Mich. Admin. Code R. 500.2201 : Insurance and Financial Services —Insurance — Discretionary Clauses — Definitions

Rule 1. As used in these rules:

(a) "Appeal" means an appeal by a policyholder or other claimant of a claim denial by an insurer. It includes appeals to administrative agencies, arbitrators, courts, and mediators.
(b) "Commissioner" means the commissioner of the office of financial and insurance services.
(c) "Discretionary clause" is a provision in a form that purports to bind the claimant to or grant deference in subsequent proceedings to the insurer's decision, denial, or interpretation on terms, coverage, or eligibility for benefits including, but not limited to, a form provision that does any of the following:
(i) Provides that a policyholder or other claimant may not appeal a denial of a claim.
(ii) Provides that the insurer's decision to deny policy coverage is binding upon a policyholder or other claimant.
(iii) Provides that on appeal the insurer's decision-making power as to policy coverage is binding.
(iv) Provides that the insurer's interpretation of the terms of a form is binding upon a policyholder or other claimant.
(v) Provides that on appeal the insurer's interpretation of the terms of a form is binding.
(vi) Provides that or gives rise to a standard of review on appeal that gives deference to the original claim decision.
(vii) Provides that or gives rise to a standard of review on appeal other than a de novo review.
(d) "Form" means a form identified in MCL 500.2236(1).
(e) Terms defined in the insurance code of 1956, 1956 PA 218, MCL 500.100 to MCL 500.8302, have the same meanings when used in these rules.

Mich. Admin. Code R. 500.2201

2007 AACS