Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 1 - Minimum Standards for Health Benefit Plans (230-RICR-20-30-1) › Section 230-RICR-20-30-1.7 - Individual Health Benefit Contracts

Current through June 14, 2024
1.7.1
Purpose, Applicability, and Definitions
A. The purpose of this part is to provide
				  reasonable standardization and simplification of terms and coverages of
				  individual health benefit contracts in order to facilitate public understanding
				  and comparison and to eliminate provisions contained in individual health
				  benefit contracts which may be misleading or confusing in connection either
				  with the purchase of such coverages or with the settlement of claims and to
				  provide for full disclosure in the sale of such coverages.
B. This part shall apply to all individual
				  health benefit contracts delivered or issued for delivery in this state on or
				  after the effective date hereof, except it shall not apply to individual health
				  benefit contracts issued pursuant to a conversion privilege under a group
				  health benefit contract or individual health benefit contract when such group
				  or individual contract includes provisions which are inconsistent with the
				  requirements of this Part, nor to health benefit contracts being issued to
				  employees or members as additions to franchise plans in existence on the
				  effective date of this Part. Neither shall this part apply to health benefit
				  contracts issued by a health maintenance organization which has been certified
				  as a health maintenance organization by the United States Secretary of Health,
				  Education and Welfare for purposes of compliance with Section  1310   of Public
				  Law 93-222 nor shall it apply to health benefit contracts issued by a health
				  maintenance organization which has been certified as a health maintenance
				  organization by the State of Rhode Island Director of Health for purposes of
				  compliance with R.I. Gen. Laws §
											42-62-9. The requirements
				  contained in this Part shall be in addition to any other applicable laws and
				  regulations.
C. Except as provided
				  hereafter, no individual health benefit contract delivered or issued for
				  delivery to any person in this State shall contain definitions respecting the
				  matters set forth below unless such definitions comply with the requirements of
				  §
											1.7.1   of this Part.
1. "Accident,"
				  "Accidental Injury," "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.
a. 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 which is the direct cause, independent of
				  disease or bodily infirmity or any other cause and occurs while the insurance
				  is in force.
b. Such definition may
				  provide that injuries shall not include injuries for which benefits are
				  provided under any workmen's compensation, employer's liability or similar law,
				  motor vehicle no fault plan, unless prohibited by law, or injuries occurring
				  while the insured person is engaged in any activity pertaining to any trade,
				  business, employment or occupation for wage or profit.
2. "Convalescent Nursing Home," "Extended
				  Care Facility," or "Skilled Nursing Facility" shall be defined in relation to
				  its status, facilities and available services and, only with respect to
				  insurers permitted to contract with convalescent nursing homes, extended care
				  facilities or skilled nursing facilities under R.I. Gen. Laws Chapter 27-19
				  such facilities may be defined to include only "contracting" facilities with
				  which the insurer or another insurer with similar powers in another state has
				  made a contract for the provision of services to its subscribers.
a. A definition of such home or facility
				  shall not be more restrictive than one requiring that it:
(1) Be operated pursuant to law and, with
				  respect to insurers permitted to contract with such facilities, be a
				  contracting facility;
(2) Be
				  approved for payment of Medicare benefits or be qualified to receive such
				  approval, if so requested;
(3) Be
				  primarily engaged in providing, in addition to room and board accommodations,
				  skilled nursing care under the supervision of a duly licensed
				  physician;
(4) Provide continuous
				  twenty-four (24) hour a day nursing service by or under the supervision of a
				  registered graduate professional nurse (R.N.);
(5) Maintain a daily medical record of each
				  patient.
b. The
				  definition of such home or facility may provide that such term shall not be
				  inclusive of:
(1) Any home, facility or part
				  thereof used primarily for rest;
(2) A home of facility for the aged or for
				  the care of drug addicts or alcoholics; or
(3) A home or facility primarily used for the
				  care and treatment of mental diseases or disorders or for custodial or
				  educational care.
3. "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 and, only with respect to
				  insurers permitted to contract with hospitals under R.I. Gen. Laws §
												27-19-5"hospital" may be defined
				  to include only "contracting" hospitals with which the insurer or another
				  insurer with similar powers in another state has made a contract for the
				  provision of services to its subscribers.
a.
