Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 42.00 - The Form And Contents Of Individual Accident And Sickness Insurance › Section 42.04 - Definitions

Current through Register 1525, July 5, 2024
As used in
				211 CMR 42.00, the following
				words shall mean:
Accident, Accidental Injury, Accidental
				Means
must be defined to employ "result" language and may 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. Such definition may be modified or an exception or limitation
				may be included to provide that injuries shall not include injuries for which
				benefits are provided under any workmen's compensation, occupational disease,
				employer's liability or similar law.
Anticipated Loss Ratio
means the
				present value at issue of the expected future benefits, excluding dividends,
				divided by the present value of the expected future annualized premiums, using
				a reasonable interest rate and reasonable assumptions as to the distribution of
				the policy form by age and by various options available.
Carrier
means a commercial insurance
				company licensed to write accident and health insurance under M.G.L. c. 175, a
				fraternal benefit society licensed under M.G.L. c. 176, a non-profit hospital
				service corporation organized under M.G.L. c. 176A, a medical service
				corporation organized under M.G.L. c. 176B, a dental service corporation
				organized under M.G.L. c. 176E, and an optometric service corporation organized
				under M.G.L. c. 176F.
Class
means underwriting and rating
				classifications used when a policy was originally issued.
Commissioner
means the Commissioner of
				Insurance, appointed pursuant to M.G.L. c. 26, § 6, or his or her
				designee.
Elimination Period
means the number of
				days during which services are provided to an insured person or during which
				the insured person is unable to work because of accident or sickness before the
				insurance policy begins to pay benefits.
Medicare
means the program established
				under Title XVIII of the federal Social Security Act, "Health Insurance for the
				Aged Act",
				42 USCS §
									1395
et seq
.
Policy
means any policy, plan,
				certificate, contract, agreement, statement of coverage, rider or endorsement
				which provides insurance benefits whether as a service or on an indemnity
				reimbursement or prepaid basis.
Pre-existing Condition
means a medical
				condition for which an insured person received medical advice or treatment
				during a period to be determined by the carrier prior to the effective date of
				coverage or because of which an individual had symptoms which would have led an
				ordinarily prudent person to seek medical advice or treatment for that medical
				condition, or a pregnancy existing on the effective date of coverage.
Sickness
must be defined to be no more
				restrictive than a sickness or disease of an insured person that first
				manifests itself after the effective d ate of insurance and while the insurance
				is in force. The definition may be modified to exclude sickness or disease for
				which benefits are provided under any workmen's compensation, occupational
				disease, employer's liability, or similar law.