N.H. Admin. Code § Ins 7001.04

Current through Register No. 50, December 12, 2024

Section Ins 7001.04 - Policy Definition Requirements

Except as provided in this part, an individual short term limited duration health insurance policy delivered or issued for delivery to any person in this state and to which this part applies shall contain definitions that comply with the requirements of this section as follows:

(a) "Accident", "accidental injury", and "accidental means" shall be defined to employ "result" language and shall not include words that establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characterization, and:

(1) The definition shall not be more restrictive than the following:

"Injury" or "injuries" means "accidental bodily injury sustained by the insured person that is the direct cause of the condition for which benefits are provided, independent of disease or bodily infirmity or any other cause and that occurs while the insurance is in force"; and

(2) The definition may provide that injuries shall not include injuries for which benefits are provided under workers' compensation, employers' liability or similar law, or injuries occurring while the insured person is engaged in any activity pertaining to a trade, business, employment, or occupation for wage or profit;

(b) "Convalescent nursing home", "extended care facility", or "skilled nursing facility" shall be defined in relation to its status, facility, and available services, and:

(1) A definition of the home or facility shall not be more restrictive than one requiring that it:

a. Be operated pursuant to law;

b. Be approved for payment of Medicare benefits or be qualified to receive approval for payment of Medicare benefits, if so requested;

c. Be primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under the supervision of a duly licensed physician;

d. Provide continuous 24-hour-a-day nursing service by or under the supervision of a registered nurse; and

e. Maintain a daily medical record of each patient; and

(2) The definition of the home or facility may provide that the term shall not be inclusive of:

a. A home, facility, or part of a home or facility used primarily for rest;

b. A home or facility for the aged or for the care of individuals diagnosed with substance use disorders; or

c. A home or facility primarily used for the care and treatment of mental diseases or disorders or for custodial or educational care;

(c) "Hospital" may be defined in relation to its status, facilities, and available services or to reflect its accreditation by The Joint Commission, previously known as The Joint Commission on Accreditation of Healthcare Organizations, and:

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

a. Be an institution licensed to operate as a hospital pursuant to law;

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 licensed physicians, medical, diagnostic, and surgical facilities for the medical care and treatment of sick or injured persons on an in-patient basis for which a charge is made; and

c. Provide 24-hour nursing service by or under the supervision of registered nurses; and

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

a. Convalescent homes or convalescent, rest, or nursing facilities;

b. Facilities affording primarily custodial, educational, or rehabilitative care;

c. Facilities for the aged or for the care of individuals diagnosed with substance use disorders; or

d. A military or veterans' hospital, a soldiers' home, or a hospital contracted for or operated by any national government or governmental agency for the treatment of members or ex-members of the armed forces, except for services rendered on an emergency basis where a legal liability for the patient exists for charges made to the individual for the services;

(d) "Mental or nervous disorder" shall not be defined more restrictively than a definition including neurosis, psychoneurosis, psychosis, or mental or emotional disease or disorder of any kind;

(e) "Nurse" may be defined so that the description of nurse is restricted to a type of nurse, such as a registered nurse, a licensed practical nurse, or a licensed vocational nurse. If the words "nurse", "trained nurse", or "registered nurse" are used without specific instruction, then the use of these terms requires the insurer to recognize the services of any individual who qualifies under the terminology in accordance with the applicable statutes or administrative rules of the New Hampshire board of nursing;

(f) "Physician" may be defined by including words such as "qualified physician" or "licensed physician." The use of these 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 the services are within the scope of the provider's licensed authority and are provided pursuant to applicable laws, including advanced practice registered nurses and physician's assistants;

(g) "Preexisting condition" shall not be defined more restrictively than the following: "Preexisting condition means the existence of symptoms that would cause an ordinarily prudent person to seek diagnosis, care, or treatment within a 6-month period preceding the effective date of the coverage of the insured person or a condition for which medical advice or treatment was recommended by a physician within a 6-month period preceding the effective date of the coverage of the insured person"; and

(h) "Sickness" shall not be defined to be more restrictive than the following: "Sickness means illness, disease, or medical condition, including pregnancy, of an insured person that first manifests itself after the effective date of insurance and while the insurance is in force." The definition may be further modified to exclude sickness or disease for which benefits are provided under workers' compensation, occupational disease, or employers' liability or similar law.

N.H. Admin. Code § Ins 7001.04

Derived from Volume XXXIX Number 24, Filed June 13, 2019, Proposed by #12798, Effective 6/10/2019, Expires 6/10/2029.