(a) No long-term
care certificate 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 certificate, 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 the time when the
certificate is delivered.
(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 certificates which are guaranteed issue, the
following caution statement, or language substantially similar, must appear as
follows in the outline of coverage.)
Caution: The issuance of this long-term care insurance
certificate 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 coverage. 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 certificate, which was delivered in
Connecticut, evidences coverage under a group policy of insurance.
2. PURPOSE OF OUTLINE OF COVERAGE. This
outline of coverage provides a very brief description of the important features
of your coverage. You should compare this outline of coverage to outlines of
coverage for other insurance available to you. This is not an insurance
contract, but only a summary of coverage. Only the group policy and your
certificate contain the governing contractual provisions of your insurance.
This means that the certificate and the group policy set 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 CERTIFICATE CAREFULLY!
3.
TERMS UNDER WHICH THE CERTIFICATE 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 INSURANCE MAY BE
CONTINUED IN FORCE OR DISCONTINUED.
(a)
(Describe policy provisions for continuation or conversion);
(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.
