Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 5 - Regulation 33-Medicare Supplement Insurance Minimum Standards › Section XIII-504 - Policy Definitions and Terms

Current through Register Vol. 50, No. 6, June 20, 2024
A. No policy or certificate may be
				advertised, solicited or issued for delivery in this state as a Medicare
				supplement policy or certificate unless the policy or certificate contains
				definitions or terms, which conform to the requirements of this Section.
Accident, Accidental Injury, or Accidental
				  Means
-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 or description or
				  characterization.
a. The definition shall not be more restrictive than the
				  following.
NOTE: "Injury or injuries for which benefits are provided
				  means accidental bodily injury sustained by the insured person which is the
				  direct result of an accident, independent of disease or bodily infirmity or any
				  other cause, and occurs while insurance coverage is in force."
b. The 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.
Health Care Expenses
-for the purposes of
				  §545, expenses of health maintenance organizations associated with the delivery
				  of health care services, which expenses 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 on Accreditation of Healthcare Organizations, but not more
				  restrictively than as defined in the Medicare program.
Medicare
-shall be defined in the policy and
				  certificate. Medicare may be substantially defined as "The Health Insurance for
				  the Aged 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 Act, as then constituted
				  and any later amendments or substitutes thereof," or words of similar
				  import.
Medicare Eligible Expenses
-expenses of the
				  kinds covered by Medicare Parts A and B, to the extent recognized as reasonable
				  and medically necessary by Medicare.
Physician
-shall not be defined more
				  restrictively than as defined in the Medicare program.
Sickness
-shall not be defined to be more
				  restrictive than the following.
a. 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.
b. 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.
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:224 and  42 U.S.C. 1395  et
				  seq.