20:06:52:01. Definitions. Terms used in this chapter mean:
(1) "Appeal," any review or appeal before an administrative agency, arbitrator, court or mediator;
(2) "Discretionary clause," a provision in a policy that purports to bind the claimant to, or grant deference in, proceedings subsequent to the insurer's decision, denial, or interpretation on terms, coverage, or eligibility for benefits, including a policy provision that provides any of the following:
(a) A policyholder or other claimant may not appeal a denial of a claim;
(b) The insurer's decision to deny policy coverage is binding upon a policyholder or other claimant or is otherwise entitled to deference upon appeal or review;
(c) On appeal or review the insurer's decision-making power as to policy coverage is binding or otherwise entitled to deference;
(d) The insurer's interpretation of the terms of a policy is binding upon a policyholder or other claimant or is otherwise entitled to deference;
(e) On appeal the insurer's interpretation of the terms of a policy is binding or is otherwise entitled to deference;
(f) A standard of review on appeal that gives deference in the original claim decision, or gives rise to such standard of review;
(g) A standard of review on appeal other than a de novo review, or gives rise to a standard of review other than de novo;
(h) The insurer has discretion to determine whether a claim is compensable or to interpret the provisions of the policy or certificate;
(3) "Policy," any plan, certificate, contract, policy, and agreement that provides for health insurance as defined by SDCL 58-9-3 or otherwise provides health or disability benefits.
Source: 35 SDR 48, effective September 8, 2008.
General Authority: SDCL 58-2-39, 58-17-87, 58-18-79, 58-18-79(14), 58-29D-34.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-29D-23, 58-29D-31(2)(6), 58-33-67.
