Section 69O-154.104 - Definition of Terms(1) Accident, accidental injury, accidental means:(a) The definition shall 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.(b) The definition shall not be more restrictive than the following: "injury or injuries for which benefits are provided means accidental bodily injuries sustained by the insured person which are the direct cause independently of disease, bodily infirmity or other cause of the loss and occur while the insurance is in force."(c) Such definitions may provide that injuries shall not include:1. Injuries for which benefits are provided under:a. Any workers' compensation, employers' liability or similar law; orb. Florida Automobile Reparations Reform Act (motor vehicle no-fault plan or similar law); or2. Injuries occurring while the insured person is engaged for wage or profit in any activity pertaining to any trade, business, employment or occupation.(2) "Categories of benefits" means the following benefits:(a) Mental health coverage;(b) Substance abuse coverage;(c) Prescription drug coverage;(d) Dental coverage; and,(3) Convalescent nursing home or extended care facility. The term "convalescent nursing home" or "extended care facility" (skilled nursing facility) may be defined in relation to its status, facilities and available services. (a) A definition 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 the supervision of a duly licensed physician;4. Provide continuous 24 hour a day nursing service by or under the supervision of a registered graduate professional nurse (R.N.); and,5. Maintain a daily medical record of each patient.(b) A the definition may provide that the term shall not include:1. Any home, facility or part thereof used primarily for rest;2. Any home or facility for the aged or for the care of drug addicts or alcoholics; or3. Any home or facility primarily used for the care and treatment of mental diseases or disorders or custodial or educational care.(4) "Earned first year premium" is the amount of gross premium to be paid by an insured for the twelve months of coverage, measured from the effective date of coverage and which is earned during the period of time being measured.(5) Hospital. The term "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 or the American Osteopathic Hospital Association.(a) The definition shall not be more restrictive than one requiring that the hospital: 1. Be an institution licensed as a hospital and operated pursuant to law;2. Be primarily and continuously engaged in providing or operating, either on its premises or in facilities controlled by the hospital, under the supervision of a staff of duly licensed physicians, medical, diagnostic and major surgery facilities for the medical care and treatment of sick or injured persons on an inpatient basis for which a charge is made; and,3. Provide 24 hour nursing service by or under the supervision of registered graduate professional nurses (R.N.'s).(b) The definition may state that the term shall not be inclusive of: 1. Any military or veteran's hospital or soldier's home or any hospital contracted for or operated by any national government or agency thereof for the treatment of members or ex-members of the armed forces;2. Convalescent homes, convalescent, rest, or nursing facilities; or3.a. Facilities for the aged, drug addicts, or alcoholics;b. Facilities primarily affording custodial, educational, or rehabilitory care; orc. Those primarily affording care for mental and nervous disorders.(6) "Medical advice, diagnosis, care or treatment" means advice, diagnosis, care or treatment recommended by, or received from an individual licensed or similarly authorized to provide such services under state law and operating within the scope of practice authorized by state law.(7) "Medical care or condition" means amounts paid for any of the following: (a) The diagnosis, cure, mitigation or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body.(b) Transportation primarily for and essential to medical care referred to in paragraph (7)(a).(c) Insurance covering medical care referred to in paragraphs (7)(a) and (b).(8) Mental or Nervous Disorders. A definition of "mental or nervous disorder" as used in a policy shall not be more restrictive than:(e) Mental or emotional disease or disorder of any kind.(9) Nurse. (a) The definition or description of "nurse" may be restricted to a type of nurse, such as: 1. Registered graduate professional nurse (R.N.);2. Licensed practical nurse (L.P.N.); or3. Licensed vocational nurse (L.V.N.).(b) If the words "nurse", "trained nurse" or "registered nurse" are used without specific instruction, then the use of such terms requires the insurer to recognize the services of any individual who qualifies under such terminology in accordance with the applicable statutes or administrative rules of the licensing or registry board of this state.(10) "Offer" means to actively market.