11 NCAC 12 .1003             POLICY DEFINITIONS; APPEALS

(a)  Unless otherwise required by federal law or regulation, no policy issued or issued for delivery in this State shall use the terms set forth below, unless the terms are defined in the policy and the definitions satisfy the following requirements:

(1)           "Activities of daily living" means at least bathing, continence, dressing, eating, toileting, and transferring.

(2)           "Acute condition" means that the individual is medically unstable and requires frequent monitoring by a medical doctor or registered nurse.

(3)           "Bathing" means washing oneself by sponge bath, or in a tub or shower, including the task of getting into and out of the tub or shower.

(4)           "Cognitive impairment" means a deficiency in a person's short or long-term memory; orientation as to person, place, and time; deductive or abstract reasoning; or judgment as it relates to safety awareness.

(5)           "Continence" means the ability to maintain control of bowel and bladder function; or, when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including caring for catheter or colostomy bag).

(6)           "Dressing" means putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs.

(7)           "Eating" means feeding oneself by getting food into the body from a receptacle (such as a plate, cup, or table); or by feeding tube or intravenously.

(8)           "Hands-on-assistance" means physical assistance (minimal, moderate, or maximal) without which the individual would not be able to perform the activity of daily living.

(9)           "Medicare" means the "Health Insurance for the Aged Act", Title XVIII of the Social Security Amendments of 1965, as amended.

(10)         "Mental of nervous disorder" shall not be defined to include mroe than neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder.

(11)         "Personal care" means the provision of hands-on services to assist an individual with activities of daily living.

(12)         "Toileting" means getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.

(13)         "Transferring" means moving into our out of a bed, chair, or wheelchair.

(14)         "Skilled nursing care," "intermediate care," "personal care," home care," and other services shall be defined in relation to the level of skill required, the nature of the care, and the setting in which care must be delivered.

(b)  The definitions contained in G.S. 58-55-20 and G.S. 58-55-35(a) are incorporated by reference into this Section.

(c)  A policy may condition the payment of benefits on a determination of the insured's ability to perform activities of daily living and on cognitive impairment as long as those conditions are defined in the policy. Assessments of activities of daily living and cognitive impairment shall be performed by licensed or certified professionals, such as medical doctors, nurses, or social workers. Policies shall include a description of the procedures for appealing and resolving benefit determinations.


History Note:        Authority G.S. 58-2-40(1); 58-55-30(a);

Eff. September 1, 1990;

Amended Eff. April 1, 1999;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 1, 2018.