Connecticut Administrative Code › Title 38a - Insurance Department › 501a - Short Term Care Insurance › Section 38a-501a-13 - Standard format outline of coverage

Current through July 10, 2024
(a) No short 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 in
			 this section 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 that is capitalized or underscored
			 in the standard format outline of coverage may be emphasized by other means
			 that 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)
SHORT TERM CARE INSURANCE
OUTLINE OF COVERAGE
(Policy Number)
(Except for policies that 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 short 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 that 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 "Guide to Health Insurance For
			 People With Medicare" available from the insurance company.
(a) (For producers) 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. THIS IS NOT A LONG TERM CARE POLICY. IT IS
			 NOT TAX QUALIFIED AND DOES NOT PROVIDE ASSET PROTECTION.
6. SHORT 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 for a limited time.
This policy provides coverage in the form of a fixed dollar
				indemnity benefit for covered short term care expenses, subject to policy
				(limitations) (waiting periods) and (coinsurance) requirements (Modify this
				paragraph if the policy is not an indemnity policy.)
7. 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 are used to determine an
				insured's eligibility for benefits then these shall be explained.)
8. LIMITATIONS AND
			 EXCLUSIONS
Describe:
(a) Any
			 pre-existing conditions provision;
(b) Non-eligible facilities or providers
			 (e.g., unlicensed providers, care or treatment provided by a family
			 member);
(c) Non-eligible levels of
			 care;
(d) Exclusions and
			 exceptions;
(e) Other limitations
(This section should provide a brief specific description of
				any policy provisions that 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
				SHORT TERM CARE NEEDS.
9. RELATIONSHIP OF COST OF CARE AND BENEFITS.
			 Because the costs of short 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, whether additional underwriting or health screening will be
			 required, the frequency and amounts of the upgrade options, and any significant
			 restrictions or limitations; and
(e) Whether there will be any additional
			 premium charge imposed, and describe how that is to be calculated.)
10. 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.)
11.
			 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.)
12. 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 that corresponds to each benefit option.)
13. ADDITIONAL FEATURES
(a) "Indicate whether medical underwriting is
			 used";
(b) (Describe other
			 important features of the policy.)