Conn. Agencies Regs. § 38a-528-3

Current through November 7, 2024

Section 38a-528-3 - Policy definitions and terms

No insurance policy or subscriber contract or certificate may be advertised, solicited or issued for delivery to any resident of this state as a long-term care policy or certificate unless the terms used in such policy, subscriber contract or certificate conform to the meanings given in this section.

(a) "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) Such definition may be further modified to exclude injuries for which benefits are provided under any workers' compensation, employers' liability or similar law, or the basic reparations benefits of a no-fault motor vehicle insurance plan.

(b) "Activities of daily living" means activities such as, for example, bathing, dressing, eating, toileting, and transferring from bed to chair.

(c) "Acute condition" means that the individual is medically unstable. Such an individual requires frequent monitoring by medical professionals such as physicians and registered nurses, in order to maintain his or her health status.

(d) "Adult day care" shall not be defined more restrictively than a program of services prescribed by a physician and provided by an organization that provides a program of adult day care outside the home which: is licensed in accordance with applicable state laws; has a full-time director; has one or more registered nurse (R.N.s) or licensed practical nurses (L.P.N.s) in attendance during operating hours for at least 4 hours a day; operates at least 5 days a week for a minimum of 6 hours a day; maintains a written record of medical services given to each client; and has established procedures for obtaining appropriate aid in the event of a medical emergency.

(e) "Convalescent Nursing Home," "Extended Care Facility," or "Skilled Nursing Facility" shall be defined in relation to its status, facilities and available services. A definition of such home or facility shall not be more restrictive than one requiring that it:

(1) be operated pursuant to law;

(2) be approved for payment of Medicare benefits or be qualified to receive such approval, if so requested;

(3) be primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under supervision of a duly licensed physician;

(4) provide continuous twenty-four hours a day nursing service by or under the supervision of a registered nurse (R.N.); and

(5) maintains a daily medical record of each patient. The definition of such home or facility may provide that such term shall not be inclusive of:

(1) any home, facility or part thereof used primarily for rest;

(2) a home or facility for the aged or for the care of drug addicts or alcoholics; or

(3) a home or facility primarily used for the care and treatment of mental disease or disorders, or custodial or educational care.

(f) "Custodial care" shall not be defined more restrictively than care which is (1) provided primarily to assist the insured in the activities of daily living; (2) can be provided without professional skills or training; and (3) could not be omitted without adversely affecting the insured's physical or mental condition.

(g) A "custodial or intermediate nursing home" is an institution which:

(1) is licensed as a nursing home or operated under the law as a nursing home or a hospice;

(2) operates primarily to provide nursing care for which a charge is made for three or more persons;

(3) provides continuous nursing care under the supervision of a licensed registered nurse (R.N.), a licensed practical nurse (L.P.N.) or a licensed physician;

(4) is not a hospital or clinic;

(5) is not a home for the aged or mentally ill, a rest home, a community living center, or a place that provides domiciliary, residency, or retirement care; and

(6) is not a facility which operates primarily for the treatment of alcoholics or drug addicts, even if it is a section of a nursing home.

(h) "Home health care services" shall not be defined more restrictively than medical and non-medical services, provided to ill, disabled or infirm persons who reside at home. Such services may include, for example, homemaker/home health aide services, personal care services, adult day care, respite care services and hospice care services.

(i) "Hospice Care" shall not be defined more restrictively than a program that:

(1) provides support and care to an insured who is terminally ill, with no reasonable prospect of cure, and who has a life expectancy of 6 months or less as estimated by a physician;

(2) is prescribed by and under the direction of a physician;

(3) is provided by an organization that meets applicable federal or state requirements for certification or licensing as a hospice care organization. Hospice Care may be defined to exclude services provided to someone other than the insured.

(j) "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.

(1) The definition of the term "hospital" shall not be more restrictive than one requiring that the hospital:

(A) be an institution operated pursuant to law; and

(B) be primarily and continuously engaged in providing or operating, either on its premises or in facilities available to the hospital on a prearranged basis and under the supervision of a staff of duly licensed physicians, 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

(C) provide twenty-four hour nursing service by or under the supervision of registered nurses (R.N.s).

(2) The definition of the term "hospital" may state that such term shall not be inclusive of:

(A) convalescent homes, convalescent, rest, or nursing facilities;

(B) facilities primarily affording custodial, educational or rehabilitive care;

(C) facilities for the aged, drug addicts or alcoholics; or

(D) any military or veterans' or soldiers' home or any hospital contracted or operated by any national government or agency thereof for the treatment of members or former members of the armed forces, except for services rendered on an emergency basis where a legal liability exists for charges made to the individual for such services.

(k) "Loss of Functional Capacity" shall mean that the insured requires care to assist in meeting day-to-day living requirements such as, but not limited to, eating, bathing and dressing.

(l) "Medicare" shall be defined as "The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended," 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.

(m) "Mental or Nervous Disorders" shall not be defined more restrictively than a definition including neuroses, psychoneurosis, psychopathy, psychosis or mental or emotional disease or disorder of any kind, except that Alzheimer's disease shall not be considered a mental or nervous disorder.

(n) "Necessary Care for Confinement in the Insured's Own Home" shall not be defined more restrictively than home health care services provided to an insured who has suffered a loss of functional capacity.

(o) "Necessary Care for Confinement in a Nursing Home" shall not be defined more restrictively than admitted upon recommendation of a physician, other than the proprietor or employee of the skilled nursing care facility, for care which is medically necessary and which is not at first custodial or intermediate in nature but may, after admission, be reduced to a level that is primarily custodial or intermediate.

(p) "One Period of Confinement" means consecutive days of confinement; it shall be deemed to include successive periods of confinement which are due to the same or related cause and are not separated by at least ninety (90) days during which the covered person is not confined whether at home or in an institution for either skilled nursing care, intermediate or custodial care.

(q) "Personal care" means the provision of hands-on services to assist an individual with activities of daily living.

(r) "Physician" shall be defined as a person who is licensed by the state in which he or she practices to give treatment for which benefits are provided under the policy and who is acting within the scope of his or her license.

(s) "Sickness or Illness" shall not be defined more restrictively than the following: Sickness or illness means 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 diseases for which benefits are provided under any workers' compensation, employers' liability or similar law.

Conn. Agencies Regs. § 38a-528-3

Effective September 30, 1994