1. (a) “Adverse benefit determination” means a denial, reduction, termination of, or a failure to provide or make payment, in whole or in part, for a benefit, including any such denial, reduction, termination of, or failure to provide or make payment that is based on a determination of a participant's or claimant's eligibility to participate in a plan and including a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit, including on appeal.
2. (b) “Average weekly wage” means the total wages earned by an insured over a specified period of time, divided by the number of weeks in that period.
3. (c) “Base period” means the period of time specified in a policy or certificate that will be used in the calculation of wage replacement benefits.
4. (d) “Benefit period” means the 12-month fixed period or 12-month rolling period starting with the employee’s first day of family or medical leave, during which the insured receives benefits.
5. (e) “Benefits waiting period” is the time measured from the effective date of coverage during which no benefits are provided.
6. (f) “Beneficiary” means the person or persons designated as such in the application.
7. (g) “Care” means the participation in providing assistance or supervision to a family member for a serious health condition or bonding with a child.
8. (h) “Conditionally renewable” means that renewal of the policy is based on certain conditions.
9. (i) “Disability” means “disability” as defined in Ins 6205.02.
10. (j) “Disability income protection coverage” means a policy or certificate that provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from either sickness or injury.
11. (k) “Eligibility waiting period” means the period of time that an employee must be in the employ of an employer or an individual must be a member of a union or a permitted group association before becoming eligible for coverage under this part.
12. (l) “Elimination period” means the length of time beginning with the first day of leave for a qualifying event during which no benefits are paid to the insured.
13. (m) “Family leave” means leave from work for a qualifying serious health condition or event of the insured’s family member.
14. (n) “Family member” means a biological, step, adopted, foster, or legal guardian of a son or daughter, a spouse, a biological, step, adoptive, or foster parent, a legal guardian, or other person as defined as a family member in the policy or certificate.
15. (o) “Intermittent leave” means periods of non-consecutive leave taken within a 12-month benefit period in intervals of not less than 4 hours in one day.
16. (p) “Medical leave” means leave from work because of the qualifying serious health condition of the insured.
17. (q) “Serious health condition” means any illness, injury, impairment, or physical or mental condition that involves inpatient care, treatment, or continuing treatment by a health care provider, including treatment for substance abuse consistent with American Society of Addiction Medicine criteria and treatment for a mental health condition consistent with American Psychiatric Association criteria.
18. (r) “Wages” means the amount of income received by the insured through employment.

Source. . #13499, eff 11-30-22