58-18A-56. Exclusion of certain expenses.
177 words·~1 min read·
/sd/title-58/chapter-58-18/58-18a-56·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
For the purposes of this chapter, the term, allowable expense, may exclude certain types of coverage or benefits such as dental care, vision care, prescription drugs, or hearing aids. A plan that limits the application of COB to certain coverages or benefits may limit the definition of allowable expense in its contract to expenses that are similar to the expenses that it provides. If COB is restricted to specific coverages or benefits in a contract, the definition of allowable expense shall include similar expenses to which COB applies.
If a plan provides benefits in the form of services, the reasonable cash value of each service shall be considered an allowable expense and a benefit paid.
The amount of the reduction may be excluded from allowable expense if a covered person's benefits are reduced under a primary plan because the covered person does not comply with the plan provisions concerning second surgical opinions or pre-certification of admissions or services, or because the covered person has a lower benefit because the covered person did not use a preferred provider.