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Utah Administrative Code (Current through November 1, 2019) |
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R590. Insurance, Administration |
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R590-249. Secondary Medical Condition Exclusion |
| R590-249-1. Authority |
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This rule is promulgated by the commissioner pursuant to Subsections 31A-2-201(3) wherein the commissioner may adopt rules to implement the provisions of Title 31A and 31A-22-613.5(2)(e) wherein the commissioner shall develop examples of limitations or exclusions of a secondary medical condition. |
| R590-249-2. Purpose and Scope |
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(1) The purpose of this rule is to establish examples of limitations or exclusions from coverage, including related secondary conditions. (2) This rule applies to all health benefit plans. |
| R590-249-3. General Instructions |
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The insurer shall provide a clear written statement that discloses the policy limitations and exclusions, including related secondary medical conditions that are set forth in the policy: (1) upon application; (2) when requested by the insured; and (3) in any materials a carrier is required to provide to an insured, including the Summary of Benefits and Coverage as defined in 45 CFR 147.200. |
| R590-249-4. Examples |
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The following policy limitation or exclusion examples are not all inclusive: (1) charges in connection with reconstructive or plastic surgery that may have limited benefits, such as, a chemical peel that does not alleviate a functional impairment; (2) complications relating to services and supplies for, or in connection with, gastric or intestinal bypass, gastric stapling, or other similar surgical procedure to facilitate weight loss, or for, or in connection with, reversal or revision of such procedures, or any direct complications or consequences thereof; (3) complications by infection from a cosmetic procedure, except in cases of reconstructive surgery: (a) when the service is incidental to or follows a surgery resulting from trauma, infection or other diseases of the involved part; or (b) related to a congenital disease or anomaly of a covered dependent child that has resulted in functional defect; or (4) complications that result from an injury or illness resulting from active participation in illegal activities. |
| R590-249-5. Penalties |
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Any insurer found, after a hearing or other regulatory process, to be in violation of this rule shall be subject to the penalties as provided under Section 31A-2-308. |
| R590-249-6. Enforcement Date |
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The commissioner will begin enforcing this rule January 1, 2016. |
| R590-249-7. Severability |
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If any provision or portion of this rule or the application of it to any person, company or circumstance is for any reason held to be invalid, the remainder of the rule or the applicability of the provision to other persons, companies, or circumstances shall not be affected. |