(a) No group
short-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 in this section, is completed as to such certificate or subscriber
agreement 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 or certificate
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 that is capitalized or underscored
in the standard format outline of coverage may be emphasized by other means
that 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:
(INSURER NAME)
(ADDRESS - CITY & STATE)
(TELEPHONE NUMBER)
GROUP SHORT-TERM CARE INSURANCE
OUTLINE OF COVERAGE
(Policy or Certificate Number)
(Except for certificates that 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 group short-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 insurer 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 insurer at this address: (Insert address).
(1) This certificate that 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 policies or certificates available to you. This is not an
insurance contract, but only a summary of coverage. Only the policy or
certificate contains governing contractual provisions. This means that the
policy and certificate set forth in detail the rights and obligations of both
you and the insurer. 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
certificate.)
(B) (Include a
statement that the policy or certificate 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 or certificate. Include a description of all such refund
provisions.)
(4) THIS IS
NOT MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare, review the
"Guide to Health Insurance For People With Medicare" available from the
insurer.
(A) (For producers) Neither (insert
insurer name) nor its agents represent Medicare, the federal government or any
state government.
(B) (For direct
response) (insert insurer name) is not representing Medicare, the federal
government or any state government.
(5) THIS IS NOT A LONG-TERM CARE POLICY OR
CERTIFICATE . IT IS NOT TAX QUALIFIED AND DOES NOT PROVIDE ASSET
PROTECTION.
(6) SHORT-TERM CARE
COVERAGE. Policies or certificates 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 for a limited time.
This policy provides coverage in the form of a fixed dollar
indemnity benefit for covered short-term care expenses, subject to policy
(limitations) (waiting periods) and (coinsurance) requirements. (Modify this
paragraph if the policy is not an indemnity policy)
(7) BENEFITS PROVIDED BY THIS (choose one:
POLICY, or CERTIFICATE).
(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 are used to determine an
insured's eligibility for benefits then these shall be explained.)
(8) LIMITATIONS AND
EXCLUSIONS Describe:
(A) Any pre-existing
conditions provision;
(B)
Non-eligible facilities or providers (e.g., unlicensed providers, care or
treatment provided by a family member);
(C) Non-eligible levels of care;
(D) Exclusions and exceptions; and
(E) Other limitations.
(This section should provide a brief specific description of
any policy or certificate provisions that limit, exclude, restrict, reduce,
delay or in any other manner operate to qualify payment of the benefits
described in (7) above.)
THIS CERTIFICATE MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH
YOUR SHORT TERM CARE NEEDS.
(9) RELATIONSHIP OF COST OF CARE AND
BENEFITS. Because the costs of short-term care services will likely increase
over time, you should consider whether and how the benefits of this group
short-term care policy 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, whether additional underwriting or health
screening will be required, the frequency and amounts of the upgrade options
and any significant restrictions or limitations; and
(E) Whether there will be any additional
premium charge imposed, and describe how that is to be calculated.)
(10) TERMS UNDER WHICH THE
CERTIFICATE MAY BE CONTINUED IN FORCE OR DISCONTINUED.
(A) (Describe certificate provisions for
continuation of coverage);
(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 insurer has a
right to change premium and, if such a right exists, describe clearly and
concisely each circumstance under which premium may change.)
(11) ALZHEIMER'S DISEASE AND OTHER
ORGANIC BRAIN DISORDERS (State that the certificate 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 benefits.)
(12) PREMIUM
(A) "State the total annual premium for the
certificate or subscriber agreement";
(B) (If the premium varies with an
applicant's choice among benefit options, indicate the portion of annual
premium that corresponds to each benefit option.)
(13) ADDITIONAL FEATURES
(A) "Indicate whether medical underwriting is
used";
(B) (Describe other
important features of the certificate.)
