1. (1)(a) A contract may not establish a probationary period when coverage is not provided, except under Subsection (1)(b), (1)(c), or (1)(d).

   1. (b) A contract may specify a probationary period not to exceed six months for a loss resulting from:

      1. (i) adenoids;
      2. (ii) appendix;
      3. (iii) disorder of a reproductive organ;
      4. (iv) hernia;
      5. (v) tonsils; or
      6. (vi) varicose veins.
   2. (c) Coverage shall be provided for a disease, condition, or procedure in Subsection (1)(b) if the disease, condition, or procedure is treated on an emergency basis.
   3. (d) A probationary period for a specified disease insurance contract may not exceed 30 days.
   4. (e) An accident insurance contract may not include a probationary period.

2. (2) Unless otherwise required by law, a contract may not limit or exclude coverage or benefits by type of illness, accident, injury, treatment, or medical condition, except:

   1. (a) abortion;
   2. (b) acupuncture or acupressure;
   3. (c) administrative charge for completing an insurance form, duplication service, interest, finance charge, or other administrative charge, unless otherwise required by law;
   4. (d) administrative exam or service;
   5. (e) allergy test or treatment;
   6. (f) aviation, to a non-fare-paying passenger;
   7. (g) axillary hyperhidrosis;

   8. (h) benefits paid for under:

      1. (i) employer's liability or occupational disease law;
      2. (ii) Medicare or another governmental program, except Medicaid; or
      3. (iii) state or federal workers' compensation;
      4. (i) charge for a missed appointment;
   9. (j) chiropractic care;

   10. (k) complementary or alternative medicine;

       1. (l) corrective lens, including an examination for the prescription or fitting, except lens implant following cataract surgery;

   11. (m) cosmetic surgery, including reversal, revision, repair, complication, or treatment related to a non-covered cosmetic surgery, except reconstructive surgery:

       1. (i) when the service is incidental to or follows surgery resulting from trauma, infection, or other disease of the involved part; or
       2. (ii) due to a congenital disease or anomaly of a covered dependent child that resulted in a functional defect;
   12. (n) custodial care;
   13. (o) dental care or treatment, except a dental contract;
   14. (p) dietary products;
   15. (q) educational or nutritional training, except as required under Rule R590-200;
   16. (r) experimental or investigational service;
   17. (s) felony, riot, or insurrection, when it is determined the insured was a voluntary participant;
   18. (t) fitness training, exercise equipment, or a membership to a spa or health club;

   19. (u)(i) foot care for a corn, a callus, a flat foot, a fallen arch, a weak foot, chronic foot strain, or symptomatic complaints of a foot, including an orthotic; and

       1. (ii) the cutting or removal of a corn, a callus, or a nail may not be excluded when provided to an insured who has a systemic disease, such as diabetes with peripheral neuropathy or circulatory insufficiency if unskilled performance of the procedure would be hazardous;
       2. (v)(i) gastric or intestinal bypass service, including lap banding, gastric stapling, or a similar procedure to facilitate weight loss;
       3. (ii) the reversal or revision of a procedure in Subsection (2)(v)(i); or
       4. (iii) a service required for the treatment of a complication from a procedure in Subsection (2)(v)(i);

   20. (w) gender reassignment;

       1. (x) gene therapy;
   21. (y) genetic testing;
   22. (z) hearing aid, including examination for the prescription or fitting;
   23. (aa) incarceration, limited to income replacement insurance;
   24. (bb) infertility service;
   25. (cc) injury as a result of a motor vehicle, to the extent the insured is required to have no-fault coverage, up to the minimum coverage required by law, whether or not such coverage is in effect;
   26. (dd) mental health condition or substance use disorder services;
   27. (ee) nuclear release;
   28. (ff) preexisting condition, except as required under Section 31A-22-605.1 and Subsection 31A-22-610(2);
   29. (gg) pregnancy, except for a complication of pregnancy;

   30. (hh) refractive eye surgery;

