Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-40 - Policy definitions and terms

Current through Register Vol. 40, No. 24, July 15, 2024
No policy or certificate may be advertised, solicited or
				  issued for delivery in this Commonwealth as a Medicare supplement policy or
				  certificate unless such policy or certificate contains definitions or terms
				  which conform to the requirements of this section.
"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 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."
2. The definition may provide that injuries
				shall not include injuries for which benefits are provided or available under
				any workers' compensation, employers' 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" means for the purposes of
				  14VAC5-170-120, 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 Hospitals, 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 ( 42 USC § 1395
				  et seq.)," 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" 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 in the Medicare program.
"Sickness" shall not be defined to be more restrictive than
				  the following:
"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."
The definition may be further modified to exclude sicknesses
				  or diseases for which benefits are provided under any workers' compensation,
				  occupational disease, employers' liability or similar law.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of Virginia.