WAC 284-23-620   Definitions.  Unless the context clearly requires otherwise, the definitions in this section apply throughout this regulation.

     (1) "Accelerated benefits" means benefits payable under an individual or group life insurance policy. They are primarily mortality risks, rather than morbidity risks. Accelerated benefits may also mean optional modes of settlement of proceeds under life insurance policies. Accelerated benefits are benefits:

     (a) Payable to either the policyholder of an individual life policy or to the certificate holder of a group life policy, during the lifetime of the insured, in anticipation of death, or upon the occurrence of certain specified life-threatening, terminal, or catastrophic conditions defined by the policy or rider as described in subsection (3) of this section; and

     (b) Which reduce or eliminate the death benefit otherwise payable under the life insurance policy or rider; and

     (c) Which are payable upon the occurrence of a single qualifying event which results in the payment of a benefit amount fixed at the time the accelerated benefit is paid.

     (2) "Qualified actuary" means a person who is a qualified actuary as defined in WAC 284-05-060.

     (3) "Qualifying event" means one or more of the following:

     (a) A medical condition which a physician has certified is reasonably expected to result in death twenty-four months or less after the date of certification;

     (b) A medical condition which has required or requires extraordinary medical intervention; for example, major organ transplants or the use of continuous life support, without which the insured would die;

     (c) Any condition which usually requires continuous confinement in any eligible institution as defined in the policy or rider, if the insured is expected to remain there for the rest of his or her life;

     (d) Any medical condition which, in the absence of extensive or extraordinary medical treatment, would result in a drastically limited life span of the insured. Such medical conditions may include, for example:

     (i) Coronary artery disease resulting in an acute infarction or requiring surgery;

     (ii) Permanent neurological deficit resulting from cerebral vascular accident;

     (iii) End stage renal failure;

     (iv) Acquired immune deficiency syndrome; or

     (v) Other medical conditions which the insurance commissioner approves for any particular filing;

     (e) Any condition which requires either community-based care or institutional care; or

     (f) A medical condition that results in an insured being certified by a licensed health care practitioner as chronically ill by meeting either or both of the following standards within the preceding twelve-month period:

     (i) The insured is expected to be unable to perform (without substantial assistance from another individual) at least two activities of daily living without a deficiency for a period of at least ninety days due to a loss of functional capacity; or

     (ii) The insured requires substantial supervision to protect himself or herself from threats to health and safety due to severe cognitive impairment.

     (4) "Community based care" means services including, but not limited to: (a) Home delivered nursing services or therapy; (b) custodial or personal care; (c) day care; (d) home and chore aid services; (e) nutritional services, both in-home and in a communal dining setting; (f) respite care; (g) adult day health care services; or (h) other similar services furnished in a home-like or residential setting that does not provide overnight care. Such services shall be provided at any level of care.

     (5) "Institutional care" means care provided in a hospital, nursing home, or other facility certified or licensed by the state primarily affording diagnostic, preventive, therapeutic, rehabilitative, maintenance or personal care services. Such a facility provides twenty-four-hour nursing services on its premises or in facilities available to the institution on a formal prearranged basis.

     (6) "Activities of daily living" on which an insurer intends to rely as a measure of functional incapacity shall be defined in the policy, and shall include all of the following:

     (a) Bathing: The ability of the insured to wash himself or herself either in the tub or shower or by sponge bath, including the task of getting into or out of a tub or shower.

     (b) Continence: The ability of the insured to control bowel and bladder functions; or in the event of incontinence, the ability to perform associated personal hygiene (including caring for catheter or colostomy bag).

     (c) Dressing: The ability of the insured to put on and take off all items of clothing, and necessary braces, fasteners, or artificial limbs.

     (d) Eating: The ability of the insured to feed himself or herself by getting food and drink from a receptacle (such as a plate, cup, or table) into the body.

     (e) Toileting: The ability of the insured to get to and from the toilet, get on and off the toilet, and perform associated personal hygiene.

     (f) Transferring: The ability of the insured to move in and out of a chair, bed, or wheelchair.

     (7) "Licensed health care practitioner" means any physician, any registered professional nurse, or registered social worker.

     (8) "Substantial assistance" means:

     (a) "Hands-on assistance" - the physical assistance of another person without which the insured would be unable to perform the activity of daily living; and

     (b) "Standby assistance" - the physical presence of another person within arm's reach of the insured that is necessary to prevent, by physical intervention, injury to the insured while the insured is performing the activity of daily living.

     (9) "Severe cognitive impairment" means a loss or deterioration in intellectual capacity that is:

     (a) Comparable to (and includes) Alzheimer's disease and similar forms of irreversible dementia; and

     (b) Measured by clinical evidence and standardized tests that reliably measure impairment in the insured's (i) short-term or long-term memory, (ii) orientation as to people, places, or time, and (iii) deductive or abstract reasoning.

     (10) "Substantial supervision" means continual supervision (which may include cuing by verbal prompting, gestures, or other demonstrations) by another person that is necessary to protect the insured from threats to his or her health or safety.



[Statutory Authority: RCW 48.02.060, 48.30.010 and 48.11.020. 98-05-026 (Matter No. R 96-13), § 284-23-620, filed 2/6/98, effective 3/9/98. Statutory Authority: RCW 48.02.060 (3)(a) and48.30.010 . 94-18-029 (Order R 94-18), § 284-23-620, filed 8/29/94, effective 9/29/94.]