Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES › Section 3.3002 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
(a) Unless otherwise provided by law or this
				  subchapter, every individual accident and sickness insurance policy or
				  subscriber contract that is subject to the provisions of this subchapter and
				  that is delivered, issued for delivery or renewed on or after the effective
				  date of this subchapter must comply with and contain definitions in conformance
				  with those in subsection (b) of this subchapter.
(b) The following words and terms, when used
				  in this subchapter, shall have the following meanings, unless the context
				  clearly indicates otherwise:
(1) Aggregate
				  period--Cumulative total of all time covered under creditable coverage without
				  a significant break in coverage.
(2) Church plan--A plan within the meaning of
				  §3(33) of the Employee Retirement and Income Security Act of 1974,
				  codified at
				  29 USC
				  1001, et seq. (ERISA).
(3) Commissioner--The commissioner of
				  insurance of the State of Texas.
(4) Creditable coverage--As used in this
				  subchapter, is defined as stated in §
											21.1101 of
				  this title (relating to Definitions) of Chapter 21, Subchapter K of this title
				  (relating to Certification of Creditable Coverage).
(5) Department--The Texas Department of
				  Insurance.
(6) Excepted benefits--
(A) Under all circumstances:
(i) Coverage only for accident, including
				  accidental death and dismemberment, such as coverage offered in accordance with
				  §
													3.3076
				  of this title (relating to Minimum Standards for Accident Only
				  Coverage);
(ii) Disability income
				  insurance, including coverage offered in accordance with §
													3.3075
				  of this title (relating to Minimum Standards for Disability Income Protection
				  Coverage);
(iii) Coverage for
				  on-site medical clinics; and
(iv)
				  Short-term limited duration coverage.
(B) Only if the benefits are provided under a
				  separate policy or contract of insurance:
(i)
				  Dental or vision benefits that are limited in scope to a narrow range or type
				  of benefits and that are generally excluded from policies that combine
				  hospital, medical, or surgical benefits.
(ii) Coverage only for a specified disease or
				  illness (for example, cancer policies), or hospital indemnity or other fixed
				  indemnity insurance (for example, "Hospital Confinement Indemnity Coverage," as
				  defined in §
													3.3073
				  of this title (relating to Minimum Standards for Hospital Confinement Indemnity
				  Coverage), provided that:
(I) there is no
				  coordination between the provision of benefits and benefits provided under any
				  other policy; and
(II) benefits are
				  paid with respect to a covered event regardless of whether benefits are
				  provided with respect to the same event under any other policy;
(iii) coverage supplemental to the
				  coverage provided under Chapter 55, Title 10, United States Code (also known as
				  CHAMPUS supplemental programs) and similar coverage supplemental to coverage
				  under a group health plan.
(7) Genetic information--Information derived
				  from the results of a genetic test.
(8) Genetic test--A laboratory test of an
				  individual's deoxyribonucleic acid (DNA), ribonucleic acid (RNA), proteins, or
				  chromosomes to identify by analysis the genetic mutations or alterations in the
				  DNA, RNA, proteins, or chromosomes that are associated with a predisposition
				  for a clinically recognized disease or disorder. The term does not include:
(A) a routine physical examination or a
				  routine test performed as a part of a physical examination;
(B) a chemical, blood or urine
				  analysis;
(C) a test to determine
				  drug use; or
(D) a test for the
				  presence of the human immunodeficiency virus.
(9) Governmental plan--A plan within the
				  meaning of §3(32) of ERISA.
(10) Group health plan--An "employee welfare
				  benefit plan," as defined in §3(1) of ERISA, to the extent that the plan
				  provides "medical care" (as defined in this subsection, and including items and
				  services paid for as medical care) to employees or their dependents (as defined
				  under the terms of the plan) directly, or through insurance, reimbursement or
				  otherwise.
(11) Health status
				  related factors--Health status; medical condition, including both physical and
				  mental illnesses; claims experience; receipt of health care; medical history;
				  genetic information; evidence of insurability, including conditions arising out
				  of acts of domestic violence; and disability.
(12) Individual hospital, medical or surgical
				  coverage--Coverage offered in all policies, contracts, riders or endorsements
				  subject to this subchapter, except when such coverage consists of "excepted
				  benefits," as defined in this subsection. Individual hospital, medical or
				  surgical coverage includes, but is not limited to, coverages described in
				  §§
											3.3071
				  of this title (relating to Minimum Standards for Basic Hospital Expense
				  Coverage), 3.3072 of this title (relating to Minimum Standards for Basic
				  Medical-Surgical Expense Coverage) and 3.3074 of this title (relating to
				  Minimum Standards Major Medical Expense Coverage), except when such coverages
				  consist of short term limited duration coverage, as defined in this
				  subsection.
(13) Insured--In
				  regards to policies subject to this subchapter, refers to the individual
				  policyholder, and, if applicable, any spouse or dependents covered under the
				  policy.
(14) Insurer--For the
				  purposes of this subchapter, any "issuer of a health benefit plan," as defined
				  in §
											21.1101 of
				  this title (relating to Definitions) of Chapter 21, Subchapter K of this title
				  (relating to Certification of Creditable Coverage).
(15) Medical care--Amounts paid for:
(A) The diagnosis, cure, mitigation,
				  treatment or prevention of disease, or amounts paid for the purpose of
				  affecting any structure or function of the body;
(B) transportation primarily for and
				  essential to the medical care described in subparagraph (A) of this paragraph;
				  or
(C) insurance covering medical
				  care described in either subparagraphs (A) or (B) of this paragraph.
(16) Policy--The entire contract
				  between the insurer and the insured, including the policy, riders, endorsements
				  and the application, if attached.
(17) Policy of accident and sickness
				  insurance--As used in this subchapter, includes any policy or contract
				  providing insurance against loss resulting from sickness or from bodily injury
				  or death by accident or both.
(18)
				  Short-term limited duration coverage--Health insurance coverage provided under
				  a contract with an insurer that has an expiration date specified in the
				  contract (taking into account any extensions that may be elected by the insured
				  without the insurer's consent) that is within 12 months of the date the
				  contract becomes effective.
(19)
				  Significant break in coverage--A period of more than 63 consecutive days during
				  all of which the individual does not have any creditable coverage. A waiting
				  period is not taken into account in determining a significant break in
				  coverage.
(20) Simplified
				  application form--An application form, with or without a question as to the
				  applicant's health at the time of application, but without any questions
				  concerning the insured's health history or medical treatment history.
(21) Waiting period--In regards to an
				  individual who seeks and obtains individual hospital, medical and surgical
				  coverage, the period between the date that the individual files a substantially
				  complete application for coverage and the first day the coverage is
				  effective.