Utah Admin. Code 590-285-3

Current through Bulletin 2024-24, December 15, 2024

Section R590-285-3 - Definitions

Terms used in this rule are defined in Sections 31A-1-301 and 31A-22-2002. Additional terms are defined as follows:

(1)

(a) "Authorized representative" means an individual authorized to act as an insured's personal representative under 45 CFR 164.502(g).

(b) "Authorized representative" includes:

(i) a person to whom an insured gives express written consent to represent the insured in an external review;

(ii) a person authorized by law to provide substituted consent for an insured; or

(iii) only when the insured is unable to provide consent:

(A) a family member of the insured; or

(B) the insured's treating health care professional

(2) "Benefit trigger," for the purposes of independent review, means a contractual provision conditioning the payment of benefits on a determination of the insured's:

(a) ability to perform activities of daily living; or

(b) cognitive impairment.

(3) "Certificate" means a limited long-term care insurance certificate.

(4) "Cold lead advertising" means using, directly or indirectly, any method of marketing that fails to disclose in a conspicuous manner the method of marketing is a solicitation of insurance and that contact will be made by a producer or an issuer.

(5) "Continuation of coverage" means a provision that maintains coverage under the existing group policy when the coverage would otherwise terminate, and that is subject only to the continued timely payment of premium when due.

(6) "Conversion of coverage" means a provision that an individual whose coverage under the group policy would otherwise terminate or has been terminated for any reason, including discontinuance of the group policy in its entirety or with respect to an insured class, shall be entitled to the issuance of a converted policy by the insurer, without evidence of insurability, if the individual was continuously insured under the group policy or another group policy which it replaced six months immediately before termination.

(7) "Converted policy" means an individual policy providing benefits identical to, or benefits determined by the commissioner to be substantially equivalent to or in excess of, those provided under the group policy from which the conversion is made.

(8) "High pressure tactics" means using a method of marketing to induce, or tend to induce, the purchase of insurance through force, fright, threat, whether explicit or implied, or undue pressure to purchase or recommend the purchase of insurance.

(9) "Licensed health care professional" means an individual qualified by education and experience in an appropriate field to determine, by record review, an insured's actual functional or cognitive impairment.

(10) "Limited distribution channel" means a sale through a discrete entity, such as a financial institution or brokerage, where a specialized product is available that is not available for sale to the general public.

(11) "Limited long-term care benefit classification" means policy benefits classified as:

(a) institutional limited long-term care benefits only;

(b) non-institutional limited long-term care benefits only; or

(c) comprehensive limited long-term care benefits.

(12) "Misrepresentation" means misrepresenting a material fact when selling or offering to sell a policy or certificate.

(13) "Policy" means a limited long-term care insurance policy.

(14) "Qualified actuary" means a member in good standing of the American Academy of Actuaries.

(15)

(a) "Similar policy forms" means all limited long-term care insurance policies and certificates issued by an insurer in the same limited long-term care benefit classification.

(b) Group limited long-term care insurance certificates are not considered similar to certificates or policies otherwise issued as limited long-term care insurance, but are similar to other comparable certificates with the same limited long-term care benefit classifications.

(16) "State of policy issue" means the state in which a policy was originally issued.

(17) "Twisting" means knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policy or issuer to induce, or tend to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on, or convert any insurance policy or to take out an insurance policy with another issuer.

Utah Admin. Code R590-285-3

Adopted by Utah State Bulletin Number 2021-05, effective 2/23/2021

Adopted by Utah State Bulletin Number 2024-21, effective 10/22/2024