R590. Insurance, Administration.R590-249. Secondary Medical Condition Exclusion.
R590-249-1. Authority.
This rule is promulgated by the commissioner pursuant to Section 31A-2-201.
R590-249-2. Purpose and Scope.
(1) The purpose of this rule is to establish examples of coverage limitations or exclusions, including a related secondary condition as required under Section 31A-22-613.5.
(2) This rule applies to an insurer offering a health benefit plan.
R590-249-3. Definitions.
Terms used in this rule are defined in Section 31A-1-301.
R590-249-4. General Instructions.
An insurer shall provide a clear written statement that discloses any policy limitation or exclusion, including a related secondary medical condition, that is 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.
R590-249-5. Examples.
The following are examples of permissible policy limitations or exclusions and are not all inclusive:
(1) a charge in connection with reconstructive or plastic surgery that may have a limited benefit, such as a chemical peel that does not alleviate a functional impairment;
(2) a complication relating to services and supplies for, or in connection with:
(a) gastric or intestinal bypass;
(b) gastric stapling;
(c) a similar surgical procedure to facilitate weight loss;
(d) a procedure related to the reversal or revision of a procedure in Subsections (2)(a) through (2)(c); or
(e) any direct complication or consequence of a procedure in Subsections (2)(a) through (2)(d);
(3) a complication due to infection from a cosmetic procedure, except in a case of reconstructive surgery:
(a) when the service is incidental to or follows a surgery resulting from trauma, infection, or other disease 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) a complication that results from an injury or illness resulting from voluntary participation in an illegal activity described in Section R590-227-4.
R590-249-6. Severability.
If any provision of this rule, Rule R590-249, or its application to any person or situation is held invalid, such invalidity does not affect any other provision or application of this rule that can be given effect without the invalid provision or application. The remainder of this rule shall be given effect without the invalid provision or application.
KEY: health insurance, exclusions
Date of Last Change: July 25, 2023
Notice of Continuation: December 18, 2023
Authorizing, and Implemented or Interpreted Law: 31A-22-613.5
