California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 11 - Standards for Health History Questionnaires in Health Insurance Applications, Pre-Issuance Medical Underwriting and Rescission of Health Insurance Policies › Section 2274.72 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For purposes of this article,
(a) "Policy" or "policies" refers to the
				  written instrument, which is a contract of insurance that puts insurance
				  coverage into effect and includes group certificates and fraternal benefit
				  society certificates.
(b)
				  "Reasonable layperson standard" means a method of evaluating health history
				  information that recognizes and takes into account the level of understanding
				  and appreciation of words and terms in a health history questionnaire by the
				  average individual who lacks professional training and experience in
				  medicine.
(c) "Questions" means
				  questions and all requests for information, including statements or disclosures
				  requested of the applicant in a health history questionnaire that is part of an
				  application for health insurance coverage.
(d) "Personal Health Record" ("PHR") means a
				  dynamic set of personal health history information derived from a private,
				  secure database maintained by a health insurer or health plan and that contains
				  medical claims and other information. A PHR may be "auto-populated" with
				  medical and related information, including claims records reflecting diagnoses
				  and procedure codes, dates of treatments, prescription records, medical testing
				  and other allowed clinical information. A PHR is distinct from an electronic
				  medical record, which is primarily intended for use by medical professionals. A
				  PHR is designed primarily for use by the insured. As used in this article, a
				  PHR refers exclusively to a record of health history information maintained by
				  an insurer or health plan for use by its covered persons. An insurer may ignore
				  any applicant-generated health information purporting to be part of a
				  PHR.
(e) "Material", when used to
				  describe information relied on by an insurer, indicates specific information
				  that would be a determining factor to the insurer in deciding whether to accept
				  or reject a proposed insurance risk associated with a health insurance policy
				  or in determining the rate that will be offered.
(f) "Medical Underwriting" means the process
				  of determining the relative risks of providing health insurance coverage to an
				  individual by examining medical and other information and applying medical
				  underwriting guidelines. The purpose of medical underwriting is to reject or
				  accept the proposed insurance risk and, if accepted, to set the level of
				  coverage and the rate that will be offered.
1. New
					 section filed 7-19-2010; operative 8-18-2010 (Register 2010, No.
					 30).
2. Change without regulatory effect amending NOTE filed
					 9-23-2010 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 2010, No. 39).
Note: Authority cited: Sections
						790.10,
						10291.5,
						10384,
						12921 and
						12926,
						Insurance Code; CalFarm Ins. Co. v. Deukmejian, 48 Cal.3d 805 (1989); and 20th
						Century Ins. Co. v. Garamendi, 8 Cal. 4th 216 (1994). Reference: Sections
						106,
						380,
						730,
						733,
						734,
						790.03,
						796.04,
						10113,
						10291.5,
						10380,
						10381.5 and
						10384,
						Insurance Code.