Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.4 - Policy Definitions and Terms

Current through Register Vol. 47, No. 3, July 24, 2024
No policy or certificate may be advertised, solicited or
				  issued for delivery in this state as a Medicare supplement policy or
				  certificate unless such policy or certificate contains definitions or terms
				  which conform to the requirements of this rule.
"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.
1.
				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 covered individual 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."
2.
				Such 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 by Medicare.
"Convalescent nursing home," "extended care
				  facility,"
or
"skilled nursing facility"
shall not be
				  defined more restrictively than as defined by Medicare.
"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 Hospitals, but not more restrictively
				  than as defined by Medicare.
"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 Pub. L. No. 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"
shall mean
				  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 by Medicare.
"Sickness"
shall not be defined to be more
				  restrictive than the following: "Sickness means illness or disease of a covered
				  individual 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.