CHAPTER 415-A STANDARDS FOR ACCIDENT AND HEALTH INSURANCE
Section 415-A:1
415-A:1 Definitions. –
In this chapter:
I. "Accident and health insurance" means insurance written under RSA 415, RSA 21-I:99-21-I:111, RSA 282-B, and coverages written under RSA 415-E, RSA 420-A, RSA 420-B, and RSA 420-C. For purposes of this chapter, multiple-employer welfare arrangements, nonprofit health service corporations, health maintenance organizations, and preferred provider agreements subject to RSA 420-C shall be deemed to be engaged in the business of insurance.
I-a. "Claim denial" means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant's or beneficiary's eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.
I-b. "Claim involving urgent care" means any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations:
(a) Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or
(b) In the opinion of a physician with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
I-c. "Claimant's representative" shall mean an individual authorized by a claimant in writing to pursue a claim or appeal on the claimant's behalf.
I-d. "Date of enrollment" means the first day of coverage under the plan, or, if there is a waiting period, the first day of the waiting period, which is typically the first day of work.
I-e. "Employee benefit plan" means employee welfare benefit plans described in section 3 of the Employee Retirement Income Security Act of 1974, 29 U.S.C., section 1002 and not exempted under section 4(b) of this Act, 29 U.S.C. section 1003, other than those plans, or portions of them, that provide disability benefits.
II. "Form" means policies, contracts, riders, endorsements, and applications as provided in RSA 415, RSA 21-I:99-21-I:111, RSA 282-B, RSA 415-E, RSA 420-A, RSA 420-B, and RSA 420-C.
III. "Policy" means the entire contract between the insurer and the insured, including the policy, riders, certificates, endorsements and the application, if attached, and also includes subscriber contracts issued by nonprofit hospital and medical service associations.
IV. "Post-service claim" means any claim for a health benefit to which the terms of the plan do not condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining the medical care. "Post-service claim" shall not include a request for reimbursement made by a provider pursuant to the terms of an agreement between the provider and the health carrier.
V. "Pre-service claim" means any claim for a benefit under a health plan with respect to which the terms of the plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care. "Pre-service claim" shall not include a request for reimbursement made by a provider pursuant to the terms of an agreement between the provider and the health carrier.