No policy or certificate may be advertised, solicited or
issued for delivery in this State as a Medicare supplement policy or
certificate unless such policy or certificate contains definitions or terms
which conform to the requirements of this section.
A. "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
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,
however, exclude 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.
B. "Benefit Period" or "Medicare Benefit
Period" shall not be defined more restrictively than as defined in the Medicare
program.
C. "Convalescent Nursing
Home," "Extended Care Facility," or "Skilled Nursing Facility" shall not be
defined more restrictively than as defined in the Medicare program.
D. "
Health Care Expenses" means, for purposes
of Section
14, expenses of health maintenance
organizations associated with the delivery of health care services, which
expenses are analogous to incurred losses of insurers.
E. "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 Health Care Organizations or by the
American Osteopathic Association Healthcare Facilities Accreditation Program,
but not more restrictively than as defined in the Medicare program.
F. "
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.
G. "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.
H. "Physician" shall not
be defined more restrictively than as defined in the Medicare
program.
I. "
Sickness" shall not be
defined to be more restrictive than the following:
"Sickness means illness or disease of an insured
person."
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.
