230 R.I. Code R. 230-RICR-20-30-1.3

Current through December 3, 2024

Section 230-RICR-20-30-1.3 - Definitions

A. "Accident and sickness insurance" means Accident and sickness insurance as defined in R.I. Gen. Laws Chapter 27-18.

B. "Agent" means an insurance agent, broker or solicitor as defined in R.I. Gen. Laws Chapters 27-2.4. 27-2.4 and 27-3 or any person who acts or aids in negotiation for a Health Benefits Plan on behalf of an insurer, as defined herein. Where this Part requires notices or printed statements referring to "your agent," such notice may refer to the agent as a "sales representative" or use other appropriate terms.

C. "Approval by the Director of Business Regulation" means personal approval by the Director or approval by any duly authorized deputy acting on behalf of the Director.

D. "Blanket health benefit contract" means any health benefit contract which is issued or intended to be issued in at least one of the following manners:

1. Under any contract issued to any railroad, steamship, motorbus or airplane carrier of passengers, which shall be deemed the contractholder, to provide health benefits for a group defined as all persons who become such passengers, insuring them while being such passengers;

2. Under a contract issued to an employer, who shall be deemed the contractholder, to provide health benefits for any group of employees defined by reference to exceptional hazards incident to such employment insuring such employees with respect to such exceptional hazards;

3. Under a contract issued to a college, school or other institution of learning, a school district or districts, or school jurisdictional unit, or to the head, principal or governing board of any such educational unit, who or which shall be deemed the contractholder, covering students, teachers or employees.

4. Under a contract issued to any religious, charitable, recreational, educational, or civic organization, or branch thereof, which shall be deemed the contractholder, covering any group of members or participants defined by reference to specified hazards incident to an activity or activities or operations sponsored or supervised by such contractholder.

5. Under a contract issued to a sports team, camp or sponsor thereof, which shall be deemed the contractholder, covering members, campers, employees, officials or supervisors.

6. Under a contract issued to any volunteer fire department, first aid, civil defense, or other such volunteer organization, which shall be deemed the contractholder, covering any group of members or participants defined by reference to specified hazards incident to an activity or activities or operations sponsored or supervised by such contractholder.

7. Under a contract issued to a newspaper or other publisher, which shall be deemed the contractholder, covering its carriers.

8. Under a contract issued to an association of persons having a common interest or calling which shall have a constitution and bylaws and which has been organized and is maintained in good faith for purposes other than that of obtaining insurance and which shall be deemed the contractholder to provide health benefits for such persons with respect to specific hazards arising out of such common interest or calling.

E. "Director" means the Director of Business Regulation.

F. "Direct response insurance" means insurance issued to an applicant who has himself completed the application and forwarded it directly to the insurer in response to a solicitation coming into his possession by any means of mass communication.

G. "Expense incurred benefits" means a health benefit which promises to pay all or part of the actual expenses incurred by a person insured for covered services.

H. "Group health benefit contract" means that form of health benefit contract covering groups of persons in one of the manners described below, with or without one or more members of their families or one or more dependents, or covering one or more members of the families or one or more dependents of such groups or persons:

1. Benefits are offered under any contract issued to an employer or trustees of a fund established by an employer, who shall be deemed the master contractholder, insuring employees of such employer for the benefit of persons other than the employer. The term "employees as used herein may include the officers, managers, and employees of the employer, the individual proprietor or partner if the employer is an individual proprietor or partnership, the officers, managers, and employees of subsidiary or affiliated corporations, the individual proprietors, partners and employees of individuals and firms, if the business of the employer and such individual or firm is under common control through stock ownership, contract, or otherwise. The term "employees" as used herein may include retired employees. The term "employees" as used with respect to a contract issued to insure employees of a public body may include elected or appointed officials. The term "employees" may include the trustees or their employees, or both, if their duties are principally connected with such trusteeship.

2. Benefits are offered under any contract issued to an association, including a labor union, which shall have a constitution and bylaws insuring members, employees, or employees of members of the association for the benefit of persons other than the association or its officers or trustees. The term "employees" as used herein may include retired employees.

3. Benefits are offered under any contract issued to the trustees of a fund established by two or more employers or by one or more labor unions or by one or more employers and one or more labor unions or by an association as defined in § 1.3(H)(2) of this Part which trustees shall be the master contractholder, to insure employees of the employers or members of the unions or of such association, or employees of members of such association for the benefit of persons other than the employers or the unions or such association. The term "employees" as used herein may include the officers, managers and employees of the employer, and the individual proprietor or partners if the employer is an individual proprietor or partnership. The term "employees" as used herein may include retired employees. The term "employees" may include the trustees or their employees, or both, if their duties are principally connected with such trusteeship.

4. Benefits are offered under any contract issued to cover any other group which in the Director's judgment is substantially similar to those described in § 1.3(H)(1) through (3) of this Part.

I. "Group-type basis" means a health benefit plan, other than "salary budget" plans utilizing individual contracts, which meets the following conditions:

1. Coverage is provided through health benefit contracts to classes of employees or members defined in terms of conditions pertaining to employment or membership.

2. The coverage is not available to the general public and can be obtained and maintained only because of the covered person's membership in or connection with the particular organization or group.

3. There are arrangements for bulk payment of premiums or subscription charges to the insurer.

4. There is sponsorship of the plan by the employer, union or association.

J. "Health benefit contract" means any policy or other contract issued, delivered or available for issue or delivery in Rhode Island by an insurer, as defined herein, which provides health benefits, as defined in R.I. Gen. Laws § 42-62-4 including both contracts which determine benefits in recognition of actual services or actual charges for services and contracts which determine benefits based on the status of hospitalization or receipt of medical treatment. Where this Part requires notices or printed statements referring to "this contract," such notice may refer to the contract as a "policy" whenever such term appropriately describes such contract. "Health benefit contract" shall also mean that portion of an accident and sickness insurance policy or life and accident and sickness insurance policy that provides health benefits, if such health benefits account for one- third (1/3) or more of the pure premium (i.e., that portion of the total premium needed for payment of benefits, exclusive of all portions of the premium intended to pay sales and administrative costs.) for accident and sickness insurance in such policy.

K. "Health maintenance organization" shall have the same meaning as that given such term in R.I. Gen. Laws § 42-62-4(d).

L. "Indemnity basis" means, with respect to Hospital Confinement Indemnity Coverage, that basis for determining benefits which depends solely on the insured person's being confined in a hospital and provides for payment of a stated amount per day of hospital confinement without regard to actual services rendered or expenses incurred during such confinement.

M. "Individual health benefit contract" means any health benefit contract that is not a group health benefit contract or a blanket health benefit contract.

N. "Insured" means any resident of the State of Rhode Island who is entitled to receive benefits in the form of cash or services under a health benefit contract.

O. "Insurance" means the benefits provided by any health benefit contract, as defined herein.

P. "Insurer" shall have the same meaning as that given such term in R.I. Gen. Laws §42 - 62-4(c).

Q. "Premium" means the consideration for any health benefit contract, including, but not limited to, the premium for an accident and sickness insurance policy and the subscription fee charged by a hospital service corporation, physicians service corporation or health maintenance organization.

R. "Qualified plan" means a qualified health program as defined in R.I. Gen. Laws § 42-62-10.

S. "Replacement" means any transaction wherein a new health benefit contract is to be purchased, and it is known to the agent or insurer at the time of application that as part of the transaction, an existing health benefit contract has been or is to be lapsed or the benefits thereof substantially reduced.

T. "Service benefit" means a health benefit which promises to defray the cost of health services provided to a person insured but which reserves the right to make payments directly to the provider and may reserve the right to negotiate the amount of payment for such services with the provider.

230 R.I. Code R. 230-RICR-20-30-1.3