Terms used in this chapter mean:

1. (1) "Appeal," any review or appeal before an administrative agency, arbitrator, court or mediator;

2. (2) "Discretionary clause," a provision in a policy that purports to bind the claimant to, or grant deference in, proceedings subsequent to the insurer's decision, denial, or interpretation on terms, coverage, or eligibility for benefits, including a policy provision that provides any of the following:

   1. (a) A policyholder or other claimant may not appeal a denial of a claim;
   2. (b) The insurer's decision to deny policy coverage is binding upon a policyholder or other claimant or is otherwise entitled to deference upon appeal or review;
   3. (c) On appeal or review the insurer's decision-making power as to policy coverage is binding or otherwise entitled to deference;
   4. (d) The insurer's interpretation of the terms of a policy is binding upon a policyholder or other claimant or is otherwise entitled to deference;
   5. (e) On appeal the insurer's interpretation of the terms of a policy is binding or is otherwise entitled to deference;
   6. (f) A standard of review on appeal that gives deference in the original claim decision, or gives rise to such standard of review;
   7. (g) A standard of review on appeal other than a de novo review, or gives rise to a standard of review other than de novo;
   8. (h) The insurer has discretion to determine whether a claim is compensable or to interpret the provisions of the policy or certificate;
3. (3) "Policy," any plan, certificate, contract, policy, and agreement that provides for health insurance as defined by SDCL 58-9-3 or otherwise provides health or disability benefits.

Source: 35 SDR 48, effective September 8, 2008.

General Authority: SDCL 58-2-39 , 58-17-87 , 58-18-79 , 58-18-79(14) , 58-29D-34.

Law Implemented: SDCL 58-17-87 , 58-18-79 , 58-29D-23 , 58-29D-31(2 )( 6), 58-33-67.