No policy or certificate may be advertised, solicited or
issued for delivery in this state as a Medicare supplement policy or
certificate unless the policy or certificate contains definitions or terms,
which conform to the requirements of this section.
A. "Accident," "accidental injury," or
"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 for which benefits
are provided means accidental bodily injury sustained by the insured person
which is the direct result of an accident, independent of disease or bodily
infirmity or any other cause, and occurs while insurance coverage is in
force."
(2) The definition may
provide that injuries shall not include injuries for which benefits are
provided or available under any workers' compensation, employer's liability or
similar law, or motor vehicle no-fault plan, unless prohibited by
law.
B. "Benefit period"
or "Medicare benefit period" shall not be defined more restrictively than as
defined in the Medicare program.
C.
"Convalescent nursing home," "extended care facility," or 'skilled nursing
facility" shall not be defined more restrictively than as defined in the
Medicare program.
D. "Health care
expenses" means, for purposes of Section 14, expenses of health maintenance
organizations associated with the delivery of health care services, which
expenses are analogous to incurred losses of insurers.
E. "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 Hospitals, but not more
restrictively than as defined in the Medicare program.
F. "Medicare" shall be defined in the policy
and certificate. Medicare may be substantially defined as "The Health Insurance
for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then
Constituted or Later Amended," or "Title I, Part I of
Public Law 89-97, as
Enacted by the Eighty-Ninth Congress of the United States of America and
popularly known as the Health Insurance for the Aged Act, as then constituted
and any later amendments or substitutes thereof," or words of similar import.
G. "Medicare eligible expenses"
shall mean expenses of the kinds covered by Medicare Parts A and B, to the
extent recognized as reasonable and medically necessary by Medicare.
H. "Physician" shall not be defined more
restrictively than as defined in the Medicare program.
I. "Sickness" shall not be defined to be more
restrictive than the following:
"Sickness means illness or disease of an insured person which
first manifests itself after the effective date of insurance and while the
insurance is in force."
The definition may be further modified to exclude sicknesses
or diseases for which benefits are provided under any workers' compensation,
occupational disease, employer's liability or similar law.