(11) One Period of Confinement.(a) "One period of confinement" as used in subsections 69O-154.106(1) and (2), F.A.C., means one or more separate or combined periods of confinement in a hospital, for the same or related causes, unless separated by an interval of not more than six consecutive months between the end of one such period and the beginning of the succeeding period.(b) When succeeding confinements for the same or related causes are separated by a six-month interval, the following confinement will be considered a new period of confinement, and any applicable benefit provisions will be restored.(12) Partial Disability. "Partial disability" may be defined in relation to: (a) One's inability to perform some part or all of the "major," "important," or "essential" duties of his employment or occupation; or(b) A "percentage" of time worked;(c) A "specified number of hours";(13) Physician.(a) The definition or description of "physician" may be restricted to a type of physician to the extent allowed by law.(b)1. The insurer may also include terms such as "duly qualified physician" or "duly licensed physician."2. The use of such terms requires an insurer to recognize and to accept, to the extent of its obligation under the contract, all providers of medical care and treatment when they are within the scope of the providers' licensed authority, and are provided pursuant to Section 627.419, F.S.(14)(a) "Placement, or being placed, for adoption" means the assumption and retention of a legal obligation for total or partial support of a child by a person with whom the child has been placed in anticipation of the child's adoption.(b) The child's placement for adoption with the person terminates upon the termination of the legal obligation.(15) "Service area" means the geographic area approved by the Agency for Health Care Administration within which an insurer is authorized pursuant to Section 627.6472, F.S., to offer a health insurance policy, or within which an HMO is authorized pursuant to Section 641.495, F.S., to provide or arrange for comprehensive health care services.(16) Sickness. (a) The definition of "sickness" shall not be more restrictive than the following: Sickness means illness or disease of an insured person which first manifests itself after the effective date of insurance and while the insurance is in force.(b)1. A definition of "sickness" which anticipates the exclusion of coverage of preexisting conditions, subject to the limitations in Section 627.607, F.S., shall not use the phrase "the cause of which originates" or any similar phrase.2. Such definitions may provide for a probationary period which will not exceed 30 days except as stated in paragraph 69O-154.105(6)(a), F.A.C.(c) The definition may be further modified to exclude sickness or disease for which benefits are provided under any workers' compensation, occupational disease, employers' liability or similar law.(17) Total Disability. (a) A general definition of "total disability" must not be more restrictive than one requiring the individual to be totally disabled from engaging in any employment or occupation for which the individual is or may become qualified by reason of education, training, or experience, and not in fact engaged in any employment or occupation for wage or profit.(b) "Total disability" may be defined in relation to the inability of the person to perform duties, but the inability may not be based solely upon an individual's ability to: 1. Perform "any occupation whatsoever" or "any occupational duty"; or2. Engage in any training or rehabilitation program;3. An insurer may specify the requirement of the complete inability of the person to perform substantially all of the material duties pertaining to his regular occupation, or words of similar import.(c)1. The definition may reasonably require regular care and attendance by a physician, other than the insured or a member of insured's immediate family.2. The definition may require that the total disability be "continuous" or "uninterrupted" for a specified period of time or to a specified age which shall be consistent with the type of coverage afforded.(d) If the insured's total disability shall continue to the specified age or for the specified period and shall then and thereafter continue, the definition of "total disability" may predicate continuance of benefits on the insured's inability to perform any work or occupation for which he is reasonably trained or qualified by education or experience.Fla. Admin. Code Ann. R. 69O-154.104
Rulemaking Authority 624.308, 627.643, 641.36 FS. Law Implemented 624.307(1), 627.642, 627.643 FS.
New 1-1-75, Formerly 4-37.04, 4-37.004, Amended 9-19-00, Formerly 4-154.104, Amended by Florida Register Volume 46, Number 023, February 4, 2020 effective 2/19/2020.New 1-1-75, Formerly 4-37.04, 4-37.004, Amended 9-19-00, Formerly 4-154.104, Amended 2-19-20.