Connecticut Administrative Code › Title 38a - Insurance Department › 528 - Group Long-Term Care Insurance › Section 38a-528-14 - Standard format outline of coverage

Current through July 10, 2024
(a) No long-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
			 herein is completed as to such certificate, 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 the time when the
			 certificate is delivered.
(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 certificates which are guaranteed issue, the
				following caution statement, or language substantially similar, must appear as
				follows in the outline of coverage.)
Caution: The issuance of this long-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 company 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 company at this address: (insert address)
1. This certificate, which 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 insurance available to you. This is not an insurance
			 contract, but only a summary of coverage. Only the group policy and your
			 certificate contain the governing contractual provisions of your insurance.
			 This means that the certificate and the group policy set 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 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 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 INSURANCE MAY BE
			 CONTINUED IN FORCE OR DISCONTINUED.
(a)
			 (Describe policy provisions for continuation or conversion);
(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.