As used in this rule, unless the context otherwise indicates,
the following terms have the following meanings:
"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
, 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
(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;
(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.
"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.
"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
(1) A preexisting condition or
(2) Mental or nervous
(3) Alcoholism and drug
condition or treatment arising from:
or act of war (whether declared or undeclared);
(b) Participation in a felony, riot or
(c) Service in the
armed forces or units auxiliary thereto;
(d) Suicide, attempted suicide or any
intentionally self-inflicted injury; or
"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
(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.
"Incidental," as used in
, 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
§2804, labor union groups as defined in
§2805, or trustee groups as defined in
§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.
"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
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