State Codes and Statutes
Statutes > Connecticut > Title38a > Chap700c > Sec38a-551Sec. 38a-551. (Formerly Sec. 38-371). Definitions. For the purposes of this section and sections 38a-552 to 38a-559, inclusive, the following terms shall have the following meanings:
(a) "Health insurance" means hospital and medical expenses incurred policies written on a direct basis, nonprofit service plan contracts, health care center contracts and self-insured or self-funded employee health benefit plans. For purposes of sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, "health insurance" does not include (1) accident only, credit, dental, vision, Medicare supplement, long-term care or disability insurance, hospital indemnity coverage, coverage issued as a supplement to liability insurance, insurance arising out of a workers' compensation or similar law, automobile medical-payments insurance, or insurance under which beneficiaries are payable without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance, or (2) policies of specified disease or limited benefit health insurance, provided: (A) The carrier offering such policies files on or before March first of each year a certification with the commissioner that contains the following: (i) A statement from the carrier certifying that such policies are being offered and marketed as supplemental health insurance and not as a substitute for hospital or medical expense insurance; and (ii) a summary description of each such policy including the average annual premium rates, or range of premium rates in cases where premiums vary by age, gender or other factors, charged for such policy in the state; and (B) for each such policy that is offered for the first time in this state on or after July 1, 2005, the carrier files with the commissioner the information and statement required in subparagraph (A) of this subdivision at least thirty days prior to the date such policy is issued or delivered in this state.
(b) "Carrier" means an insurer, health care center, hospital service corporation or medical service corporation or fraternal benefit society.
(c) "Insurer" means an insurance company licensed to transact accident and health insurance business in this state.
(d) "Health care center" means a health care center, as defined in section 38a-175.
(e) "Self-insurer" means an employer or an employee welfare benefit fund or plan which provides payment for or reimbursement of the whole or any part of the cost of covered hospital or medical expenses for covered individuals. For purposes of sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, "self-insurer" shall not include any such employee welfare benefit fund or plan established prior to April 1, 1976, by any organization which is exempt from federal income taxes under the provisions of Section 501 of the United States Internal Revenue Code and amendments thereto and legal interpretations thereof, except any such organization described in Subsection (c)(15) of said Section 501.
(f) "Commissioner" means the Insurance Commissioner of the state of Connecticut.
(g) "Physician" means a doctor of medicine, chiropractic, natureopathy, podiatry, a qualified psychologist and, for purposes of oral surgery only, a doctor of dental surgery or a doctor of medical dentistry and, subject to the provisions of section 20-138d, optometrists duly licensed under the provisions of chapter 380.
(h) "Qualified psychologist" means a person who is duly licensed or certified as a clinical psychologist and has a doctoral degree in and at least two years of supervised experience in clinical psychology in a licensed hospital or mental health center.
(i) "Skilled nursing facility" shall have the same meaning as "skilled nursing facility", as defined in Section 1395x, Chapter 7 of Title 42, United States Code.
(j) "Hospital" shall have the same meaning as "hospital", as defined in Section 1395x, Chapter 7 of Title 42, United States Code.
(k) "Home health agency" shall have the same meaning as "home health agency", as defined in Section 1395x, Chapter 7 of Title 42, United States Code.
(l) "Copayment" means the portion of a charge that is covered by a plan and not payable by the plan and which is thus the obligation of the covered individual to pay.
(m) "Resident employer" means any person, partnership, association, trust, estate, limited liability company, corporation, whether foreign or domestic, or the legal representative, trustee in bankruptcy or receiver or trustee, thereof, or the legal representative of a deceased person, including the state of Connecticut and each municipality therein, which has in its employ one or more individuals during any calendar year, commencing January 1, 1976. For purposes of sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, the term "resident employer" shall refer only to an employer with a majority of employees employed within the state of Connecticut.
(n) "Eligible employee" means, with respect to any employer, an employee who either is considered a full-time employee, or who is expected to work at least twenty hours a week for at least twenty-six weeks during the next twelve months or who has actually worked at least twenty hours a week for at least twenty-six weeks in any continuous twelve-month period.
