836-052-0756 Standards for Benefit Triggers (1) 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 three of the activities of daily living or the presence of cognitive impairment. (2)(a) Activities of daily living shall include at least the following as defined in OAR 836-052-0516 and in the policy: (A) Bathing; (B) Continence; (C) Dressing; (D) Eating; (E) Toileting; and (F) Transferring; (b) An insurer may use activities of daily living to trigger covered benefits in addition to those contained in subsection (a) of this section as long as they are defined in the policy. (c) For purposes of this rule, a cognitive impairment must be a result of a clinically diagnosed organic dementia, including but not limited to Alzheimer's disease or a related progressive degenerative dementia of an organic origin such as the following, by way of example only: (A) Parkinson's Disease; (B) Huntington's Disease; (C) Creutzfeldt-Jakob Disease; (D) Picks Disease; (E) Multi-infarct dementia; (F) Normal pressure hydrocephalus; (G) Multiple sclerosis; (H) Inoperable tumors of the brain. (3) An insurer may use additional provisions for determining when benefits are payable under a policy, certificate or rider, but the provisions shall not restrict, and are not in lieu of, the requirements contained in sections (1) and (2) of this rule. (4) For purposes of this rule, the determination of a deficiency shall not be more restrictive than: (a) Requiring the hands-on assistance of another person to perform the prescribed activities of daily living; or (b) Requiring that if the deficiency is due to the presence of a cognitive impairment, supervision or verbal cueing by another person is needed in order to protect the insured or others. (5) Assessments of activities of daily living and cognitive impairment shall be performed by licensed or certified professionals, such as physicians, nurses or social workers. (6) A long term care insurance policy shall include a clear description of the process for appealing and resolving benefit determinations. (7) If an insurer denies payment of benefits under a long term care policy, the insurer shall include in its denial letter information about how the insured may contact the Division of Financial Regulation of the Department of Consumer and Business Services for assistance either by contacting the Division of Financial Regulation Consumer Advocacy Unit at its toll free telephone number or visiting the division’s website at the website address currently provided by the division as may be updated from time to time on the division website. (8) The requirements set forth in this rule are effective March 1, 2006, except for the following: (a) The requirements of this rule apply to a long-term care policy or rider issued in this state on or after March 1, 2005. (b) This rule does not apply to a certificate issued on or after March 1, 2006, under a group long-term care insurance policy as defined in ORS 743.652(3)(a) that was in force on March 1, 2005. Statutory/Other Authority: ORS 731.244, 743.655, 743.656, 746.240, 742.023 & 743.013 Statutes/Other Implemented: ORS 731.244, 743.655, 743.656, 746.240, 742.003, 742.005, 742.009, 743.010, 743.013, 743.650 & 743.653 History: ID 21-2024, minor correction filed 08/12/2024, effective 08/12/2024 ID 4-2011, f. & cert. ef. 2-10-11 ID 10-2007, f. 12-3-07, cert. ef. 1-1-08 ID 3-2005, f. & cert. ef. 3-1-05