Sec. 31.10.30.02. Definitions

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) "Adverse appeal determination" means a decision made by an insurer on an appeal of an adverse benefit determination to uphold:

(a) A denial, reduction, or termination of a disability benefit;

(b) A failure to provide or make payment, in whole or in part, for a disability benefit; or

(c) Any denial, reduction, termination, or failure to provide or make payment that is based on a determination of a covered individual's eligibility for coverage of a disability benefit.

(2) "Adverse benefit determination" means a determination arising from a claim for disability benefits which results in:

(a) A denial, reduction, or termination of a disability benefit;

(b) A failure to provide or make payment, in whole or in part, for a disability benefit; or

(c) Any denial, reduction, termination, or failure to provide or make payment that is based on a determination of a covered individual's eligibility for coverage of a disability benefit.

(3) "Authorized representative" means a person, including a health care provider, authorized by the covered individual to act on behalf of the covered individual.

(4) "Covered individual" means an individual covered under an insurance policy that provides a disability benefit.

(5) Disability benefit.

(a) "Disability benefit" means a benefit that is payable based on the disability of a covered individual.

(b) "Disability benefit" does not include:

(i) Benefits under a long-term care insurance policy;

(ii) A benefit that is payable based solely on a dismemberment of a covered individual;

(iii) Benefits in a life insurance policy that operate to safeguard the contract from lapse or to provide a special surrender value, special benefit, or annuity in the event of total and permanent disability; or

(iv) Benefits in a health insurance policy that operate to safeguard the contract from lapse due to disability.