IDAPA 18.04.07
This rule applies to health carriers transacting insurance in Idaho, excluding health insurance contract for group coverage offered by or through an employer to it employees.
This rule sets forth uniform requirements regarding the use of discretionary clauses to be followed by health carriers.
This rule implements the following statutes passed by the Idaho Legislature:
Department of Insurance 700 W. State Street, 3rd Floor Boise, ID 83720-0043
P.O. Box 83720 Boise, ID 83720-0043 Phone: 1(800) 721-3272 or (208) 334-4250 Fax: (208) 334-4398 Email: rulesreview@doi.idaho.gov Web: https://doi.idaho.gov/
This rule chapter will be reviewed in compliance with Section 67-5292, Idaho Code, and in accordance with the 8-year rule review schedule linked here.
18.04.07 – Restrictions on Discretionary Clauses in Health Insurance Contracts
000. Legal Authority. ... 3
001. Scope. ... 3
002. -- 009. (Reserved) ... 3
010. Definitions. ... 3
011. Discretionary Clauses. ... 3
012. -- 999. (Reserved) ... 3
Title 41, Chapters 2, 13 and 18, Idaho Code.
(3-31-22)
This rule sets forth uniform requirements regarding the use of discretionary clauses to be followed by health carriers transacting insurance in Idaho. This chapter does not apply to a health insurance contract for group coverage offered by or through an employer to its employees. (3-31-22)
01. Discretionary Clause. Any health insurance contract provision that provides the health carrier with sole discretionary authority to determine eligibility for benefits or to interpret the terms and provisions of the health insurance contract. (3-31-22)
03. Health Care Services. Services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury, or disease. (3-31-22)
04. Health Carrier. An entity subject to regulation under Title 41, Chapters 21, 22, 32, 34, 39, 40, 41, 47, 52 or 55, Idaho Code. (3-31-22)
05. Health Insurance Contract. Any policy, contract, certificate, agreement, or other form or document providing, defining, or explaining coverage for health care services offered, delivered, issued for delivery, continued, or renewed in this state by a health carrier. (3-31-22)
No health insurance contract may contain a discretionary clause.
(3-31-22)