Connecticut Administrative Code › Title 38a - Insurance Department › 528a - Group Short-Term Care Insurance › Section 38a-528a-13 - Standard format outline of coverage

Current through July 10, 2024
(a) No group
			 short-term care certificate 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 certificate or subscriber
			 agreement 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 or certificate
			 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:
(INSURER NAME)
(ADDRESS - CITY & STATE)
(TELEPHONE NUMBER)
GROUP SHORT-TERM CARE INSURANCE
OUTLINE OF COVERAGE
(Policy or Certificate Number)
(Except for certificates 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 group short-term care insurance
				certificate 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 insurer has 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 insurer at this address: (Insert address).
(1) This certificate that was delivered in
			 Connecticut evidences coverage under a group policy of insurance.
(2) PURPOSE OF OUTLINE OF COVERAGE. This
			 outline of coverage provides a very brief description of the important features
			 of your coverage. You should compare this outline of coverage to outlines of
			 coverage for other policies or certificates available to you. This is not an
			 insurance contract, but only a summary of coverage. Only the policy or
			 certificate contains governing contractual provisions. This means that the
			 policy and certificate set forth in detail the rights and obligations of both
			 you and the insurer. Therefore, if you purchase this coverage, or any other
			 coverage, it is important that you READ YOUR CERTIFICATE CAREFULLY!
(3) TERMS UNDER WHICH THE CERTIFICATE MAY BE
			 RETURNED AND PREMIUM REFUNDED.
(A) (Provide a
			 brief description of the right to return- "Free look" provision of the
			 certificate.)
(B) (Include a
			 statement that the policy or certificate 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 or certificate. 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
			 insurer.
(A) (For producers) Neither (insert
			 insurer name) nor its agents represent Medicare, the federal government or any
			 state government.
(B) (For direct
			 response) (insert insurer name) is not representing Medicare, the federal
			 government or any state government.
(5) THIS IS NOT A LONG-TERM CARE POLICY OR
			 CERTIFICATE . IT IS NOT TAX QUALIFIED AND DOES NOT PROVIDE ASSET
			 PROTECTION.
(6) SHORT-TERM CARE
			 COVERAGE. Policies or certificates 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 (choose one:
			 POLICY, or CERTIFICATE).
(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; and
(E) Other limitations.
(This section should provide a brief specific description of
				any policy or certificate provisions that limit, exclude, restrict, reduce,
				delay or in any other manner operate to qualify payment of the benefits
				described in (7) above.)
THIS CERTIFICATE 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 group
			 short-term care policy 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
			 CERTIFICATE MAY BE CONTINUED IN FORCE OR DISCONTINUED.
(A) (Describe certificate provisions for
			 continuation of coverage);
(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 insurer 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 certificate 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 benefits.)
(12) PREMIUM
(A) "State the total annual premium for the
			 certificate or subscriber agreement";
(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 certificate.)