       1. (ii) rehabilitation therapy service, such as physical, speech, and occupational, unless required to correct an impairment caused by a covered accident, injury, or illness;
   31. (jj) respite care;

   32. (kk) rest cure;

       1. (ll) routine physical examination;
   33. (mm) services performed by an insured's parent, spouse, sibling, or child, including a step or in-law relationship;
   34. (nn) services performed by an employee of a hospital, laboratory, or other institution;
   35. (oo) services for which no charge is normally made in the absence of insurance;
   36. (pp) services while in the armed forces or an auxiliary unit;
   37. (qq) sexual dysfunction procedure, equipment, or drug;
   38. (rr) shipping or handling;
   39. (ss) suicide, sane or insane, attempted suicide, or intentionally self-inflicted injury;
   40. (tt) telephone or electronic consultation;

   41. (uu) territorial limitation outside the United States, except as required under Section 31A-22-627;

       1. (vv) terrorism, including an act of terrorism;

   42. (ww) transplant;

       1. (xx) transportation;
   43. (yy) treatment provided in a government hospital, except for fixed indemnity insurance;
   44. (zz) war or act of war, whether declared or undeclared;

   45. (aaa) except under Subsection (2)(bbb), a loss directly related to the insured's voluntary participation in an activity when the insured:

       1. (i) is found guilty of an illegal activity in a criminal proceeding, including a plea of guilty, a no contest plea, and a plea in abeyance; or
       2. (ii) is found liable for the activity in a civil proceeding;

   46. (bbb) a loss established under Subsection (3) that is directly related to the insured violating:

       1. (i) Section 41-6a-502, if the loss occurred in Utah; or
       2. (ii) a law in a state other than Utah that prohibits operating a motor vehicle while exceeding the legal limit of concentration of alcohol, drugs, or a combination of both, in the blood, if the loss occurred in the other state; or
   47. (ccc) any other exclusion that, in the opinion of the commissioner, is not inequitable, misleading, deceptive, obscure, unjust, unfair, or unfairly discriminatory to an insured.

3. (3)(a) A violation under Subsection (2)(bbb) shall be established:

   1. (i) in a criminal proceeding in which the insured is found guilty, enters a no contest plea, a plea in abeyance, or enters into a diversion agreement; or

      1. (ii) by a request for an independent review when the findings support a decision to deny coverage based on the exclusion.

   2. (b)(i) For purposes of Subsection (3)(a)(ii), an independent review means a process that:

      1. (A) is conducted by an independent entity designated by the insurer;
      2. (B) renders an independent and impartial decision on a decision to deny coverage based on the exclusion; and
      3. (C) is paid for by the insurer.

      4. (ii) The independent review entity may not have a material professional, familial, or financial conflict with:

         1. (A) the insurer;
         2. (B) an officer, director, or management employee of the insurer;
         3. (C) the insured;
         4. (D) the insured's health care provider;
         5. (E) the health care provider's medical group or independent practice association; or
         6. (F) a health care facility where services were provided.
   3. (c) The exclusion in Subsection (2)(bbb) does not apply to an insured who is under age 18.

4. (4)(a) An insurer may use a waiver to exclude, limit, or reduce coverage or benefits for a specifically named or described preexisting condition, physical condition, or extra hazardous activity.

   1. (b) A signed acceptance by the insured is required if a waiver is required as a condition of issuance, renewal, or reinstatement.
5. (5) A contract provision precluded in this section may not be construed as a limitation on the commissioner's authority to prohibit a contract provision that, in the opinion of the commissioner, is unjust, unfair, or unfairly discriminatory to an insured.

KEY: health insurance

Date of Last Change: May 8, 2026

Notice of Continuation: December 8, 2021

Authorizing, and Implemented or Interpreted Law: 31A-2-201; 31A-2-202; 31A-21-201; 31A-22-605; 31A-22-623; 31A-22-626; 31A-23a-402; 31A-26-301