For the purposes of this chapter, the term
(1) “Director” means the Director of the Department of Health Care Finance.”.
(2) “Emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in (i) placing the health of the individual in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part.
(3) “Grievance” means a written request by a member or a member representative for review of a decision of an insurer to deny, reduce, limit, terminate or delay covered health care services to a member.
(4) “Grievance decision” means a determination accepting or denying the basis or requested remedy of the grievance.
(5) “Health benefits plan” means a group or individual insurance policy or contract, medical or hospital service agreement, membership or subscription contract, or similar group arrangement provided by an insurer or subcontracting facility of an insurer for the purpose of providing, paying for, or reimbursing expenses for health related services. “Health benefits plan” does not include disability income or accident only insurance.
(6) “Health care services” means items or services provided under the supervision of a physician or other person trained or licensed to render health care necessary for the prevention, care, diagnosis, or treatment of human disease, pain, injury, deformity or other physical or mental condition including the following: pre-admission, outpatient, inpatient, and post-discharge care; home care; physician's care; nursing care; medical care provided by interns or residents in training; other paramedical care; ambulance service and care; bed and board; drugs; supplies; appliances; equipment; laboratory services; any form of diagnostic imaging or therapeutic radiological services; and services mandated under Chapter 31 of Title 31.
(7) “Independent review organization” means an impartial, certified health entity engaged by the Director to review any adverse grievance decision by an insurer, including an insurer's decision to deny, terminate, or limit covered health care services.
(8) “Insurer” means any individual, partnership, corporation, association, fraternal benefit association, hospital and medical services corporation, health maintenance organization, or other business entity that issues, amends, or renews group or individual health insurance policies or contracts, including health maintenance organization membership contracts in the District.
(9) “Member” means an individual who is enrolled in a health benefits plan.
(10) “Member representative” means any person acting on behalf of a member with the member's consent.
(11) “Urgent medical condition” means a condition which, if not treated within 24 hours, could reasonably be expected to result in (i) placing the health of the individual in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part.
CREDIT(S)
(Apr. 27, 1999, D.C. Law 12-274, § 101, 46 DCR 1294; Aug. 16, 2008, D.C. Law 17-219, § 5025, 55 DCR 7598.)
HISTORICAL AND STATUTORY NOTES
Prior Codifications
1981 Ed., § 32-571.1.
Effect of Amendments
D.C. Law 17-219, in par. (1), substituted “Department of Health Care Finance” for “District of Columbia Department of Health”.
Temporary Amendments of Section
Section 2(a) of D.C. Law 19-63 added par. (10A) to read as follows:
“(10A) ‘Month’ means the period that runs from a given day in one month through the date preceding the numerically corresponding day in the next month.”.
Section 4(b) of D.C. Law 19-63 provides that the act shall expire after 225 days of its having taken effect.
Emergency Act Amendments
For temporary (90 day) amendment of section, see § 2(a) of Health Benefits Plan Grievance Emergency Amendment Act of 2011 (D.C. Act 19-166, October 11, 2011, 58 DCR 8898).
For temporary (90 day) amendment of section, see § 2(a) of the Health Benefits Plan Grievance Emergency Amendment Act of 2012 (D.C. Act 19-409, July 24, 2012, 59 DCR 9135).
Legislative History of Laws
Law 12-274, the “Health Benefits Plan Members Bill of Rights Act of 1998,” was introduced in Council and assigned Bill No. 12-501. The Bill was adopted on first and second readings on December 1, 1998, and December 15, 1998, respectively. Signed by the Mayor on December 29, 1998, it was assigned Act No. 12-607 and transmitted to both Houses of Congress for its review. D.C. Law 12-274 became effective on April 27, 1999.
For Law 17-219, see notes following § 44-114.01.
Miscellaneous Notes
Short title: Section 5024 of D.C. Law 17-219 provided that subtitle J of title V of the act may be cited as the “Health Benefits Plan Members Bill of Rights Amendment Act of 2008”.