Utah Code 31A-22-605. Accident and health insurance standards
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(1) The purposes of this section include:
Terms Used In Utah Code 31A-22-605
- Accident and health insurance: means insurance to provide protection against economic losses resulting from:(1)(a)(i) a medical condition including:(1)(a)(i)(A) a medical care expense; or(1)(a)(i)(B) the risk of disability;(1)(a)(ii) accident; or(1)(a)(iii) sickness. See Utah Code 31A-1-301
- Application: means a document:
(10)(a)(10)(a)(i) completed by an applicant to provide information about the risk to be insured; and(10)(a)(ii) that contains information that is used by the insurer to evaluate risk and decide whether to:(10)(a)(ii)(A) insure the risk under:(10)(a)(ii)(A)(I) the coverage as originally offered; or(10)(a)(ii)(A)(II) a modification of the coverage as originally offered; or(10)(a)(ii)(B) decline to insure the risk; or(10)(b) used by the insurer to gather information from the applicant before issuance of an annuity contract. See Utah Code 31A-1-301- Certificate: means evidence of insurance given to:
(23)(a) an insured under a group insurance policy; or(23)(b) a third party. See Utah Code 31A-1-301- Direct response insurance policy: means an insurance policy solicited and sold without the policyholder having direct contact with a natural person intermediary. See Utah Code 31A-1-301
- Form: means one of the following prepared for general use:
(74)(a)(i) a policy;(74)(a)(ii) a certificate;(74)(a)(iii) an application;(74)(a)(iv) an outline of coverage; or(74)(a)(v) an endorsement. See Utah Code 31A-1-301- health insurance: means insurance providing:
(84)(a)(i) a health care benefit; or(84)(a)(ii) payment of an incurred health care expense. See Utah Code 31A-1-301- Indemnity: means the payment of an amount to offset all or part of an insured loss. See Utah Code 31A-1-301
- Individual: means a natural person. See Utah Code 31A-1-301
- Insurance: includes :
(96)(b)(i) a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;(96)(b)(ii) a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and(96)(b)(iii) a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301- Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy and includes:
(103)(a)(i) a policyholder;(103)(a)(ii) a subscriber;(103)(a)(iii) a member; and(103)(a)(iv) a beneficiary. See Utah Code 31A-1-301- Medicare: means the "Health Insurance for the Aged Act" Title XVIII of the federal Social Security Act, as then constituted or later amended. See Utah Code 31A-1-301
- Medicare supplement insurance: means health insurance coverage that is advertised, marketed, or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical, or surgical expenses of individuals eligible for Medicare. See Utah Code 31A-1-301
- Outline of coverage: means a summary that explains an accident and health insurance policy. See Utah Code 31A-1-301
- Policy: includes a service contract issued by:
(150)(b)(i) a motor club under Chapter 11, Motor Clubs;(150)(b)(ii) a service contract provided under Chapter 6a, Service Contracts; and(150)(b)(iii) a corporation licensed under:(150)(b)(iii)(A) Chapter 7, Nonprofit Health Service Insurance Corporations; or(150)(b)(iii)(B) Chapter 8, Health Maintenance Organizations and Limited Health Plans. See Utah Code 31A-1-301- Policyholder: means a person who controls a policy, binder, or oral contract by ownership, premium payment, or otherwise. See Utah Code 31A-1-301
- Premium: includes , however designated:
(156)(b)(i) an assessment;(156)(b)(ii) a membership fee;(156)(b)(iii) a required contribution; or(156)(b)(iv) monetary consideration. See Utah Code 31A-1-301- 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: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
(1)(a) reasonable standardization and simplification of terms and coverages of individual and franchise accident and health insurance policies, including accident and health insurance contracts of insurers licensed under Chapter 7, Nonprofit Health Service Insurance Corporations, and Chapter 8, Health Maintenance Organizations and Limited Health Plans, to facilitate public understanding and comparison in purchasing;(1)(b) elimination of provisions contained in individual and franchise accident and health insurance contracts that may be misleading or confusing in connection with either the purchase of those types of coverages or the settlement of claims; and(1)(c) full disclosure in the sale of individual and franchise accident and health insurance contracts.(2) This section applies to all individual and franchise accident and health policies.