211 CMR, § 55.04
As used in 211 CMR 55.00, the following words mean:
Accelerated Benefit Product: a provision in, or rider to, any policy of individual or group life insurance delivered or issued for delivery in Massachusetts under which benefits that reduce the otherwise payable death benefit of the policy are payable to a policyholder or certificateholder, during the lifetime of the insured, in the event the insured becomes totally and permanently disabled, as defined in 211 CMR 55.04.
Activities of Daily Living: eating, toileting, transferring, bathing, dressing, and continence.
Carrier: a commercial insurance company licensed to issue life insurance policies under M.G.L. c.175 or a fraternal benefit society licensed under M.G.L. c. 176.
Chronic Illness: a condition because of which an individual has been certified by a licensed health care practitioner as:
(a) being unable to perform (without substantial assistance from another individual) at least two Activities of Daily Living for a period of at least 90 days due to a loss of functional capacity;
(b) having a level of disability similar to the level of disability described in 211 CMR 55.04: Chronic Illness (a); or
(c) requiring substantialsupervision to protect such individual from threats to health and safety due to severe cognitive impairment.
Such term shall not include conditions otherwise meeting these requirements unless within the preceding 12-month period a licensed health care practitioner has certified that such individual meets such requirements.
Commissioner: the Commissioner of Insurance appointed pursuant to M.G.L. c. 26, § 6 or his or her designee.
Licensed Health Care Practitioner: any physician (asdefined insection 1861(r)(1) of the federal Social Security Act) and any registered professional nurse, licensed social worker or other individual who meets such requirements as may be prescribedbythe federal Secretary of Health and Human Services, or as defined in the federal Health Insurance Portabilityand Accountability Act or any successor law or anyregulationpromulgatedthereunder. The Licensed Health Care Practitioner must be acting within the scope of his or her license in the state of licensure when providing covered services or performing actions required by the contract.
Medicaid: the medical assistance program administered by the Massachusetts Division of Medical Assistance pursuant to M.G.L. c. 118E and Title XIX of the federal Social Security Act, 42 USCS 1396, et seq.
Medicare: the federal health insurance program established under Title XVIII of the federal Social Security Act, "Health Insurance for the Aged Act," 42 USCS 1395 et seq.
Policy: any policy, plan, certificate, contract, agreement, statement of coverage, amendment, rider or endorsement that provides insurance benefits.
Policyholder:
(a) the named insured under a life insurance policy or the owner of the policy if not the named insured;
(b) in the case of a group life insurance policy, the group life insurance certificateholder; or
(c) the contract holder, in the case of an annuity contract.
Qualified Long-term Care Services: the necessary diagnostic, preventive, therapeutic, curing, treating, mitigating and rehabilitative services, and maintenance or personal care services that are required by a chronically ill individualand are provided pursuant to a plan of care prescribed by a licensed health care practitioner.
Special Benefits: benefits including, but not limited to:
(a) the acceleration of the death benefit in life insurance policies, as well as payments made over and above the accelerated benefit for expenses incurred for Qualified Long-Term Care Services in policies providing benefits for conditions of Chronic Illness only, or
(b) the waiver of the surrender charge for early withdrawal of annuity proceeds in annuity contracts.
Supplemental Security Income: the entitlement program under Title XVI, § 1601, 42 USCS 1381, et seq.
Terminal Illness: a condition that a physician certifies will reasonably be expected to result in a drastically limited life span as specified in the contract, for example, of 24 months or less.
Total and Permanent Disability: any of the following conditions as specified in the policy:
(a) terminal illness, as defined in 211 CMR 55.04;
(b) chronic illness, as defined in 211 CMR 55.04;
(c) a medical condition, including but not limited to one of the following specifically named or described conditions, which the insured's physician certifies has required or will require extraordinary medical intervention without which the insured would have died, or will die:
1. Acquired Immune Deficiency Syndrome;
2. Coronary artery disease resulting in acute infarction or requiring surgery;
3. End-stage Renal Disease;
4. Major organ transplant;
5. Medical condition requiring continuous life support; or
6. Permanent neurological deficit resulting from cerebral vascular accident; or
(d) other qualifying conditions that meet the definition in 211 CMR 55.04: Total and Permanent Disability (c) and that are approved by the Commissioner for any particular filing.
211 CMR, § 55.04