specific period or number of treatments.
(5) "Days" means calendar days.
(6) "Documentation" means a physical or an electronic record related to a claim.
(7) "General business practice" means a pattern of conduct in a business.
(8) "Investigation" means an activity of an insurer related to the determination of liability of a claim.
(9) "Medical necessity" means:
(10) "Misrepresentation" for a health benefit plan means an intentional misrepresentation of a material fact.
(11) "Notice of loss" means a claimant's notice that reasonably informs an insurer of the facts related to a claim.
(12) "Proof of loss" means a claimant's reasonable documentation in support of a claim.
(13)