Connecticut Administrative Code › Title 38a - Insurance Department › 501 - Long-Term Care Insurance › Individual Long-Term Care Insurance › Section 38a-501-21 - Standard format outline of coverage

Current through July 10, 2024
(a) No long-term
				care policy shall be delivered or issued for delivery to any resident of this
				state unless an appropriate outline of coverage in the format prescribed herein
				is completed as to such policy, and is delivered to the applicant at the time
				application or solicitation is made and acknowledgement of receipt or
				certification of delivery of such outline of coverage is provided to the
				insurer. In the case of direct response solicitations, the insurer shall
				deliver the outline of coverage upon the applicant's request, but regardless of
				such request, shall make such delivery no later than at the time of policy
				delivery.
(b) The outline of
				coverage shall be a free standing document, using no smaller than twelve point
				type.
(c) The outline of coverage
				shall contain no material of an advertising nature.
(d) Text which is capitalized or underscored
				in the standard format outline of coverage may be emphasized by other means
				which provide prominence equivalent to such capitalization or
				underscoring.
(e) Use of the text
				and sequence of text of the standard format outline of coverage is mandatory,
				unless otherwise specifically indicated.
(f) Format for outline of coverage:
(COMPANY NAME)
(ADDRESS - CITY & STATE)
(TELEPHONE NUMBER)
LONG-TERM CARE INSURANCE
OUTLINE OF COVERAGE
(Policy Number)
(Except for policies which are guaranteed issue, the
				  following caution statement, or language substantially similar, shall appear as
				  follows in the outline of coverage.)
Caution: The issuance of this long-term care insurance policy
				  is based upon your responses to the questions on your application. A copy of
				  your application (is enclosed) (was retained by you when you applied). If your
				  answers are incorrect or untrue, the company has the right to deny benefits or
				  rescind 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 company at this address: (insert address)
1. This policy is an individual policy of
				insurance which was issued in Connecticut.
2. PURPOSE OF OUTLINE OF COVERAGE. This
				outline of coverage provides a very brief description of the important features
				of the policy. You should compare this outline of coverage to outlines of
				coverage for other policies available to you. This is not an insurance
				contract, but only a summary of coverage. Only the individual policy contains
				governing contractual provisions. This means that the policy sets forth in
				detail the rights and obligations of both you and the insurance company.
				Therefore, if you purchase this coverage, or any other coverage, it is
				important that you READ YOUR POLICY CAREFULLY!
3. TERMS UNDER WHICH THE POLICY MAY BE
				RETURNED AND PREMIUM REFUNDED.
(a) (Provide a
				brief description of the right to return-"free look" provision of the
				policy.)
(b) (Include a statement
				that the policy contains provisions providing for a refund or partial refund of
				premium upon the death of an insured and does or does not contain provisions
				providing for such a refund upon surrender of the policy. Include a description
				of all such refund provisions.)
4. THIS IS NOT MEDICARE SUPPLEMENT COVERAGE.
				If you are eligible for Medicare, review the Medicare Supplement Buyer's Guide
				available from the insurance company.
(a) (For
				agents) Neither (insert company name) nor its agents represent Medicare, the
				federal government or any state government.
(b) (For direct response) (insert company
				name) is not representing Medicare, the federal government or any state
				government.
5. LONG-TERM
				CARE COVERAGE. Policies of this category are designed to provide coverage for
				one or more necessary or medically necessary diagnostic, preventive,
				therapeutic, rehabilitative, maintenance, or personal care services, provided
				in a setting other than an acute care unit of a hospital, such as in a nursing
				home, in the community or in the home.
This policy provides coverage in the form of a fixed dollar
				  indemnity benefit for covered long-term care expenses, subject to policy
				  (limitations) (waiting periods) and (coinsurance) requirements (Modify this
				  paragraph if the policy is not an indemnity policy.)
6. BENEFITS PROVIDED BY THIS POLICY.
(a) (Covered services, related deductible(s),
				waiting periods, elimination periods and benefit maximums.)
(b) (Institutional benefits, by level of care
				provided.)
(c) (Non-institutional
				benefits, by level of care provided.)
(An explanation of any qualifying criteria used to determine
				  an insured's eligibility for benefits shall accompany each benefit description.
				  If an attending physician or other specified person must certify to a loss of
				  functional capacity in order for the insured to be eligible for benefits, this
				  shall be specified. If activities of daily living (ADLs) are used to determine
				  an insured's eligibility for benefits then these shall be explained.)
7. LIMITATIONS AND
				EXCLUSIONS
(Describe:
(a) Any
				pre-existing conditions provision;
(b) Non-eligible facilities/providers (e.g.,
				unlicensed providers, care or treatment provided by a family member,
				etc.);
(c) Non-eligible levels of
				care;
(d)
				Exclusions/exceptions;
(e) Other
				limitations)
(This section should provide a brief specific description of
				  any policy provisions which limit, exclude, restrict, reduce, delay, or in any
				  other manner operate to qualify payment of the benefits described in (6)
				  above.)
THIS POLICY MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH
				  YOUR LONG-TERM CARE NEEDS.
8. RELATIONSHIP OF COST OF CARE AND BENEFITS.
				Because the costs of long-term care services will likely increase over time,
				you should consider whether and how the benefits of this plan may be adjusted.
				(As applicable, indicate the following:
(a)
				That the benefit level will not increase over time;
(b) Any automatic benefit adjustment
				provision;
(c) Whether the insured
				will be guaranteed the option to buy additional benefits and the basis upon
				which benefits will be increased over time if not by a specified amount or
				percentage;
(d) If there is such a
				guarantee, indicate whether additional underwriting or health screening will be
				required, the frequency and amounts of the upgrade options, and any significant
				restrictions or limitations;
(e)
				And finally, indicate whether there will be any additional premium charge
				imposed, and describe how that is to be calculated.)
9. TERMS UNDER WHICH THE POLICY MAY BE
				CONTINUED IN FORCE OR DISCONTINUED.
(a)
				(Describe policy renewability provisions);
(b) (Describe waiver of premium provisions,
				including whether the insured is entitled to a refund of unearned premium in
				the event of a waiver);
(c) (State
				whether or not the company has a right to change premium, and if such a right
				exists, describe clearly and concisely each circumstance under which premium
				may change.)
10.
				ALZHEIMER'S DISEASE AND OTHER ORGANIC BRAIN DISORDERS (State that the policy
				provides coverage for insureds clinically diagnosed as having Alzheimer's
				disease or related degenerative and dementing illnesses. Specifically describe
				any qualifying criteria that determines such an insured's eligibility for
				policy benefits.)
11. PREMIUM
(a) State the total annual premium for the
				policy;
(b) if the premium varies
				with an applicant's choice among benefit options indicate the portion of annual
				premium which corresponds to each benefit option.)
12. ADDITIONAL FEATURES
(a) Indicate whether medical underwriting is
				used;
(b) Describe other important
				features.)