				  The definition of the term "hospital" shall not be more restrictive than one
				  requiring that the hospital:
(1) Be an
				  institution operated pursuant to law and, with respect to insurers permitted to
				  contract with hospitals, be a contracting hospital; and
(2) Be primarily and continuously engaged in
				  providing or operating either on its premises or in facilities available to the
				  hospital on a prearranged basis and under the supervision of a staff of duly
				  licensed physicians, medical, diagnostic and major surgical facilities for the
				  medical care and treatment of sick or injured persons on an in-patient basis
				  for which a charge is made; and
(3)
				  Provide twenty-four (24) hour nursing service by or under the supervision of
				  registered graduate professional nurses (R.N.'s).
b. The definition of the term "hospital" may
				  state that such term shall not be inclusive of:
(1) Convalescent homes, convalescent, rest or
				  nursing facilities; or
(2)
				  Facilities primarily affording custodial, educational or rehabilitory care;
				  or
(3) Facilities for the aged,
				  drug addicts, or alcoholics; or
(4)
				  Any military or veterans hospital or soldiers home or any hospital contracted
				  for or operated by any national government or agency thereof for the treatment
				  of members or ex-members of the armed forces, except for services rendered on
				  an emergency basis where a legal liability exists for charges made to the
				  individual for such services, except that, with respect to "Hospital
				  Confinement Indemnity Coverage," the same benefits must be provided for the
				  first thirty five (35) days of any one confinement in any of the above
				  government hospitals as is provided for confinement in any other hospital.
				  Benefits for confinement in any of the above government hospitals may be
				  reduced after the 35th day of confinement to no less than 2/3 of the benefit
				  payable for confinement in any other hospital.
4. "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 Laws 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.
5. "Mental or
				  Nervous Disorders" shall not be defined more restrictively than a definition
				  including neurosis, psychoneurosis, psychopathy, psychosis, or mental or
				  emotional disease or disorder of any kind.
6. "Nurses" may be defined so that the
				  description of nurse is restricted to a type of nurse, such as a registered
				  graduate professional nurse (R.N.), a licensed practical nurse (L.P.N.), or a
				  licensed vocational nurse (L.V.N.). If the words "nurse," "trained nurse," or
				  "registered nurse" are used without specific instruction, then the use of such
				  terms requires the insurer to recognize the services of any individual who
				  qualifies under such terminology in accordance with R.I. Gen. Laws Chapter 5-34
				  and any administrative rules of the Board of Nursing Registration and Nursing
				  Education or in accordance with similar laws or rules of other
				  states.
7. "One period of
				  confinement" means consecutive days of in-hospital service received as an
				  in-patient, or successive confinements when discharge from and readmission to
				  the hospital occurs within a period of time not more than ninety (90) days or
				  three (3) times the maximum number of days of in-hospital coverage provided by
				  the policy to a maximum of one hundred eighty (180) days.
8. "Physician" may be defined by including
				  words such as "legally qualified physician" or "legally licensed physician."
				  The use of such terms requires an insurer to recognize and to accept, to the
				  extent of its obligation under the contract, all providers of medical care and
				  treatment when such services are within the scope of the provider's licensed
				  authority and are provided pursuant to applicable laws, except to the extent
				  provided to the contrary in R.I. Gen. Laws Title 27.
9. "Pre-Existing Condition" shall not be
				  defined to be more restrictive than the following: Pre-existing condition means
				  the existence of symptoms which would cause an ordinarily prudent person to
				  seek diagnosis, care or treatment within a thirty six (36) month period
				  preceding the effective date of the coverage of the insured person; or a
				  condition for which medical advice or treatment was recommended by a physician
				  or received from a physician within a thirty six (36) month period preceding
				  the effective date of coverage of the insured person.
a. This definition does not prohibit an
				  insurer, using an application form designed to elicit the complete health
				  history of a prospective insured and on the basis of the answers on that
				  application, from underwriting in accordance with that insurer's established
				  standards. It is assumed that an insurer that elicits a complete health history
				  of a prospective insured will act on the information and if the review of the
				  health history results in a decision to exclude a condition, the policy will be
				  endorsed or amended by including the specific exclusion. This same requirement
				  of notice to the prospective insured of the specific exclusion will also apply
				  to insurers which elect to use simplified application forms containing
				  questions relating to the prospective insured's health.
b. This definition does, however, prohibit an
				  insurer that elects to use a simplified application, with or without a question
				  as to the applicant's health at the time of application, from reducing or
				  denying a claim on the basis of the existence of a pre-existing condition that
				  is defined more restrictively than above.
10. "Sickness" shall not be defined to be
				  more restrictive than the following: Sickness means sickness or disease of an
				  insured person which first manifests itself after the effective date of the
				  insurance and while the insurance is in force. A definition of sickness may
				  provide for a probationary period which will not exceed thirty (30) days from
				  the effective date of the coverage of the insured person. The definition may be
				  further modified to exclude sickness or accident for which benefits are
				  provided under any workman's compensation, occupational disease, employer's
				  liability or similar law.