(a) No long-term
care policy shall be delivered or issued for delivery to any resident of this
state unless an appropriate outline of coverage in the format prescribed herein
is completed as to such policy, and is delivered to the applicant at the time
application or solicitation is made and acknowledgement of receipt or
certification of delivery of such outline of coverage is provided to the
insurer. In the case of direct response solicitations, the insurer shall
deliver the outline of coverage upon the applicant's request, but regardless of
such request, shall make such delivery no later than at the time of policy
delivery.
(b) The outline of
coverage shall be a free standing document, using no smaller than twelve point
type.
(c) The outline of coverage
shall contain no material of an advertising nature.
(d) Text which is capitalized or underscored
in the standard format outline of coverage may be emphasized by other means
which provide prominence equivalent to such capitalization or
underscoring.
(e) Use of the text
and sequence of text of the standard format outline of coverage is mandatory,
unless otherwise specifically indicated.
(f) Format for outline of coverage:
|
(COMPANY NAME) |
|
(ADDRESS - CITY & STATE) |
|
(TELEPHONE NUMBER) |
|
LONG-TERM CARE INSURANCE |
|
OUTLINE OF COVERAGE |
|
(Policy Number) |
(Except for policies which are guaranteed issue, the
following caution statement, or language substantially similar, shall appear as
follows in the outline of coverage.)
Caution: The issuance of this long-term care insurance policy
is based upon your responses to the questions on your application. A copy of
your application (is enclosed) (was retained by you when you applied). If your
answers are incorrect or untrue, the company has the right to deny benefits or
rescind your policy. The best time to clear up any questions is now before a
claim arises! If, for any reason, any of your answers are incorrect, contact
the company at this address: (insert address)
1. This policy is an individual policy of
insurance which was issued in Connecticut.
2. PURPOSE OF OUTLINE OF COVERAGE. This
outline of coverage provides a very brief description of the important features
of the policy. You should compare this outline of coverage to outlines of
coverage for other policies available to you. This is not an insurance
contract, but only a summary of coverage. Only the individual policy contains
governing contractual provisions. This means that the policy sets forth in
detail the rights and obligations of both you and the insurance company.
Therefore, if you purchase this coverage, or any other coverage, it is
important that you READ YOUR POLICY CAREFULLY!
3. TERMS UNDER WHICH THE POLICY MAY BE
RETURNED AND PREMIUM REFUNDED.
(a) (Provide a
brief description of the right to return-"free look" provision of the
policy.)
(b) (Include a statement
that the policy contains provisions providing for a refund or partial refund of
premium upon the death of an insured and does or does not contain provisions
providing for such a refund upon surrender of the policy. Include a description
of all such refund provisions.)
4. THIS IS NOT MEDICARE SUPPLEMENT COVERAGE.
If you are eligible for Medicare, review the Medicare Supplement Buyer's Guide
available from the insurance company.
(a) (For
agents) Neither (insert company name) nor its agents represent Medicare, the
federal government or any state government.
(b) (For direct response) (insert company
name) is not representing Medicare, the federal government or any state
government.
5. LONG-TERM
CARE COVERAGE. Policies of this category are designed to provide coverage for
one or more necessary or medically necessary diagnostic, preventive,
therapeutic, rehabilitative, maintenance, or personal care services, provided
in a setting other than an acute care unit of a hospital, such as in a nursing
home, in the community or in the home.
This policy provides coverage in the form of a fixed dollar
indemnity benefit for covered long-term care expenses, subject to policy
(limitations) (waiting periods) and (coinsurance) requirements (Modify this
paragraph if the policy is not an indemnity policy.)
6. BENEFITS PROVIDED BY THIS POLICY.
(a) (Covered services, related deductible(s),
waiting periods, elimination periods and benefit maximums.)
(b) (Institutional benefits, by level of care
provided.)
(c) (Non-institutional
benefits, by level of care provided.)
(An explanation of any qualifying criteria used to determine
an insured's eligibility for benefits shall accompany each benefit description.
If an attending physician or other specified person must certify to a loss of
functional capacity in order for the insured to be eligible for benefits, this
shall be specified. If activities of daily living (ADLs) are used to determine
an insured's eligibility for benefits then these shall be explained.)
7. LIMITATIONS AND
EXCLUSIONS
(Describe:
(a) Any
pre-existing conditions provision;
(b) Non-eligible facilities/providers (e.g.,
unlicensed providers, care or treatment provided by a family member,
etc.);
(c) Non-eligible levels of
care;
(d)
Exclusions/exceptions;
(e) Other
limitations)
(This section should provide a brief specific description of
any policy provisions which limit, exclude, restrict, reduce, delay, or in any
other manner operate to qualify payment of the benefits described in (6)
above.)
THIS POLICY MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH
YOUR LONG-TERM CARE NEEDS.
8. RELATIONSHIP OF COST OF CARE AND BENEFITS.
Because the costs of long-term care services will likely increase over time,
you should consider whether and how the benefits of this plan may be adjusted.
(As applicable, indicate the following:
(a)
That the benefit level will not increase over time;
(b) Any automatic benefit adjustment
provision;
(c) Whether the insured
will be guaranteed the option to buy additional benefits and the basis upon
which benefits will be increased over time if not by a specified amount or
percentage;
(d) If there is such a
guarantee, indicate whether additional underwriting or health screening will be
required, the frequency and amounts of the upgrade options, and any significant
restrictions or limitations;
(e)
And finally, indicate whether there will be any additional premium charge
imposed, and describe how that is to be calculated.)
9. TERMS UNDER WHICH THE POLICY MAY BE
CONTINUED IN FORCE OR DISCONTINUED.
(a)
(Describe policy renewability provisions);
(b) (Describe waiver of premium provisions,
including whether the insured is entitled to a refund of unearned premium in
the event of a waiver);
(c) (State
whether or not the company has a right to change premium, and if such a right
exists, describe clearly and concisely each circumstance under which premium
may change.)
10.
ALZHEIMER'S DISEASE AND OTHER ORGANIC BRAIN DISORDERS (State that the policy
provides coverage for insureds clinically diagnosed as having Alzheimer's
disease or related degenerative and dementing illnesses. Specifically describe
any qualifying criteria that determines such an insured's eligibility for
policy benefits.)
11. PREMIUM
(a) State the total annual premium for the
policy;
(b) if the premium varies
with an applicant's choice among benefit options indicate the portion of annual
premium which corresponds to each benefit option.)
12. ADDITIONAL FEATURES
(a) Indicate whether medical underwriting is
used;
(b) Describe other important
features.)
