31.10.09.02

.02 Definitions.

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

B. Terms Defined.

(1) "Bereavement counseling" means counseling provided to the immediate family or family caregiver of the insured after the insured's death to help the immediate family or family caregiver cope with the death of the insured.

(2) "Carrier" means an insurer, a nonprofit health service plan, or a health maintenance organization.

(3) Expense Incurred.

(a) "Expense incurred" means the benefits payable under the contract are based on the medical expenses the insured incurs.

(b) For the purpose of this chapter, a contract which includes both expense-incurred benefits and indemnity benefits shall be considered to be written on an "expense-incurred" basis.

(4) "Family caregiver" means a relative by blood, marriage, or adoption who lives with or is the primary caregiver of the terminally ill insured.

(5) "Family counseling" means counseling given to the immediate family or family caregiver of the terminally ill insured for the purpose of learning to care for the insured and to adjust to the death of the insured.

(6) "Hospice care program" means a coordinated, interdisciplinary program of hospice care services for meeting the special physical, psychological, spiritual, and social needs of terminally ill individuals and their families, by providing palliative and supportive medical, nursing, and other health services through home or inpatient care during the illness and bereavement to:

(a) Individuals who have no reasonable prospect of cure as estimated by a physician; and

(b) The immediate families or family caregivers of those individuals described in §B(6)(a) of this regulation.

(7) "Immediate family" means the spouse, parents, siblings, grandparents, and children of the terminally ill insured.

(8) "Indemnity" means the benefits payable under the contract are flat amounts which are not related to the expenses the insured incurs, such as a hospital indemnity contract which pays a flat fee for each day the insured is confined in a hospital regardless of the actual expenses the insured incurs during the hospital confinement.

(9) "Insured" means a person who is covered under a:

(a) Group, blanket, or individual health insurance policy written on an expense-incurred basis;

(b) Nonprofit health service plan contract; or

(c) Health maintenance organization contract.

(10) "Respite care" means temporary care provided to the terminally ill insured to relieve the family caregiver from the daily care of the insured.

(11) "Terminally ill" means a medical prognosis given by a physician that the insured's life expectancy is 6 months or less.