Utah Admin. Code R590-285-3 - Definitions
Terms used in this rule are defined in Sections 31A-1-301 and 31A-22-2002. Additional terms are defined as follows:
(1)
(a) "Authorized representative" means an
individual authorized to act as an insured's personal representative under
45 CFR
164.502(g).
(b) "Authorized representative" includes:
(i) a person to whom an insured gives express
written consent to represent the insured in an external review;
(ii) a person authorized by law to provide
substituted consent for an insured; or
(iii) only when the insured is unable to
provide consent:
(A) a family member of the
insured; or
(B) the insured's
treating health care professional
(2) "Benefit trigger," for the purposes of
independent review, means a contractual provision conditioning the payment of
benefits on a determination of the insured's:
(a) ability to perform activities of daily
living; or
(b) cognitive
impairment.
(3)
"Certificate" means a limited long-term care insurance certificate.
(4) "Cold lead advertising" means using,
directly or indirectly, any method of marketing that fails to disclose in a
conspicuous manner the method of marketing is a solicitation of insurance and
that contact will be made by a producer or an issuer.
(5) "Continuation of coverage" means a
provision that maintains coverage under the existing group policy when the
coverage would otherwise terminate, and that is subject only to the continued
timely payment of premium when due.
(6) "Conversion of coverage" means a
provision that an individual whose coverage under the group policy would
otherwise terminate or has been terminated for any reason, including
discontinuance of the group policy in its entirety or with respect to an
insured class, shall be entitled to the issuance of a converted policy by the
insurer, without evidence of insurability, if the individual was continuously
insured under the group policy or another group policy which it replaced six
months immediately before termination.
(7) "Converted policy" means an individual
policy providing benefits identical to, or benefits determined by the
commissioner to be substantially equivalent to or in excess of, those provided
under the group policy from which the conversion is made.
(8) "High pressure tactics" means using a
method of marketing to induce, or tend to induce, the purchase of insurance
through force, fright, threat, whether explicit or implied, or undue pressure
to purchase or recommend the purchase of insurance.
(9) "Licensed health care professional" means
an individual qualified by education and experience in an appropriate field to
determine, by record review, an insured's actual functional or cognitive
impairment.
(10) "Limited
distribution channel" means a sale through a discrete entity, such as a
financial institution or brokerage, where a specialized product is available
that is not available for sale to the general public.
(11) "Limited long-term care benefit
classification" means policy benefits classified as:
(a) institutional limited long-term care
benefits only;
(b)
non-institutional limited long-term care benefits only; or
(c) comprehensive limited long-term care
benefits.
(12)
"Misrepresentation" means misrepresenting a material fact when selling or
offering to sell a policy or certificate.
(13) "Policy" means a limited long-term care
insurance policy.
(14) "Qualified
actuary" means a member in good standing of the American Academy of
Actuaries.
(15)
(a) "Similar policy forms" means all limited
long-term care insurance policies and certificates issued by an insurer in the
same limited long-term care benefit classification.
(b) Group limited long-term care insurance
certificates are not considered similar to certificates or policies otherwise
issued as limited long-term care insurance, but are similar to other comparable
certificates with the same limited long-term care benefit
classifications.
(16)
"State of policy issue" means the state in which a policy was originally
issued.
(17) "Twisting" means
knowingly making any misleading representation or incomplete or fraudulent
comparison of any insurance policy or issuer to induce, or tend to induce, any
person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow
on, or convert any insurance policy or to take out an insurance policy with
another issuer.
Notes
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