Ill. Admin. Code tit. 50, § 2007.50 - Definitions
Except as provided hereafter, no individual accident or health insurance policy delivered or issued for delivery to any person in this State shall contain definitions respecting the matters set forth in this Part unless the definitions comply with the requirements of this Section.
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"Accident and Accidental Injury" shall be defined to employ
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AGENCY NOTE: The fact that the injury combined with other factors to produce the loss does not necessarily relieve the insurer of liability. Each claim must be judged on the basis of its particular facts and in light of the court decisions, to determine whether the injury is to be considered as the cause of the loss.
The definition may provide that injuries shall not include injuries for which benefits are provided under any workers' compensation, employer's liability or similar law, motor vehicle no-fault plan, unless prohibited by law, or injuries occurring while the insured person is engaged in any activity pertaining to any trade, business, employment or occupation for wage or profit.
"Convalescent Nursing Home, Extended Care Facility, or Skilled Nursing Facility" shall be defined in relation to its status, facilities and available services.
A definition of the home or facility shall not be more restrictive than one requiring that it:
be operated pursuant to law;
be approved for payment of
be primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under the supervision of a duly licensed physician;
provide continuous 24 hours a day nursing service by or under the supervision of a registered graduate professional nurse (R.N.); and
maintains a daily medical record of each patient.
The definition of a home or facility may provide that the term shall not be inclusive of:
any home, facility or part thereof used primarily for rest;
a home or facility for the aged or for the care of drug addicts or alcoholics; or
a home or facility primarily used for the care and treatment of mental diseases or disorders, or custodial or educational care.
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Benefits not subject to requirements:
Coverage only for accident or disability income insurance, or any combination thereof;
Coverage issued as a supplement to liability insurance;
Liability insurance, including general liability insurance and automobile liability insurance;
Workers' compensation or similar insurance;
Automobile medical payment insurance;
Credit-only insurance;
Coverage for on-site medical clinics; or
Other similar insurance coverage under which benefits for medical care are secondary or incidental to other insurance benefits.
Benefits not subject to requirements if offered separately:
Limited scope dental or vision benefits; and
Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof.
Benefits not subject to requirements if offered as independent, noncoordinated benefits:
Coverage only for a specified disease or illness; or
Benefits not subject to requirements if offered as separate
insurance policy
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"Home Health Care Agency" shall not be defined more restrictively than a public agency or private organization that provides skilled nursing services and meets the following requirements:
It is primarily engaged in providing home health care services;
Its policies are established by a group of professional personnel (including at least one physician and one registered nurse (R.N.));
Supervision of home health care services is provided by a physician or a registered nurse (R.N.);
It maintains clinical records on all patients; and
It has a full time administrator.
"Home Health Care" shall not be defined more restrictively than skilled nursing care or services provided to a person at a residence according to a plan of treatment for illness or infirmity prescribed by a physician. These services shall include, but are not limited to, the following:
Part time and intermittent skilled nursing services - Services given to a patient at least once every 60 days or as frequently as a few hours per day, several days per week.
Therapeutic Services:
Physical Therapy;
Occupational Therapy;
Speech and Hearing Therapy;
Medical social services, medical supplies, drugs and medicines
prescribed by a physician and related pharmaceutical services and laboratory
services to the extent the charges or costs would have been covered under the
policy if the insured person had remained in the
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The definition of the term "
be an institution operated pursuant to the law; and
be primarily and continuously engaged in providing or operating
medical and diagnostic facilities, with major surgical facilities either on its
premises or in facilities available to the
provide 24 hours nursing service by or under the supervision of registered graduate professional nurses (R.N.s).
The definition of the term "
convalescent, rest or nursing homes or facilities;
facilities primarily affording custodial or educational care or care or treatment for persons suffering from mental diseases or disorders;
facilities for the aged, mentally ill, drug addicts or
alcoholics (except for a unit of a
any military or veterans
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"Mental or Nervous Disorders" shall not be defined more restrictively than a definition including neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease, disorder or condition, including serious mental illness and substance use disorder or condition.
"Nurses" may be defined so that the description of nurse is restricted to a type of nurse, such as a registered graduate professional nurse (R.N.), a licensed practical nurse (L.P.N.), or a licensed vocational nurse (L.V.N.). If the words "nurse", "trained nurse" or "registered nurse" are used without specific instruction, then the use of those terms requires the insurer to recognize the services of any individual who qualifies under that terminology in accordance with the applicable statutes or administrative rules of the state licensing or registry board.
"One Period of Confinement or Continuous
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"Physician" may be defined by including words such as "duly qualified physician" or "duly licensed physician". The use of such terms requires an insurer to recognize and to accept, to the extent of its obligation under the contract, all providers of medical care and treatment when the services are within the scope of the provider's licensed authority and are provided pursuant to applicable laws dealing with physician licensure.
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"Total Disability"
A general definition of total disability cannot be more restrictive than one requiring the individual to be totally disabled from engaging in any employment or occupation that he or she could, giving due consideration of his education, training or experience be reasonably expected to engage in and is not in fact engaged in any employment or occupation for wage or profit.
Total disability may be defined in relation to the inability of the person to perform duties but may not be based solely upon an individual's inability to:
Perform "any occupation whatsoever", "any occupational duty", or "any and every duty of his or her occupation";
Engage in any training or rehabilitation program.
An insurer may specify the requirement of the complete inability of the person to perform all of the substantial and material duties of his or her regular occupation or words of similar import. An insurer may require care by a physician other than the insured or a member of the insured's immediate family.
When through a specific provision of a policy, disability coverage is provided to a retired person, the definition shall not require more than the insured be completely unable to engage in the normal activities of a retired person of like age and good health.
Notes
Amended at 38 Ill. Reg. 2138, effective January 2, 2014
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