Utah Code 31A-22-614. Claims under accident and health policies
Current as of: 2024 | Check for updates
|
Other versions
(1) Section 31A-21-312 applies generally to claims under accident and health policies.
Terms Used In Utah Code 31A-22-614
- 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
- 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
- Disability: means a physiological or psychological condition that partially or totally limits an individual's ability to:(51)(a) perform the duties of:(51)(a)(i) that individual's occupation; or(51)(a)(ii) an occupation for which the individual is reasonably suited by education, training, or experience; or(51)(b) perform two or more of the following basic activities of daily living:(51)(b)(i) eating;(51)(b)(ii) toileting;(51)(b)(iii) transferring;(51)(b)(iv) bathing; or(51)(b)(v) dressing. 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
- Indemnity: means the payment of an amount to offset all or part of an insured loss. 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
- Network provider: means a health care provider who has an agreement with a managed care organization to provide health care services to an enrollee with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly from the managed care organization. See Utah Code 31A-1-301
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- Person: includes :(146)(a) an individual;(146)(b) a partnership;(146)(c) a corporation;(146)(d) an incorporated or unincorporated association;(146)(e) a joint stock company;(146)(f) a trust;(146)(g) a limited liability company;(146)(h) a reciprocal;(146)(i) a syndicate; or(146)(j) another similar entity or combination of entities acting in concert. 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
(2)
(2)(a) Subject to Subsection (1), an accident and health insurance policy may not contain a claim notice requirement less favorable to the insured, or an insured’s network provider, than one which requires written notice of the claim within 20 days after the occurrence or commencement of any loss covered by the policy. The policy shall specify to whom claim notices may be given.
(2)(b) If a loss of time benefit under a policy may be paid for a period of at least two years, an insurer may require periodic notices that the insured continues to have a disability, unless the insured is legally incapacitated. The insured’s, or the insured’s network provider’s, delay in giving that notice does not impair the insured’s, the insured’s network provider’s, or beneficiary‘s right to any indemnity which would otherwise have accrued during the six months preceding the date on which that notice is actually given.
(3) An accident and health insurance policy may not contain a time limit on proof of loss which is more restrictive to the insured, or the insured’s network provider, than a provision requiring written proof of loss, delivered to the insurer, within the following time:
(3)(a) for a claim where periodic payments are contingent upon continuing loss, within 120 days after the termination of the period for which the insurer is liable; or
(3)(b) for any other claim, within 120 days after the date of the loss.
(4)
(4)(a)
(4)(a)(i) Section 31A-26-301 applies generally to the payment of claims.
(4)(a)(ii) Indemnity for loss of life is paid in accordance with the beneficiary designation effective at the time of payment. If no valid beneficiary designation exists, the indemnity is paid to the insured’s estate. Any other accrued indemnities unpaid at the insured’s death are paid to the insured’s estate.
(4)(b) Reasonable facility of payment clauses, specified by the commissioner by rule or in approving the policy form, are permitted. Payment made in good faith and in accordance with those clauses discharges the insurer’s obligation to pay those claims.
(4)(c) All or a portion of any indemnities provided under an accident and health policy on account of hospital, nursing, medical, or surgical services may, at the insurer’s option, be paid directly to the hospital or person rendering the services.