Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
Exclusion: means for the purposes of accident and health insurance that an insurer does not provide insurance coverage, for whatever reason, for one of the following:
(a)
a specific physical condition;
(b)
a specific medical procedure;
(c)
a specific disease or disorder; or
(d)
a specific prescription drug or class of prescription drugs. See Utah Code 31A-1-301
Form: means one of the following prepared for general use:
Health benefit plan: means a policy, contract, certificate, or agreement offered or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care, including major medical expense coverage. See Utah Code 31A-1-301
a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;
(ii)
a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and
(iii)
a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301
Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy and includes:
Significant break in coverage: means a period of 63 consecutive days during each of which an individual does not have creditable coverage. See Utah Code 31A-1-301
State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
(2)
Except as provided in this section, an insurer that elects to use an applicationform without questions concerning the insured‘s health or medical treatment history shall provide coverage under the policy for any loss which occurs more than 12 months after the effective date of coverage due to a preexisting condition which is not specifically excluded from coverage.
(3)
(a)
An insurer that issues a specified disease policy may not deny a claim for loss due to a preexisting condition that occurs more than six months after the effective date of coverage.
(b)
A specified disease policy may impose a preexisting condition exclusion only if the exclusion relates to a preexisting condition which first manifested itself within six months prior to the effective date of coverage or which was diagnosed by a physician at any time prior to the effective date of coverage.
(4)
(a)
Except as otherwise provided in this section, a health benefit plan may impose a preexisting condition exclusion only if:
(i)
the exclusion relates to a preexisting condition for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period ending on the enrollment date from an individual licensed or similarly authorized to provide those services under state law and operating within the scope of practice authorized by state law;
(ii)
the exclusion period ends no later than 12 months after the enrollment date, or in the case of a late enrollee, 18 months after the enrollment date; and
(iii)
the exclusion period is reduced by the number of days of creditable coverage the enrollee has as of the enrollment date, in accordance with Subsection (4)(b).
(b)
(i)
The amount of creditable coverage allowed under Subsection (4)(a)(iii) is determined by counting all the days on which the individual has one or more types of creditable coverage.
(ii)
Days of creditable coverage that occur before a significant break in coverage are not required to be counted.
(A)
Days in a waiting period or affiliation period are not taken into account in determining whether a significant break in coverage has occurred.
(B)
For an individual who elects federal COBRA continuation coverage during the second election period provided under the federal Trade Act of 2002, the days between the date the individual lost group health plan coverage and the first day of the second COBRA election period are not taken into account in determining whether a significant break in coverage has occurred.
(c)
A group health benefit plan may not impose a preexisting condition exclusion relating to pregnancy.
(d)
(i)
An insurer imposing a preexisting condition exclusion shall provide a written general notice of preexisting condition exclusion as part of any written application materials.
(ii)
The general notice under this subsection shall include:
(A)
a description of the existence and terms of any preexisting condition exclusion under the plan, including the six-month period ending on the enrollment date, the maximum preexisting condition exclusion period, and how the insurer will reduce the maximum preexisting condition exclusion period by creditable coverage;
(B)
a description of the rights of individuals:
(I)
to demonstrate creditable coverage, including any applicable waiting periods, through a certificate of creditable coverage or through other means; and
(II)
to request a certificate of creditable coverage from a prior plan;
(C)
a statement that the current plan will assist in obtaining a certificate of creditable coverage from any prior plan or issuer if necessary; and
(D)
a person to contact, and an address and telephone number for the person, for obtaining additional information or assistance regarding the preexisting condition exclusion.
(e)
An insurer may not impose any limit on the amount of time that an individual has to present a certificate or other evidence of creditable coverage.
(f)
This Subsection (4) does not preclude application of any waiting period applicable to all new enrollees under the plan.
(5)
(a)
If a short-term limited duration health insurance policy provides for an extension or renewal of the policy, the insurer may not exclude coverage for a loss due to a preexisting condition for a period greater than 12 months following the original effective date of the coverage, unless the insurer specifically and expressly excludes the preexisting condition in the terms of the policy or certificate.
(b)
(i)
An insurer that includes a preexisting condition exclusion in a short-term limited duration health insurance policy in accordance with this subsection shall provide a written general notice of the preexisting condition exclusion as part of any written application materials.
(ii)
A written general notice described in this subsection shall:
(A)
include a description of the existence and terms of any preexisting condition exclusion under the policy, including the maximum preexisting exclusion period; and
(B)
state that the exclusion period ends no later than 12 months after the original effective date of the coverage.
