02-031 C.M.R. ch. 425, § 4 - Rule Definitions

Current through 2022-14, April 6, 2022

As used in this rule, unless the context otherwise indicates, the following terms have the following meanings:

A. "Adverse benefit trigger determination" means a claims denial determining that the insured has not satisfied a required clinical standard for benefit eligibility, as described more fully in Sections 27 and 28, including, when applicable under the contract, the existence or degree of cognitive impairment, chronic illness, or inability to perform one or more specified activities of daily living.
B. "Authorized representative" means:
(1) A person to whom an insured has given express written consent to represent the insured in a standard appeal or an external review;
(2) A person authorized by law to provide consent to request an internal appeal or an external review for an insured; or
(3) A family member of an insured or an insured's treating health care professional when the insured is unable to provide consent to request an internal appeal or an external review.
C. "Bureau" means the Maine Bureau of Insurance.
D. "Claims denial" means any reduction of a benefit, termination of a benefit, or failure to provide or make payment (in whole or in part) for a benefit, including a determination of an insured's ineligibility for benefits. The term "claims denial" includes both clinical decisions and benefit determinations that do not involve clinical decisions.
E. "Claimsdenial eligible forexternal review" means an adverse benefit trigger determination or a claims denial that requires the exercise of professional judgment within the scope of practice of a health care professional on the applicability of the following policy limitations or exclusions:
(1) A preexisting condition or disease;
(2) Mental or nervous disorders;
(3) Alcoholism and drug addiction;
(4) Illness, medical condition or treatment arising from:
(a) War or act of war (whether declared or undeclared);
(b) Participation in a felony, riot or insurrection;
(c) Service in the armed forces or units auxiliary thereto;
(d) Suicide, attempted suicide or any intentionally self-inflicted injury; or
(e) Aviation.
F. "Exceptional increase" in premiums means a rate increase the insurer designates as exceptional, and that the superintendent determines is justified because it arises from any of the following causes:
(1) Changes in laws or regulations applicable to long-term care insurance in this state; or
(2) Increased and unexpected utilization that affects at least a majority of insurers of similar products.
G. "Incidental," as used in Section 20(J), means that the value of the long-term care benefits is less than ten percent of the total value of benefits provided over the life of the policy. These values shall be measured as of the date of issue.
H. "Qualified actuary" means a member in good standing of the American Academy of Actuaries.
I. "Similar policy forms" means all of the long-term care policies and certificates issued by an insurer in the same long-term care benefit classification as the policy form being considered. Certificates of employee groups as defined in 24-A M.R.S.A. §2804, labor union groups as defined in 24-A M.R.S.A. §2805, or trustee groups as defined in 24-A M.R.S.A. §2806 are not considered similar to certificates or policies otherwise issued as long-term care insurance, but are similar to other comparable certificates with the same long-term care benefit classifications. The different benefit classifications are: institutional benefits only; non-institutional benefits only; and comprehensive (institutional and non-institutional) benefits.
J. "Substantive issue" means a matter that is integralto the determination of whether the insured is eligible for benefits under a policy and that involves information essential for the insurer to have prior to paying the claim. A substantive issue includes the issues generated by the items described in Sections 31(A)(1) through 31(A)(5). A substantive issue also includes information necessary to pay the claim that the insurer is unable to obtain because the provider refuses to provide it or because it is not available from sources other than the insured or the insured's authorized representative.
K. "Technical issue" means a matter that is procedural in nature or not integral to the determination of whether the insured is entitled to benefits under the policy. Examples of a technical issue are an insurer's lack of receipt of completed forms that duplicate information that the insurer already has or the license number for a long-term care facility.

Notes

02-031 C.M.R. ch. 425, § 4

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