24-A §2204. Definitions - Maine Statutes

Title 24-A: MAINE INSURANCE CODE

Chapter 24: INSURANCE INFORMATION AND PRIVACY PROTECTION ACT HEADING: PL 1997, C. 677, §3 (NEW)

§2204. Definitions

As used in this chapter, unless the context indicates otherwise, the following terms have the following meanings. [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

1. Adverse underwriting decision. "Adverse underwriting decision" means any of the following actions with respect to consumer insurance transactions involving insurance coverage that is individually underwritten:

A. A declination, cancellation or nonrenewal of insurance coverage, in whole or part; [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

B. Failure of a producer or agency to apply for insurance coverage with a specific insurance institution that the producer or agency represents and that is requested by an applicant; [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

C. An offer to insure at higher than standard rates; or [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

D. Any other increase in any charge for, any reduction in or other adverse or unfavorable change in the terms of coverage or amount of any insurance, existing or applied for. [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

2. Affiliate; affiliated. "Affiliate" or "affiliated" means a person that directly, or indirectly through one or more intermediaries, controls, is controlled by or is under common control with another person.

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

3. Applicant. "Applicant" means any person who seeks to contract for insurance coverage other than a person seeking group insurance that is not individually underwritten.

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

4. Confidential investigative information. "Confidential investigative information" means any information that:

A. Relates to a claim for insurance benefits or a civil or criminal proceeding involving an individual; [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

B. Is collected in connection with or in reasonable anticipation of a claim for insurance benefits or a civil or criminal proceeding involving an individual; and [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

C. Has not been disclosed to 3rd parties in violation of section 2215. [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

5. Consumer insurance transaction. "Consumer insurance transaction" means an insurance transaction involving insurance primarily for personal, family or household needs rather than business or professional needs.

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

6. Consumer report. "Consumer report" has the same meaning as in Title 10, section 1312, subsection 3.

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

7. Consumer reporting agency. "Consumer reporting agency" has the same meaning as in Title 10, section 1312, subsection 4.

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

8. Control; controlled by; under common control with. "Control," including the terms "controlled by" and "under common control with," means the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other than a commercial contract for goods or nonmanagement services or otherwise, unless the power is the result of an official position with or a corporate office held by the person.

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

9. Health care. "Health care" means preventative, diagnostic, therapeutic, rehabilitative, maintenance or palliative care, services, procedures or counseling, including appropriate assistance with disease or symptom management and maintenance, that affects an individual's physical, mental or behavioral condition, including individual cells or their components or genetic information, or affects the structure or function of the human body or any part of the human body. "Health care" includes prescribing, dispensing, furnishing or providing to a patient drugs, biologicals, medical devices, health care equipment and supplies or hospice services and the banking of blood, sperm, organs or any other tissue.

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

10. Health care facility. "Health care facility" means a facility, institution or entity licensed pursuant to Title 22 that offers health care to persons in this State, including a home health care entity and a hospice program, or a pharmacy licensed pursuant to Title 32. For the purposes of this chapter, "health care facility" does not include a state mental health institute, the Elizabeth Levinson Center, the Aroostook Residential Center or Freeport Towne Square.

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

11. Health care information. "Health care information" means information that:

A. Relates to an individual's physical, mental or behavioral condition, personal or family medical history or health care; and [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

B. Is obtained from a health care provider, from the individual or from the individual's spouse, parent or legal guardian. [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

12. Health care practitioner. "Health care practitioner" means a person licensed in this State to provide or otherwise lawfully providing health care, and includes a partnership or corporation made up of health care practitioners, or an officer, employee, agent or contractor of a health care practitioner acting in the course and scope of employment, agency or contract related to or supportive of the provision of health care to an individual.

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

13. Health care provider. "Health care provider" means a health care practitioner or health care facility.

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

14. Institutional source. "Institutional source" means any person or governmental entity that provides information about an individual to a regulated insurance entity or insurance support organization other than:

A. A producer or producer agency; [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

B. The individual who is the subject of the information; or [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

C. An individual acting in a personal capacity rather than in a business or professional capacity. [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

15. Insurance carrier; carrier. "Insurance carrier" or "carrier" means:

A. Any person or entity required to be licensed by the superintendent to assume risk, including without limitation an insurer, nonprofit hospital, medical or health care service organization, health maintenance organization or multiple-employer welfare arrangement; [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

B. A self-funded plan subject to state regulation as described in section 2848-A; [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

C. A preferred provider arrangement administrator as defined in section 2671; or [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

D. A 3rd-party administrator, as described in section 1901, that provides administrative services for an entity that is not a carrier. [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

"Carrier" does not include other nonrisk-bearing regulated insurance entities, such as producers or agencies.

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

16. Insurance consumer; consumer. "Insurance consumer" or "consumer" means any individual who resides or obtains insurance in this State and:

A. Is a past, present or proposed principal insured or certificate holder; [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

B. Is a past, present or proposed policyowner; [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

C. Is a past or present applicant; [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

D. Is a past or present claimant; or [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

E. Derived, derives or is proposed to derive insurance coverage under an insurance policy or certificate subject to this chapter. [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

17. Insurance support organization. "Insurance support organization" means any person, other than a regulated insurance entity, health care provider or governmental agency, who regularly engages, in whole or in part, in the practice of assembling or collecting information for the primary purpose of providing the information to carriers, producers or agencies for insurance transactions, including:

A. Furnishing consumer reports or investigative consumer reports for use in connection with insurance transactions; or [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

B. Collecting personal information from regulated insurance entities or other insurance support organizations for the purpose of detecting or preventing fraud, material misrepresentation or material nondisclosure in connection with insurance underwriting or insurance claim activity. [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

18. Insurance transaction. "Insurance transaction" means any transaction that entails:

A. The determination of an individual's eligibility for an insurance coverage, benefit or payment; or [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

B. The servicing of an insurance application, policy, contract or certificate. [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

19. Investigative consumer report. "Investigative consumer report" has the same meaning as in Title 10, section 1312, subsection 7.

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

20. Personal information. "Personal information" means any information that identifies an individual gathered in connection with an insurance transaction from which judgments can be made about an individual's character, habits, avocations, finances, occupation, general reputation, credit, health or any other personal characteristics. "Personal information" includes but is not limited to an individual's name and address and health care information.

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

21. Policyholder. "Policyholder" means any person who:

A. Is a present policyowner; or [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

B. In the case of group insurance that is individually underwritten, is a present group certificate holder. [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

22. Pretext interview. "Pretext interview" means an interview wherein a person, in an attempt to obtain information, performs one or more of the following acts:

A. Pretends to be someone the person is not; [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

B. Pretends to represent a person that person is not in fact representing; [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

C. Misrepresents the true purpose of the interview; or [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

D. Refuses to provide that person's identity upon request. [1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF).]

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

23. Regulated insurance entity. "Regulated insurance entity" means any person or entity required to be licensed by the superintendent under this Title or Title 24, including without limitation a carrier, producer, producer agency or administrator.

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

24. Residual market. "Residual market" means any special-purpose insurer, association, organization or other entity that provides insurance coverage to persons who are unable to obtain it in the voluntary market.

[ 1997, c. 677, §3 (NEW); 1997, c. 677, §5 (AFF) .]

SECTION HISTORY

1997, c. 677, §3 (NEW). 1997, c. 677, §5 (AFF).