Section 89.773. Policy definitions and terms

A policy or certificate may not be advertised, solicited or issued for delivery in this Commonwealth as a Medicare supplement policy or certificate, unless the policy or certificate contains definitions or terms which conform to the requirements of this section.

(1) The terms ‘‘accident,’’ ‘‘accidental injury’’ or ‘‘accidental means’’ shall be defined to employ ‘‘result’’ language and may not include words which establish an accidental means test or use words, such as ‘‘external, violent, visible wounds’’ or similar words of description or characterization.

(i) The definition may not be more restrictive than the following: ‘‘Injury or injuries for which benefits are provided means accidental bodily injury sustained by the insured person which is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while insurance coverage is in force.’’

(ii) The definition may provide that injuries may not include injuries for which benefits are provided or available under workers’ compensation, employer’s liability or similar law or motor vehicle no-fault plan, unless prohibited by law.

(2) The terms ‘‘benefit period’’ or ‘‘Medicare benefit period’’ may not be defined more restrictively than as defined in the Medicare Program.

(3) The terms ‘‘convalescent nursing home,’’ ‘‘extended care facility’’ or ‘‘skilled nursing facility’’ may not be defined more restrictively than as defined in the Medicare Program.

(4) The term ‘‘health care expenses’’ for purposes of § 89.780 (relating to loss ratio standards and refund or credit of premium), shall be defined to mean expenses of health maintenance organizations associated with the delivery of health care services, which expenses are analogous to incurred losses of insurers.

(5) The term ‘‘hospital’’ may be defined in relation to its status, facilities and available services or to reflect its accreditation by the Joint Commission on Accreditation of Hospitals, but not more restrictively than as defined in the Medicare Program.

(6) The term ‘‘Medicare’’ shall be defined in the policy and certificate. Medicare may be substantially defined as ‘‘The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended,’’ or ‘‘Title I, Part I of Public Law 89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof,’’ or words of similar import.

(7) The term ‘‘Medicare eligible expenses’’ shall be defined to mean expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare.

(8) The term ‘‘physician’’ may not be defined more restrictively than as defined in the Medicare Program.

(9) The term ‘‘sickness’’ may not be defined to be more restrictive than the following: ‘‘Sickness means illness or disease of an insured person which is diagnosed or treated after the effective date of insurance and while the insurance is in force.’’ The definition may be further modified to exclude sicknesses or diseases for which benefits are provided under any workers’ compensation, occupational disease, employer’s liability or similar law.

The provisions of this § 89.773 adopted July 24, 1992, effective July 25, 1992, 22 Pa.B. 3841; amended May 6, 2005, effective May 7, 2005, 35 Pa.B. 2729. Immediately preceding text appears at serial pages (272513) to (272514).

Notation

Cross References

This section cited in 31 Pa. Code § 89.777 (relating to standard Medicare supplement benefit plans for 1990 standardized Medicare supplement benefit plan policies or certificates issued or delivered on or after July 30, 1992, and prior to June 1, 2010); and 31 Pa. Code § 89.777b (relating to standard Medicare supplement benefit plans for 2010 standardized Medicare supplement benefit plan policies or certificates issued or delivered on or after June 1, 2010).