Utah Admin. Code R590-148-8 - Benefit Trigger Standards

(1)

(a) A policy shall condition the payment of benefits on a determination of the insured's:

(i) ability to perform activities of daily living; or

(ii) cognitive impairment.

(b) Eligibility for the payment of benefits may not be more restrictive than requiring either:

(i) a deficiency in the ability to perform not more than three of the activities of daily living; or

(ii) the presence of cognitive impairment.

(2) An insurer may use additional activities of daily living to trigger covered benefits in addition to those listed in Section R590-148-4 if the terms are defined in the policy.

(3) An insurer may use additional provisions to determine when benefits are payable, but the provisions may not restrict, and are not in lieu of, the requirements under Subsections (1) and (2).

(4) For purposes of this section, the determination of a deficiency may not be more restrictive than:

(a) requiring the hands-on assistance of another person to perform the prescribed activities of daily living; or

(b) if the deficiency is due to the presence of a cognitive impairment, needing supervision or verbal cuing by another person to protect the insured or others.

(5) An assessment of activities of daily living or cognitive impairment shall be performed by a licensed or certified professional, such as a physician, nurse, or social worker.

(6) A policy shall include a clear description of the process for appealing and resolving a benefit determination.

(7) The requirements in this section are effective January 1, 2003.

(a) This section applies to a policy issued in this state on or after July 1, 2002.

(b) This section does not apply to a certificate issued on or after July 1, 2002, under a group policy that was in force before July 1, 2002.

Notes

Utah Admin. Code R590-148-8

Adopted by Utah State Bulletin Number 2024-21, effective 10/22/2024