Utah Admin. Code R590-126-4 - Prohibited Contract Provisions

(1)

(a) A contract may not establish a probationary period when coverage is not provided, except under Subsection (1)(b), (1)(c), or (1)(d).

(b) A contract may specify a probationary period not to exceed six months for a loss resulting from:

(i) adenoids;

(ii) appendix;

(iii) disorder of a reproductive organ;

(iv) hernia;

(v) tonsils; or

(vi) varicose veins.

(c) Coverage shall be provided for a disease, condition, or procedure in Subsection (1)(b) if the disease, condition, or procedure is treated on an emergency basis.

(d) A probationary period for a specified disease insurance contract may not exceed 30 days.

(e) An accident insurance contract may not include a probationary period.

(2) Unless otherwise required by law, a contract may not limit or exclude coverage or benefits by type of illness, accident, injury, treatment, or medical condition, except:

(a) abortion;

(b) acupuncture or acupressure;

(c) administrative charge for completing an insurance form, duplication service, interest, finance charge, or other administrative charge, unless otherwise required by law;

(d) administrative exam or service;

(e) allergy test or treatment;

(f) aviation, to a non-fare-paying passenger;

(g) axillary hyperhidrosis;

(h) benefits paid for under:

(i) employer's liability or occupational disease law;

(ii) Medicare or another governmental program, except Medicaid; or

(iii) state or federal workers' compensation;

(i) charge for a missed appointment;

(j) chiropractic care;

(k) complementary or alternative medicine;

(l) corrective lens, including an examination for the prescription or fitting, except lens implant following cataract surgery;

(m) cosmetic surgery, including reversal, revision, repair, complication, or treatment related to a non-covered cosmetic surgery, except reconstructive surgery:

(i) when the service is incidental to or follows surgery resulting from trauma, infection, or other disease of the involved part; or

(ii) due to a congenital disease or anomaly of a covered dependent child that resulted in a functional defect;

(n) custodial care;

(o) dental care or treatment, except a dental contract;

(p) dietary products;

(q) educational or nutritional training, except as required under Rule R590-200;

(r) experimental or investigational service;

(s) felony, riot, or insurrection, when it is determined the insured was a voluntary participant;

(t) fitness training, exercise equipment, or a membership to a spa or health club;

(u)

(i) foot care for a corn, a callus, a flat foot, a fallen arch, a weak foot, chronic foot strain, or symptomatic complaints of a foot, including an orthotic; and

(ii) the cutting or removal of a corn, a callus, or a nail may not be excluded when provided to an insured who has a systemic disease, such as diabetes with peripheral neuropathy or circulatory insufficiency if unskilled performance of the procedure would be hazardous;

(v)

(i) gastric or intestinal bypass service, including lap banding, gastric stapling, or a similar procedure to facilitate weight loss;

(ii) the reversal or revision of a procedure in Subsection (2)(v)(i); or

(iii) a service required for the treatment of a complication from a procedure in Subsection (2)(v)(i);

(w) gender reassignment;

(x) gene therapy;

(y) genetic testing;

(z) hearing aid, including examination for the prescription or fitting;

(aa) incarceration, limited to income replacement insurance;

(bb) infertility service;

(cc) injury as a result of a motor vehicle, to the extent the insured is required to have no-fault coverage, up to the minimum coverage required by law, whether or not such coverage is in effect;

(dd) mental health condition or substance use disorder services;

(ee) nuclear release;

(ff) preexisting condition, except as required under Section 31A-22-605.1 and Subsection 31A-22-610(2);

(gg) pregnancy, except for a complication of pregnancy;

(hh) refractive eye surgery;

(ii) rehabilitation therapy service, such as physical, speech, and occupational, unless required to correct an impairment caused by a covered accident, injury, or illness;

(jj) respite care;

(kk) rest cure;

(ll) routine physical examination;

(mm) services performed by an insured's parent, spouse, sibling, or child, including a step or in-law relationship;

(nn) services performed by an employee of a hospital, laboratory, or other institution;

(oo) services for which no charge is normally made in the absence of insurance;

(pp) services while in the armed forces or an auxiliary unit;

(qq) sexual dysfunction procedure, equipment, or drug;

(rr) shipping or handling;

(ss) suicide, sane or insane, attempted suicide, or intentionally self-inflicted injury;

(tt) telephone or electronic consultation;

(uu) territorial limitation outside the United States, except as required under Section 31A-22-627;

(vv) terrorism, including an act of terrorism;

(ww) transplant;

(xx) transportation;

(yy) treatment provided in a government hospital, except for fixed indemnity insurance;

(zz) war or act of war, whether declared or undeclared;

(aaa) except under Subsection (2)(bbb), a loss directly related to the insured's voluntary participation in an activity when the insured:

(i) is found guilty of an illegal activity in a criminal proceeding, including a plea of guilty, a no contest plea, and a plea in abeyance; or

(ii) is found liable for the activity in a civil proceeding;

(bbb) a loss established under Subsection (3) that is directly related to the insured violating:

(i) Section 41-6a-502, if the loss occurred in Utah; or

(ii) a law in a state other than Utah that prohibits operating a motor vehicle while exceeding the legal limit of concentration of alcohol, drugs, or a combination of both, in the blood, if the loss occurred in the other state; or

(ccc) any other exclusion that, in the opinion of the commissioner, is not inequitable, misleading, deceptive, obscure, unjust, unfair, or unfairly discriminatory to an insured.

(3)

(a) A violation under Subsection (2)(bbb) shall be established:

(i) in a criminal proceeding in which the insured is found guilty, enters a no contest plea, a plea in abeyance, or enters into a diversion agreement; or

(ii) by a request for an independent review when the findings support a decision to deny coverage based on the exclusion.

(b)

(i) For purposes of Subsection (3)(a)(ii), an independent review means a process that:

(A) is conducted by an independent entity designated by the insurer;

(B) renders an independent and impartial decision on a decision to deny coverage based on the exclusion; and

(C) is paid for by the insurer.

(ii) The independent review entity may not have a material professional, familial, or financial conflict with:

(A) the insurer;

(B) an officer, director, or management employee of the insurer;

(C) the insured;

(D) the insured's health care provider;

(E) the health care provider's medical group or independent practice association; or

(F) a health care facility where services were provided.

(c) The exclusion in Subsection (2)(bbb) does not apply to an insured who is under age 18.

(4)

(a) An insurer may use a waiver to exclude, limit, or reduce coverage or benefits for a specifically named or described preexisting condition, physical condition, or extra hazardous activity.

(b) A signed acceptance by the insured is required if a waiver is required as a condition of issuance, renewal, or reinstatement.

(5) A contract provision precluded in this section may not be construed as a limitation on the commissioner's authority to prohibit a contract provision that, in the opinion of the commissioner, is unjust, unfair, or unfairly discriminatory to an insured.

Notes

Utah Admin. Code R590-126-4

Adopted by Utah State Bulletin Number 2025-07, effective 3/24/2025