31A-22-644. Denial of coverage under a health benefit plan because of life expectancy or terminal condition.

377 words·~2 min read·/ut/title-31a/chapter-22/31a-22-644

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Effective 5/12/2015

(1)As used in this section:

(a)"Health benefit plan" means the same as that term is defined in Section 31A-1-301 .

(b)"Terminal condition" means an irreversible condition:

(i)caused by disease, illness, or injury; and

(ii)if:

(A)the irreversible condition will result in imminent death within a six-month period after the date the condition is diagnosed; and

(B)the application of life-sustaining treatment only prolongs the process of dying.

(2)This section applies to a health benefit plan under:

(a)this part; or

(b)Chapter 8, Health Maintenance Organizations and Limited Health Plans .

(3)Except as provided by law, and subject to the other provisions of this section, a health benefit plan may not deny coverage for medically necessary treatment if the medically necessary treatment is:

(a)prescribed by a physician;

(b)agreed to:

(i)by a person who is:

(A)insured under the health benefit plan; and

(B)fully informed regarding the person's life expectancy or diagnosis with a terminal condition; or

(ii)if the person described in Subsection (3)(b)(i) lacks legal capacity to consent, by another person who:

(A)has legal authority to consent on behalf of the person described in Subsection (3)(b)(i) ; and

(B)is fully informed regarding the life expectancy or diagnosis with a terminal condition of the person described in Subsection (3)(b)(i) ; and

(c)denied solely because:

(i)of the life expectancy of the person described in Subsection (3)(b)(i) ; or

(ii)the person has been diagnosed with a terminal condition.

(4)A denial of coverage described in Subsection

(3)for medically necessary treatment is a violation of this section.

(5)Whether treatment is considered to be medically necessary treatment is determined by the defined standards and policies of the health benefit plan.

(6)This section may not be interpreted to:

(a)require an insurer to offer a particular benefit or service as part of a health benefit plan; or

(b)alter the clinical policies of a health benefit plan regarding the appropriate location for services.

(7)This section does not create a new or additional private right of action.

Enacted by Chapter 375 , 2015 General Session