211 CMR 40.03 - Definitions

Current through Register 1466, April 1, 2022

As used in 211 CMR 40.00 the following mean:

Carrier, shall include, but not be limited to, an insurer licensed or otherwise authorized to transact accident and health insurance under M.G.L. c. 175, a fraternal benefit society licensed under M.G.L. c. 176, a hospital service corporation organized under M.G.L. c. 176A, a medical service corporation organized under M.G.L. c. 176B, a dental service corporation organized under M.G.L. c. 176E, an optometric service corporation organized under M.G.L. c. 176F, and a health maintenance organization licensed under M.G.L. c. 176G.

Exception shall mean any provision in a policy whereby coverage for a specified hazard is entirely eliminated; it is a statement of a risk not assumed under the policy.

Insured health plan shall include any individual, blanket, association, or group policy of health, accident or sickness insurance offered by a carrier.

Limitation shall mean any provision which restricts coverage under the policy other than an exception or a reduction.

Marketing or marketing methods shall include any of the following including, but not limited to advertisements, when they are used by any person with the intent of soliciting an offer to contract for an insured health plan:

(a) Printed and published material, audio-visual material and descriptive literature used in direct mail, newspapers, magazines, radio or TV scripts, billboards, computer or electronic transmissions and similar displays;

(b) Descriptive literature and sales aids of all kinds issued for presentation to members of the insurance-buying public, including but not limited to circulars, leaflets, booklets, depictions, illustrations and form letters;

(c) Prepared sales talks, presentations and material; and

(d) All oral and written solicitations and presentations.

Medicare shall mean Title XVIII of the Social Security Act, "Health Insurance for the Aged Act," 42 USCS ยง1396 et seq., as amended.

Person shall mean any individual, carrier, or any other legal entity engaged in the marketing or advertising of a policy, including agents, brokers, and advisors.

Policy shall include any policy, plan, certificate, contract, agreement, statement of coverage, rider, or endorsement which provides insured health benefits, including surgical or hospital expense benefits and disability or loss of time benefits, whether such are issued individually or on a general or blanket basis, whether such are issued on an indemnity, reimbursement, service or prepaid basis, except when issued in connection with another kind of insurance other than life and except disability, waiver of premium and double indemnity benefits included in life insurance and annuity contracts.

Reduction shall mean any provision which reduces the amount of the benefit; a risk of loss is assumed but payment upon the occurrence of such loss is limited to some amount or period less than would be otherwise payable had such reduction not been used.


211 CMR 40.03

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