(o) "Alcoholism treatment facility" shall have the same meaning as in section 38a-533.
(p) "Totally disabled" means with respect to an employee, the inability of the employee because of an injury or disease to perform the duties of any occupation for which he is suited by reason of education, training or experience, and, with respect to a dependent, the inability of the dependent because of an injury or disease to engage in substantially all of the normal activities of persons of like age and sex in good health.
(q) "Deductible" means the amount of covered expenses which must be accumulated during each calendar year before benefits become payable as additional covered expenses incurred.
(r) For purposes of sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, "disease or injury" shall include pregnancy and resulting childbirth or miscarriage.
(s) "Complications of pregnancy" means (1) conditions requiring hospital stays, when the pregnancy is not terminated, whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion and similar medical and surgical conditions of comparable severity, and shall not include false labor, occasional spotting, physician-prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsia and similar conditions associated with management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy; and (2) nonelective caesarean section, ectopic pregnancy which is terminated, and spontaneous termination of pregnancy, which occurs during a period of gestation in which a viable birth is not possible.
(t) "Resident" means (1) a person who maintains a residence in this state for a period of at least one hundred eighty days, or (2) a HIPAA or health care tax credit eligible individual who maintains a residence in this state.
(u) "HIPAA eligible individual" means an eligible individual as defined in subsection (b) of section 2741 of the Public Health Service Act, as set forth in the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) (HIPAA).
(v) "Health care tax credit eligible individual" means a person who is eligible for the credit for health insurance costs under Section 35 of the Internal Revenue Code of 1986 in accordance with the Pension Benefit Guaranty Corporation and Trade Adjustment Assistance programs of the Trade Act of 2002 (P.L. 107-210).
(P.A. 75-616, S. 1, 12; P.A. 76-399, S. 2, 5; P.A. 77-614, S. 163, 610; P.A. 80-482, S. 331, 345, 348; P.A. 90-243, S. 154; P.A. 91-100, S. 1; P.A. 93-338, S. 1; P.A. 95-79, S. 143, 189; June 18 Sp. Sess. P.A. 97-8, S. 67, 72, 88; P.A. 99-102, S. 45; P.A. 01-174, S. 11; June 30 Sp. Sess. P.A. 03-6, S. 66; P.A. 05-270, S. 1.)
History: P.A. 76-399 added Subdivs. (o) to (r) defining "totally disabled", "deductible", "disease or injury" and "complications of pregnancy"; P.A. 77-614 placed insurance commissioner within the department of business regulation and made insurance department a division within that department, effective January 1, 1979; P.A. 80-482 restored insurance commissioner and division to prior independent status and abolished the department of business regulation; P.A. 90-243 made technical changes for statutory consistency; Sec. 38-371 transferred to Sec. 38a-551 in 1991; P.A. 91-100 added Subdiv. (s) to define "resident"; P.A. 93-338 in Subdiv. (a) added references to "health care center contracts" in definition of "health insurance", in Subdiv. (b) added reference to "health care center" in definition of "carrier", inserted new Subdiv. (d) defining "health care center" and relettered the former Subdivs. (e) to (t), inclusive, accordingly; P.A. 95-79 redefined "resident employer" to include a limited liability company, effective May 31, 1995; June 18 Sp. Sess. P.A. 97-8 redefined "resident" in Subsec. (t) to include HIPAA eligible individual who maintains a residence in this state, and added new Subsec. (u) to define "HIPAA eligible individual", effective July 1, 1997; P.A. 99-102 amended Subsec. (g) by deleting an obsolete reference to osteopathy and making a technical change; P.A. 01-174 substituted reference to Sec. 38a-696 for Sec. 38a-697 in Subsec. (a); June 30 Sp. Sess. P.A. 03-6 made a technical change in Subsecs. (d), (i), (j) and (k), amended Subsec. (t) to include in definition of "resident" a health care tax credit eligible individual and make a technical change, and added Subsec. (v) defining "health care tax credit eligible individual", effective August 20, 2003; P.A. 05-270 redefined "health insurance" in Subsec. (a), effective July 1, 2005.
