N.H. Admin. Code § Ins 1901.04 - Policy Definitions

(a) Except as provided in this part, an individual accident and health policy or group supplemental accident and health insurance policy or certificate delivered or issued for delivery to any person in this state and to which this part applies shall contain definitions respecting matters set forth below that comply with the requirements of this section.

(b) "Accident," "accidental injury, "and "accidental means" shall be defined to employ "result" language and shall not include words that 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" means accidental bodily injury sustained by the insured person that is the direct cause of the condition for which benefits are provided, independent of disease or bodily infirmity or any other cause and that occurs while the insurance is in force.

(2) The definition may provide that injuries shall not include injuries for which benefits are provided under workers' compensation, employers' liability or similar law; or under a motor vehicle no-fault plan, unless prohibited by law; or injuries occurring while the insured person is engaged in any activity pertaining to a trade, business, employment or occupation for wage or profit.

(c) "Convalescent nursing home," "extended care facility," or "skilled nursing facility" shall be defined in relation to its status, facility and available services.

(1) A definition of the home or facility shall not be more restrictive than one requiring that it:

a. Be operated pursuant to law;

b. Be approved for payment of Medicare benefits or be qualified to receive approval for payment of Medicare benefits, if so requested;

c. Be primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under the supervision of a duly licensed physician;

d. Provide continuous 24 hour-a-day nursing service by or under the supervision of a registered nurse; and

e. Maintain a daily medical record of each patient.

(2) The definition of the home or facility may provide that the term shall not be inclusive of:

a. A home, facility or part of a home or facility used primarily for rest;

b. A home or facility for the aged or for the care of drug addicts or alcoholics; or

c. A home or facility primarily used for the care and treatment of mental diseases or disorders, or for custodial or educational care.

(d) "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 Healthcare Organizations.

(1) The definition of the term "hospital" shall not be more restrictive than one requiring that the hospital:

a. Be an institution licensed to operate as a hospital pursuant to law;

b. Be primarily and continuously engaged in providing or operating, either on its premises or in facilities available to the hospital on a prearranged basis and under the supervision of a staff of licensed physicians, medical, diagnostic and major surgical facilities for the medical care and treatment of sick or injured persons on an in-patient basis for which a charge is made; and

c. Provide 24 hour nursing service by or under the supervision of registered nurses.

(2) The definition of the term "hospital" may state that the term shall not be inclusive of:

a. Convalescent homes or, convalescent, rest or nursing facilities;

b. Facilities affording primarily custodial, educational or rehabilitory care;

c. Facilities for the aged, drug addicts or alcoholics; or

d. A military or veterans' hospital, a soldiers' home or a hospital contracted for or operated by any national government or government agency for the treatment of members or ex-members of the armed forces, except for services rendered on an emergency basis where a legal liability for the patient exists for charges made to the individual for the services.

(e) "Medicare" means The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended.

(f) "Mental or nervous disorder" shall not be defined more restrictively than a definition including neurosis, psychoneurosis, psychosis, or mental or emotional disease or disorder of any kind.

(g) "Nurse" may be defined so that the description of nurse is restricted to a type of nurse, such as registered nurse, a licensed practical nurse, or a licensed vocational nurse. If the words "nurse," "trained nurse" or "registered nurse" are used without specific instruction, then the use of these terms requires the insurer to recognize the services of any individual who qualifies under the terminology in accordance with the applicable statutes or administrative rules of the licensing or registry board of the state.

(h) "One period of confinement" means consecutive days of in-hospital services received as an in-patient, or successive confinements when discharge from and readmission to the hospital occurs within a period of time not more than 90 days or 3 times the maximum number of days of in-hospital coverage provided by the policy to a maximum of 180 days.

(i) "Partial disability" shall be defined in relation to the individual's inability to perform one or more but not all of the "major," "important" or "essential" duties of employment or occupation, or may be related to a percentage of time worked or to a specified number of hours or to compensation.

(j) "Physician" may be defined by including words such as "qualified physician" or "licensed physician." The use of these 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.

(k) "Preexisting condition" shall not be defined more restrictively than the following: "Preexisting condition means the existence of symptoms that would cause an ordinarily prudent person to seek diagnosis, care or treatment within a 2 year period preceding the effective date of the coverage of the insured person or a condition for which medical advice or treatment was recommended by a physician or received from a physician within a 2 year period preceding the effective date of the coverage of the insured person." Medical expense policies and certificates shall comply with RSA 420-G:7.

(l) "Residual disability" shall be defined in relation to the individual's reduction in earnings and may be related either to the inability to perform some part of the "major," "important" or "essential duties" of employment or occupation, or to the inability to perform all usual business duties for as long as is usually required. A policy that provides for residual disability benefits may require a qualification period, during which the insured shall be continuously totally disabled before residual disability benefits are payable. The qualification period for residual benefits may be longer than the elimination period for total disability. In lieu of the term "residual disability," the insurer may use "proportionate disability" or other terms of similar import that in the opinion of the commissioner adequately and fairly describes the benefit.

(m) "Sickness" shall not be defined to be more restrictive than the following: "Sickness means sickness or disease of an insured person that first manifests itself after the effective date of insurance and while the insurance is in force. The definition may be further modified to exclude sickness or disease for which benefits are provided under a workers' compensation, occupational disease, employer's liability or similar law. Probationary periods shall not apply to policies or certificates issued pursuant to RSA 420-G.

(n) "Total disability"

(1) A general definition of total disability shall not be more restrictive than one requiring that the individual who is totally disabled not be engaged in any employment or occupation for which he or she is or becomes qualified by reason of education, training or experience; and is not in fact engaged in any employment or occupation for wage or profit.

(2) Total disability may be defined in relation to the inability of the person to perform duties but shall not be based solely upon an individual's inability to:

a. Perform "any occupation whatsoever," "any occupational duty," or "any and every duty of his occupation;" or

b. Engage in a training or rehabilitation program.

(3) An insurer may require 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.

Notes

N.H. Admin. Code § Ins 1901.04

#1900, eff 1-1-82; amd by #2101, eff 10-1-82; amd by #2732, eff 5-31-84; amd by #3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #8609, eff 4-17-06