Terms Used In South Carolina Code > Title 38 > Chapter 74 - Health Insurance Pool

• Accident and health insurance: means insurance of human beings against death or personal injury by accident, and each insurance of human beings against sickness, ailment, and any type of physical disability resulting from accident or disease, and prepaid dental service, but not including coverages required by the Workers' Compensation Law of this State. See South Carolina Code 38-1-20
• Admitted assets: means assets of an insurer considered admitted on the most recent statutory financial statement of the insurer filed with the department pursuant to § 38-13-80. See South Carolina Code 38-1-20
• Advice and consent: Under the Constitution, presidential nominations for executive and judicial posts take effect only when confirmed by the Senate, and international treaties become effective only when the Senate approves them by a two-thirds vote.
• Affiliation period: means a period which, under the terms of the health insurance coverage offered by a health maintenance organization, must expire before the health insurance coverage becomes effective. See South Carolina Code 38-74-10
• Appointment: means an individual designated by an official or authorized representative of an authorized insurer to act on its behalf as a producer. See South Carolina Code 38-1-20
• Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
• Beneficiary: has the meaning given under Section 3(8) of the Employee Retirement Income Security Act of 1974. See South Carolina Code 38-74-10
• Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. ^{Source: OCC}
• Board: means the board of directors of the pool. See South Carolina Code 38-74-10
• Church plan: has the meaning given the term under Section 3(33) of the Employee Retirement Income Security Act of 1974. See South Carolina Code 38-74-10
• COBRA continuation provision: means :
  
  (a) Part 6 of subtitle B of Title I of the Employee Retirement Income Security Act of 1974, other than Section 609 of the act;
  
  (b) Section 4908B of the Internal Revenue Code of 1986, other than subsection (f)(1) of the section insofar as it relates to pediatric vaccines; or
  
  (c) Title XXII of the Public Health Service Act. See South Carolina Code 38-74-10
• Coinsurance: means a stipulation or requirement that the insured undertakes to be his own insurer to the extent that he fails to maintain insurance of a given percentage of the value of the property against loss or damage. See South Carolina Code 38-1-20
• Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
• Contract: A legal written agreement that becomes binding when signed.
• Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
• Creditable coverage: means , with respect to an individual, coverage of the individual under:
  
  (a) a group health plan;
  
  (b) health insurance;
  
  (c) Part A or B of Title XVIII of the Social Security Act;
  
  (d) Title XIX of the Social Security Act, other than coverage consisting solely of benefits under Section 1928;
  
  (e) Chapter 55 of Title 10 of the United States Code;
  
  (f) a medical care program of the Indian Health Service or of a tribal organization;
  
  (g) a state health benefits risk pool, including the South Carolina Health Insurance Pool;
  
  (h) a health plan offered under Chapter 89 of Title 5 of the United States Code;
  
  (i) a public health plan, as defined in regulations;
  
  (j) a health benefit plan under Section 5(e) of the Peace Corps Act (22 U. See South Carolina Code 38-74-10
• Department: means the South Carolina Insurance Department. See South Carolina Code 38-74-10
• Designee or deputy director: means the person or persons appointed by the director, serving at the will and pleasure of the director as his designee, to supervise and carry out the functions and duties of the department as provided by law. See South Carolina Code 38-1-20
• Director: means the person who is appointed by the Governor upon the advice and consent of the Senate and who is responsible for the operation and management of the Department of Insurance, including all of its divisions. See South Carolina Code 38-74-10
• Employee: has the meaning given the term under Section 3(6) of the Employee Retirement Income Security Act of 1974. See South Carolina Code 38-74-10
• Enrollment date: means , with respect to an individual covered under a group health plan or health insurance coverage, the date of enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period for the enrollment. See South Carolina Code 38-74-10
• Equitable: Pertaining to civil suits in "equity" rather than in "law." In English legal history, the courts of "law" could order the payment of damages and could afford no other remedy. See damages. A separate court of "equity" could order someone to do something or to cease to do something. See, e.g., injunction. In American jurisprudence, the federal courts have both legal and equitable power, but the distinction is still an important one. For example, a trial by jury is normally available in "law" cases but not in "equity" cases. ^{Source: U.S. Courts}
• Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
• Federally defined eligible individual: means an individual:
  
  (a) for whom, as of the date on which the individual seeks coverage under this chapter, the aggregate of the periods of creditable coverage is eighteen or more months;
  
  (b) whose most recent prior creditable coverage was under a group health plan, governmental plan, or church plan or health insurance coverage offered in connection with one of these plans;
  
  (c) who is not eligible for coverage under a group health plan, part A or part B of Title XVIII of the Social Security Act, or a state plan under Title XIX of the Social Security Act or any successor program and who does not have other health insurance coverage;
  
  (d) with respect to whom the most recent coverage within the period of aggregate creditable coverage was not terminated based on a factor relating to nonpayment of premiums or fraud;
  
  (e) who, if offered the option of continuation coverage under a COBRA continuation provision or under a similar state program, elected the coverage; and
  