(3) The commissioner shall adopt rules, made in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, relating to the following matters:(3)(a) standards for the manner and content of policy provisions, and disclosures to be made in connection with the sale of policies covered by this section, dealing with at least the following matters:(3)(a)(i) terms of renewability;(3)(a)(ii) initial and subsequent conditions of eligibility;(3)(a)(iii) nonduplication of coverage provisions;(3)(a)(iv) coverage of dependents;(3)(a)(v) preexisting conditions;(3)(a)(vi) termination of insurance;(3)(a)(vii) probationary periods;(3)(a)(viii) limitations;(3)(a)(ix) exceptions;(3)(a)(x) reductions;(3)(a)(xi) elimination periods;(3)(a)(xii) requirements for replacement;(3)(a)(xiii) recurrent conditions;(3)(a)(xiv) coverage of persons eligible for Medicare; and(3)(a)(xv) definition of terms;(3)(b) minimum standards for benefits under each of the following categories of coverage in policies covered in this section:(3)(b)(i) basic hospital expense coverage;(3)(b)(ii) basic medical-surgical expense coverage;(3)(b)(iii) hospital confinement indemnity coverage;(3)(b)(iv) major medical expense coverage;(3)(b)(v) income replacement coverage;(3)(b)(vi) accident only coverage;(3)(b)(vii) specified disease or specified accident coverage;(3)(b)(viii) limited benefit health coverage; and(3)(b)(ix) nursing home and long-term care coverage;(3)(c) the content and format of the outline of coverage, in addition to that required under Subsection (5);(3)(d) the method of identification of policies and contracts based upon coverages provided; and(3)(e) rating practices.(4) Nothing in Subsection (3)(b) precludes the issuance of policies that combine categories of coverage in Subsection (3)(b) provided that any combination of categories meets the standards of a component category of coverage.(5) The commissioner may adopt rules, made in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, relating to the following matters:(5)(a) establishing disclosure requirements for insurance policies covered in this section, designed to adequately inform the prospective insured of the need for and extent of the coverage offered, and requiring that this disclosure be furnished to the prospective insured with the application form, unless it is a direct response insurance policy;(5)(b)(5)(b)(i) prescribing caption or notice requirements designed to inform prospective insureds that particular insurance coverages are not Medicare supplement insurance; and(5)(b)(ii) applying the requirements of Subsection (5)(b)(i) to all insurance policies and certificates sold to persons eligible for Medicare; and(5)(c) requiring the disclosures or information brochures to be furnished to the prospective insured on direct response insurance policies, upon his request or, in any event, no later than the time of the policy delivery.(6) A policy covered by this section may be issued only if it meets the minimum standards established by the commissioner under Subsection (3), an outline of coverage accompanies the policy or is delivered to the applicant at the time of the application, and, except with respect to direct response insurance policies, an acknowledged receipt is provided to the insurer. The outline of coverage shall include:(6)(a) a statement identifying the applicable categories of coverage provided by the policy as prescribed under Subsection (3);(6)(b) a description of the principal benefits and coverage;(6)(c) a statement of the exceptions, reductions, and limitations contained in the policy;(6)(d) a statement of the renewal provisions, including any reservation by the insurer of a right to change premiums;(6)(e) a statement that the outline is a summary of the policy issued or applied for and that the policy should be consulted to determine governing contractual provisions; and(6)(f) any other contents the commissioner prescribes.(7) If a policy is issued on a basis other than that applied for, the outline of coverage shall accompany the policy when it is delivered and it shall clearly state that it is not the policy for which application was made.(8)(8)(a) Notwithstanding Subsection31A-22-606 (1), limited accident and health policies or certificates issued to persons eligible for Medicare shall contain a notice prominently printed on or attached to the cover or front page which states that the policyholder or certificate holder has the right to return the policy for any reason within 30 days after its delivery and to have the premium refunded.(8)(b) This Subsection (8) does not apply to a policy issued to an employer group. - Application: means a document: