Section R590-285-23 - Standards for a Benefit Trigger(1)(a) A policy shall condition the payment of benefits on a determination of the insured's: (i) ability to perform activities of daily living; or(ii) cognitive impairment.(b) Eligibility for the payment of benefits may not be more restrictive than requiring either:(i) a deficiency in the ability to perform not more than three of the activities of daily living; or(ii) the presence of cognitive impairment.(2)(a) Activities of daily living shall include at least: (b) An insurer may use additional activities of daily living to trigger a covered benefit if the terms are defined in the policy or certificate.(3) An insurer may use additional provisions to determine when benefits are payable, but the provisions may not restrict, and are not in lieu of, the requirements under Subsections (1) and (2).(4) For the purposes of this section, the determination of a deficiency may not be more restrictive than: (a) requiring the hands-on assistance of another person to perform the prescribed activities of daily living; or(b) if the deficiency is due to the presence of a cognitive impairment, needing supervision or verbal cueing by another person to protect the insured or others.(5) An assessment of activities of daily living or cognitive impairment shall be performed by a licensed or certified professional, such as a physician, nurse, or social worker.(6) A policy or certificate shall include a clear description of the process for appealing and resolving a benefit determination.Utah Admin. Code R590-285-23
Adopted by Utah State Bulletin Number 2021-05, effective 2/23/2021Adopted by Utah State Bulletin Number 2024-21, effective 10/22/2024