Utah Admin. Code R590-285-23 - Standards for a Benefit Trigger
(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)
(a) Activities of daily living shall include
at least:
(i) bathing;
(ii) continence;
(iii) dressing;
(iv) eating;
(v) toileting; and
(vi) transferring.
(b) An insurer may use additional activities
of daily living to trigger a covered benefit if the terms are defined in the
policy or certificate.
(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 the 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 cueing 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 or certificate shall include a
clear description of the process for appealing and resolving a benefit
determination.
Notes
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