Haw. Code R. § 16-12-4 - Policy definitions and terms
(a) No policy or
certificate may be advertised, solicited, or issued for delivery in this State
as a Medicare supplement policy or certificate unless the policy or certificate
contains definitions or terms which conform to the requirements of this
section.
(b) "Accident,"
"accidental injury," or "accidental means" shall be defined to employ "result"
language and shall 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.
(1) The
definition shall not be more restrictive than the following: "Injury or
injuries for which benefits are provided means accidental bodily injury
sustained by the insured person which is the direct result of an accident,
independent of disease or bodily infirmity or any other cause, and occurs while
insurance coverage is in force."
(2) The definition may provide that injuries
shall not include injuries for which benefits are provided or available under
any workers' compensation, employer's liability or similar law, or motor
vehicle no-fault plan, unless prohibited by law.
(c) "Benefit period" or "Medicare benefit
period" shall not be defined more restrictively than as defined in the Medicare
program.
(d) "Convalescent nursing
home," "extended care facility," or 'skilled nursing facility" shall not be
defined more restrictively than as defined in the Medicare program.
(e) "Health care expenses" mean, for purposes
of section
16-12-7,
expenses of health maintenance organizations associated with the delivery of
health care services, which expenses are analogous to incurred losses of
insurers.
(f) "Hospital" may be
defined in relation to its status, facilities, and available services or to
reflect its accreditation by the Joint Commission on Accreditation of
Hospitals, but not more restrictively than as defined in the Medicare
program.
(g) "Medicare" shall be
defined in the policy and certificate. Medicare may be substantially defined as
"The Health Insurance for the Aged Act, Title XVIII of the Social Security
Amendments of 1965 as Then Constituted or Later Amended," or "Title I, Part I
of Public Law 89-97, as Enacted by the Eighty-Ninth Congress of the United
States of America and popularly known as the Health Insurance for the Aged Act,
as then constituted and any later amendments or substitutes thereof," or words
of similar import.
(h) "Medicare
eligible expenses" shall mean expenses of the kinds covered by Medicare Parts A
and B, to the extent recognized as reasonable and medically necessary by
Medicare.
(i) "Physician" shall not
be defined more restrictively than as defined in the Medicare
program.
(j) "Sickness" shall not
be defined to be more restrictive than the following:
(1) "Sickness means illness or disease of an
insured person which first manifests itself after the effective date of
insurance and while the insurance is in force."
(2) The definition may be further modified to
exclude sicknesses or diseases for which benefits are provided under any
workers' compensation, occupational disease, employer's liability, or similar
law.
Notes
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