Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 65.00 - Long-term Care Insurance
Section 65.11 - Prohibition Against Post Claims Underwriting

Universal Citation: 211 MA Code of Regs 211.65

Current through Register 1531, September 27, 2024

(1) All applications and enrollment forms for individual and group long-term care insurance policies, except those that are guaranteed issue, shall contain clear and unambiguous questions designed to ascertain the health condition of the applicant.

(2) If an application or enrollment form contains a question that asks whether the applicant has had medication prescribed by a physician, then it must also ask the applicant to list the medication that has been prescribed and the reason that the medication was prescribed.

(3) Except for policies that are guaranteed issue:

(a) The following language shall be set out conspicuously near the applicant's signature block on an application:

"Caution: If your answers on this application are incorrect or untrue, [carrier] has the right to deny benefits or rescind your policy."

(b) The following language, or language substantially similar to the following, shall be set out conspicuously on the policy, as well as the outline of coverage, at the time of delivery:

"Caution: The issuance of this long-term care insurance [policy] [certificate] is based upon your responses to the questions on your application. A copy of your [application] [enrollment form] [is enclosed] [was retained by you when you applied]. If your answers were incorrect or untrue as of the date you signed the application, the carrier has the right to deny benefits or rescind your policy subject to the [time limit on certain defenses, incontestable] section of 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 carrier at this address: [insert address]"

(c) A carrier may not deny any claims for services under a long-term care policy issued to an applicant age 80 or older unless the carrier obtained any one of the following prior to issuing the policy:
1. a report of a physical examination;

2. an assessment of functional capacity;

3. an attending physician's statement; or

4. copies of medical records.

(4) A carrier shall deliver a copy of the completed application or enrollment form to the insured no later than at the time of delivery of the policy unless the form was retained by the insured at the time of application.

(5) Every carrier selling or issuing individual or group long-term care insurance policies in Massachusetts shall maintain a record of all individual policy or group certificate rescissions, both on a state and national basis, except those that the insured voluntarily effectuated, and shall furnish this information to the commissioner upon request.

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