Wis. Admin. Code Office of the Commissioner of Insurance Ins 18.01

Current through November 25, 2024

Section Ins 18.01 - Definitions

In this chapter:

(1) "Commissioner" means the "commissioner of insurance" of this state or the commissioner's designee.

(2) "Complaint" means any expression of dissatisfaction expressed to the insurer by the insured, or an insured's authorized representative, about an insurer or its providers with whom the insurer has a direct or indirect contract.

(2m) "Coverage denial determination" has the meaning as defined in s. 632.835(1) (ag), Stats., and includes, for individual insurance products, a policy reformation or change in premium charged based upon underwriting or claims information greater than 25% from the premium in effect during the period of contestability except to the extent the modification is due to the applicant's age or a rate increase applied by the insurer to all similar individual policy forms applied uniformly.

(3) "Expedited grievance" means a grievance where any of the following applies:

(a) The duration of the standard resolution process will result in serious jeopardy to the life or health of the insured or the ability of the insured to regain maximum function.

(b) In the opinion of a physician with knowledge of the insured's medical condition, the insured is subject to severe pain that cannot be adequately managed without the care or treatment that is the subject of the grievance.

(c) A physician with knowledge of the insured's medical condition determines that the grievance shall be treated as an expedited grievance.

(4) "Grievance" means any dissatisfaction with an insurer offering a health benefit plan or administration of a health benefit plan by the insurer that is expressed in writing to the insurer by, or on behalf of, an insured including any of the following:

(a) Provision of services.

(b) Determination to reform or rescind a policy.

(c) Determination of a diagnosis or level of service required for evidence-based treatment of autism spectrum disorders.

(d) Claims practices.

(5) "Independent review organizations" means an organization certified under s. 632.835(4), Stats.

(6) "Independent review" means a review conducted by a certified independent review organization.

(7) "Insured" has the meaning provided in s. 600.03(23), Stats.

(8) "OCI complaint" means any complaint received by the office of the commissioner of insurance by, or on behalf of, an insured of an insurer offering coverage under a health benefit plan.

(9) "Office" means the "office of the commissioner of insurance."

(10) "Rescission" or "reformation" of a policy means a determination by an insurer offering health benefit plan, subject to s. 628.34(3), Stats., to withdraw the coverage back to the initial date of coverage, modify the terms of the policy or adjust the premium rate by more than 25% from the premium in effect during the period of contestability. A modification in premium based upon the applicant's or insured's age or a rate increase uniformly applied by the insurer to all similar individual policy forms is not a rescission or reformation of a policy.

Wis. Admin. Code Office of the Commissioner of Insurance Ins 18.01

CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-01; CR 10-023: cr. (2m), (10), am. (4) Register September 2010 No. 657, eff. 10-1-10.