Connecticut Administrative Code
Title 38a - Insurance Department
528a - Group Short-Term Care Insurance
Section 38a-528a-4 - Minimum standards
Current through March 14, 2024
No group insurance policy or certificate shall be advertised, solicited or issued for delivery in this state as a group short-term care policy or certificate that does not meet the minimum standards set forth in this section. The standards set forth in this section are minimum standards and do not preclude the inclusion of other provisions or benefits that are not inconsistent with these standards.
(a) Continuation.
(b) A group short-term care policy or certificate shall not deny a claim for loss that occurs or confinement that begins more than six (6) months after the effective date of the policy for a preexisting condition. The group policy or certificate shall not define a pre-existing condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six (6) months immediately preceding the effective date of coverage.
(c) A group short-term care policy or certificate shall not indemnify against losses resulting from sickness on a different basis from losses resulting from accidents.
(d) Limitations and Exclusions . A group short-term care policy or certificate shall not include limitations or exclusions that are more restrictive than the following:
(e) No group short-term care policy or certificate shall use waivers to exclude, limit or reduce coverage or benefits for specifically named or described pre-existing diseases or physical conditions.
(f) Group short-term care policies or certificates shall make reasonable provision for waiver of premium. As to benefits for institutional confinement, this requirement is met if the policy or certificate provides for a waiver of premium after benefits have been paid for a period not to exceed thirty (30) consecutive days inclusive of any elimination period, and thereafter during the continuance of the consecutive days for which benefits are paid.
(g) Group short-term care certificates, other than those issued pursuant to direct response solicitation, shall have a notice prominently printed on the first page of the certificate or attached thereto stating in substance that the certificate holder shall have the right to return the certificate to the insurer or its agent within thirty (30) days of its delivery and to have the premium refunded if, after examination of the certificate, the certificate holder is not satisfied for any reason. Group short-term care certificates issued pursuant to a direct response solicitation shall have a notice prominently printed on the first page or attached thereto stating in substance that the certificate holder shall have the right to return the certificate to the insurer within thirty (30) days of its delivery and to have the premium refunded if, after examination of the certificate, the certificate holder is not satisfied for any reason.
(h) Group short-term care policies or certificates shall not condition benefits upon prior hospitalization or institutionalization.
(i) Short-term care policies and certificates shall include a provision that states that upon notification to the insurer of an insured's death, the insurer will refund on a pro-rata basis any part of a periodic premium paid by such insured that applies to the period after death.
(j) Short-term care policies and certificates shall not have an elimination period greater than thirty (30) days of confinement.
(k) Group short-term care policies and certificates shall include a provision that the policy shall be incontestable, except for nonpayment of premium, after it has been in force for two (2) years from its date of issue.
(l) Extension of Benefits. Termination of group short-term care insurance shall be without prejudice to any benefits payable for institutionalization if such institutionalization began while the group short-term care insurance was in force and continues without interruption after termination. Such extension of benefits beyond the period the group short-term care insurance was in force may be limited to the duration of the benefit period or to payment of the maximum benefits, and may be subject to any policy waiting period and all other applicable provisions of the policy or certificate.
(m) The premiums charged to an insured for group short-term care insurance shall not increase due solely to either the increasing age of the insured at ages beyond sixty-five (65) or the duration the insured has been covered under the policy.
(n) Payment of Benefits. A group short-term care policy or certificate that provides for the payment of benefits based on standards described as ''usual and customary,'' '' reasonable and customary'' or words of similar import shall include a definition of such terms and an explanation of such terms in its accompanying outline of coverage.
(o) A group short-term care policy or certificate that only provides benefits for confinement in the insured's own home shall include a statement to that effect on the first page of the certificate in bold print.
(p) A group short-term care policy or certificate that provides benefits for home health care shall not limit or exclude such benefits by:
(q) The application for every group short-term care certificate shall include a section inviting the applicant to give the name of an individual who is to receive notice of lapse concurrently with any such notice sent to the certificate holder. Along with space for the name and address of such individual, this section shall include a notice to the applicant as follows (or in substantially similar language): YOU WILL RECEIVE NOTICE IF YOUR COVERAGE IS ABOUT TO LAPSE (TERMINATE) BECAUSE YOU HAVE NOT PAID PREMIUMS. WE WILL BE GLAD TO SEND A COPY OF THIS NOTICE TO ANOTHER PERSON, IF YOU WOULD LIKE. THAT PERSON WILL NOT BE RESPONSIBLE FOR PAYMENT OF THE PREMIUM, AND YOU WILL ALWAYS RECEIVE YOUR OWN COPY OF THE NOTICE. IF YOU WANT AN EXTRA COPY SENT TO ANOTHER PERSON, PLEASE GIVE US THAT PERSON'S NAME AND ADDRESS.
(r) No group short-term care certificate shall contain a coordination of benefits provision unless such policy is issued on a non-contributory basis.