Illinois Administrative Code › Title 50 - INSURANCE › Part 2008 - MINIMUM STANDARDS FOR INDIVIDUAL AND GROUP MEDICARE SUPPLEMENT INSURANCE › Subpart B - COVERAGE, POLICY & BENEFIT PROVISIONS › Section 2008.50 - Policy Definitions and Terms

Current through Register Vol. 48, No. 28, July 12, 2024
No policy or certificate may be advertised, solicited or
				  issued for delivery in this State as a Medicare supplement policy or
				  certificate unless that policy or certificate contains definitions or terms
				  that conform to the requirements of this Section.
"Accident", "Accidental Injury" or "Accidental Means" shall
				  be defined to employ "result" language and shall not include words which
				  establish an accidental means test or use words such as "external, violent,
				  visible wounds" or similar words of description or characterization.
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 that is the direct result of an
				  accident, independent of disease or bodily infirmity or any other cause, and
				  occurs while the insurance is in force."
That 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.
"Benefit Period" or "Medicare Benefit Period" shall not be
				  defined more restrictively than as defined in the Medicare program.
"Convalescent Nursing Home", "Extended Care Facility" or
				  "Skilled Nursing Facility" shall not be defined more restrictively than as
				  defined in the Medicare program.
"Duplication of Insurance" means a transaction in which new
				  accident and health insurance is to be purchased and it is known to the
				  producer or should be known to the producer or the issuer, in the case of a
				  direct response solicitation, that the new insurance will provide some of the
				  benefits or coverages which the proposed insured already has under existing
				  accident and health insurance.
"Health Care Expenses", for purposes of Section
				  2008.80,
				  means expenses of a nonprofit health, hospital or medical service corporation,
				  prepaid health plan or similar organization associated with the delivery of
				  health care services in which providers of the health care services are
				  reimbursed for such services on an other than fee for service basis that are
				  analogous to incurred losses of insurers.
"Hospital" may be defined in relation to its status,
				  facilities and available services or to reflect its accreditation by the Joint
				  Commission but not more restrictively than as defined in the Medicare
				  program.
"Medicare" shall be defined in the policy and certificate as
				  "The Health Insurance for the Aged and Disabled 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 and Disabled Act, as then constituted and any later amendments or
				  substitutes thereof", or words of similar import.
"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.
"Over-Insurance" means duplication of insurance to such
				  extent that the combination of the existing insurance and the proposed
				  insurance would substantially exceed any loss reasonably expected to be
				  incurred.
"Physician" shall not be defined more restrictively than as
				  defined in the Medicare program.
"Sickness" shall not be defined more restrictively 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.