Current through Reg. 50, No. 13; March 28, 2025
(a) No long-term care insurance policy may be
cancelled, nonrenewed, or otherwise terminated on the grounds of age or the
deterioration of the mental or physical health of the insured individual or
certificate holder.
(b) No
long-term care insurance policy may contain a provision establishing a new
waiting period in the event existing coverage is converted to, or replaced by,
a new or other form within the same company, except with respect to an increase
in benefits voluntarily selected by the insured individual or group
policyholder.
(c) No long-term care
insurance policy may provide coverage for skilled nursing care only, or provide
significantly more coverage for skilled care than coverage for lower levels of
care.
(d) No long-term care
insurance policy or certificate shall be utilized in such manner as would
result in post-claims underwriting.
(1) All
applications for long-term care insurance policies or certificates, except
those that do not provide the company any rights to deny benefits or to rescind
coverage based on answers in the application, shall contain questions designed
to ascertain the health condition of the applicant, and such questions shall be
clear and unambiguous.
(2) If an
application for long-term care insurance contains a question which asks whether
the applicant has had medication prescribed by a physician, it must also ask
the applicant to list the medication that has been prescribed. If the
medications listed in such application were known by the insurer, or should
have been known at the time of application, to be directly related to a medical
condition for which coverage would otherwise be denied, then the policy or
certificate shall not be rescinded for that condition.
(3) Except for policies or certificates which
do not provide the company any rights to deny benefits or to rescind coverage
based on answers in the application, the following language shall be set out
conspicuously in bold print and in close proximity to the applicant's signature
block on an application for a long-term care insurance policy or certificate:
"Caution: If your answers on this application are incorrect or untrue,
(company) may have the right to deny benefits or rescind your
coverage."
(4) Except for policies
or certificates which do not provide the company any rights to deny benefits or
to rescind coverage based on answers in the application, the following
language, or language substantially similar to the following, shall be set out
conspicuously in bold print on the long-term care insurance policy or
certificate 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 are
incorrect or untrue, the company may have 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)."
(5) Prior to issuance of a long-term care
policy or certificate to an applicant age 80 or older, the insurer shall obtain
one of the following:
(A) a report of a
physical examination;
(B) an
assessment of functional capacity;
(C) an attending physician's statement;
or
(D) copies of medical
records.
(6) A copy of
the completed application (or enrollment form if applicable) shall be delivered
to the insured no later than at the time of delivery of the policy or
certificate unless it was retained by the applicant at the time of
application.