  (f) who, if the individual elected the continuation coverage, has exhausted the continuation coverage under the provision or program. See South Carolina Code 38-74-10
• Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
• Foreign limited partnership: means a partnership formed under the laws of any state other than this State and having as partners one or more general partners and one or more limited partners. See South Carolina Code 33-42-20
• Fraud: Intentional deception resulting in injury to another.
• General partner: means a person who has been admitted to a limited partnership as a general partner in accordance with the partnership agreement and named in the certificate of limited partnership as a general partner. See South Carolina Code 33-42-20
• Governmental plan: has the meaning given the term under Section 3(32) of the Employee Retirement Income Security Act of 1974 and any governmental plan established or maintained for its employees by the government of the United States or by an agency or instrumentality of the government. See South Carolina Code 38-74-10
• Group health insurance coverage: means , in connection with a group health plan, health insurance offered by an insurer in connection with the plan. See South Carolina Code 38-74-10
• Group health plan: means an employee welfare benefit plan, as defined in Section 3(1) of the Employee Retirement Income Security Act of 1974, to the extent that the plan provides medical care, 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. See South Carolina Code 38-74-10
• health insurance coverage: means benefits consisting of medical care provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care under a hospital or medical service policy or certificate, hospital, or medical service plan contract, or health maintenance organization contract offered by an insurer, except:
  
  (a) coverage only for accident or disability income insurance, or any combination thereof;
  
  (b) coverage issued as a supplement to liability insurance;
  
  (c) liability insurance, including general liability insurance and automobile liability insurance;
  
  (d) workers' compensation or similar insurance;
  
  (e) automobile medical payment insurance;
  
  (f) credit-only insurance;
  
  (g) coverage for on-site medical clinics;
  
  (h) other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits;
  
  (i) if offered separately:
  
  (i) limited scope dental or vision benefits;
  
  (ii) benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof;
  
  (iii) such other similar, limited benefits as are specified in regulations;
  
  (j) if offered as independent, noncoordinated benefits:
  
  (i) coverage only for a specified disease or illness; and
  
  (ii) hospital indemnity or other fixed indemnity insurance;
  
  (k) if offered as a separate insurance policy, coverage supplement to the coverage provided under Chapter 55 of Title 10 of the United States Code. See South Carolina Code 38-74-10
• Health maintenance organization: means an organization as defined in § 38-33-20(7). See South Carolina Code 38-74-10
• Hospital: means an institution operated pursuant to law under the supervision of a staff of duly licensed physicians which is primarily and continuously engaged in providing or operating, either on its premises or in facilities available to the public on a prearranged basis, medical, diagnostic, and major surgical facilities for the medical care and treatment of sick or injured persons on an inpatient basis for which a charge is made and provides twenty-four hour nursing service under the supervision of registered nurses. See South Carolina Code 38-74-10
• Individual market: means the market for health insurance coverage offered to individuals other than in connection with a group health plan. See South Carolina Code 38-74-10
• insurance: includes annuities. See South Carolina Code 38-1-20
• Insurance company: means an "insurer". See South Carolina Code 38-1-20
• Insured: means any individual resident of this State who is eligible to receive benefits from any insurer. See South Carolina Code 38-74-10
• Insurer: means any entity that provides health insurance in this State. See South Carolina Code 38-74-10
• Limited partner: means a person who has been admitted to a limited partnership as a limited partner in accordance with the partnership agreement. See South Carolina Code 33-42-20
• Medical care: means 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) amounts paid for transportation primarily for and essential to medical care referred to in subitem (a); and
  
  (c) amounts paid for insurance covering medical care referred to in subitems (a) and (b). See South Carolina Code 38-74-10
• Medicare: means Title XVIII of the Social Security Act, 42 U. See South Carolina Code 38-74-10
• Member: means each insurer participating in the pool. See South Carolina Code 38-74-10
• Net loss: means the excess of incurred claims plus expenses over the sum of earned premiums, accrued investment income, and other appropriate gains and losses. See South Carolina Code 38-74-10
• Participant: has the meaning given the term under Section 3(7) of the Employee Retirement Income Security Act of 1974. See South Carolina Code 38-74-10
• Partner: means a limited or general partner. See South Carolina Code 33-42-20
• Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
• Person: means a corporation, agency, partnership, association, voluntary organization, individual, or another entity, organization, or aggregation of individuals. See South Carolina Code 38-1-20
• Person: means a natural person, partnership, limited partnership (domestic or foreign), trust, estate, association, or corporation. See South Carolina Code 33-42-20
• Personal property: All property that is not real property.
• Plaintiff: The person who files the complaint in a civil lawsuit.
• Plan of operation: means the plan of operation of the pool, including articles, bylaws, and operating rules adopted by the board. See South Carolina Code 38-74-10
• Policy: means a contract of insurance. See South Carolina Code 38-1-20
• Pool: means the South Carolina Health Insurance Pool. See South Carolina Code 38-74-10
• Preexisting condition exclusion: means , with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for the coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before the date. See South Carolina Code 38-74-10
• Premium: means payment given in consideration of a contract of insurance. See South Carolina Code 38-1-20
• Qualified TAA eligible individual: means an individual who is eligible for the credit for health insurance costs under Section 35 of the Internal Revenue Code of 1986. See South Carolina Code 38-74-10
• Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
• Service of process: The service of writs or summonses to the appropriate party.
• Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
• State: means a state, territory, or possession of the United States, the District of Columbia, or the Commonwealth of Puerto Rico. See South Carolina Code 33-42-20
• Statute: A law passed by a legislature.
• Waiting period: means , with respect to a group health plan and an individual who is a potential participant or beneficiary in the plan, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan. See South Carolina Code 38-74-10