Illinois Administrative Code
Title 50 - INSURANCE
Part 2012 - LONG-TERM CARE INSURANCE
Section 2012.128 - Standards for Benefit Triggers
Current through Register Vol. 48, No. 12, March 22, 2024
a) A long-term care insurance policy shall condition the payment of benefits on a determination of the insured's ability to perform activities of daily living and on cognitive impairment. Eligibility for the payment of benefits shall not be more restrictive than requiring either a deficiency in the ability to perform not more than 3 of the activities of daily living or the presence of cognitive impairment.
b) Insurers may use activities of daily living to trigger covered benefits as long as they are defined in the policy. Activities of daily living shall include but not be limited to the following, as defined in Section 2012.40 of this Part and in the policy:
c) An insurer may use additional provisions for the determination of when benefits are payable under a policy or certificate; however, the provisions shall not restrict, and are not in lieu of, the requirements contained in subsections (a) and (b) of this Section.
d) For purposes of this Section the determination of a deficiency shall not be more restrictive than:
e) Assessments of activities of daily living and cognitive impairment shall be performed by licensed or certified professionals, such as physicians, nurses or social workers.
f) Long-term care insurance policies shall include a clear description of the process for appealing and resolving benefit determinations.
g) The requirements set forth in this Section shall apply as follows: