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

2. B. Terms Defined.

   1. (1) “Adverse appeal determination” means a decision made by an insurer on an appeal of an adverse benefit determination to uphold:

      1. (a) A denial, reduction, or termination of a disability benefit;
      2. (b) A failure to provide or make payment, in whole or in part, for a disability benefit; or
      3. (c) Any denial, reduction, termination, or failure to provide or make payment that is based on a determination of a covered individual's eligibility for coverage of a disability benefit.

   2. (2) “Adverse benefit determination” means a determination arising from a claim for disability benefits which results in:

      1. (a) A denial, reduction, or termination of a disability benefit;
      2. (b) A failure to provide or make payment, in whole or in part, for a disability benefit; or
      3. (c) Any denial, reduction, termination, or failure to provide or make payment that is based on a determination of a covered individual's eligibility for coverage of a disability benefit.
   3. (3) “Authorized representative” means a person, including a health care provider, authorized by the covered individual to act on behalf of the covered individual.
   4. (4) “Covered individual” means an individual covered under an insurance policy that provides a disability benefit.

   5. (5) Disability benefit.

      1. (a) “Disability benefit” means a benefit that is payable based on the disability of a covered individual.

      2. (b) “Disability benefit” does not include:

         1. (i) Benefits under a long-term care insurance policy;
         2. (ii) A benefit that is payable based solely on a dismemberment of a covered individual;
         3. (iii) Benefits in a life insurance policy that operate to safeguard the contract from lapse or to provide a special surrender value, special benefit, or annuity in the event of total and permanent disability; or
         4. (iv) Benefits in a health insurance policy that operate to safeguard the contract from lapse due to disability.

Authority: Insurance Article, §§2-109(a)(1) and 15-1010, Annotated Code of Maryland

Effective date: August 2, 2004 (31:15 Md. R. 1186)

Regulation .03B amended effective April 15, 2024 (51:7 Md. R. 334)

Regulation .04 amended effective April 15, 2024 (51:7 Md. R. 334)

Regulation .05 amended effective April 15, 2024 (51:7 Md. R. 334)