Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 55.00 - Disclosure Requirements For Life Insurance Policies With Accelerated Benefit Provisions And Annuity Contracts With Waivers Of Surrender Charges For Early Withdrawal Of Annuity Proceeds In The Event Of Total And Permanent Disability › Section 55.100 - Disclosure Statement Required at the Time of Application for the Policy or Contract

Current through Register 1525, July 5, 2024
REQUIRED DISCLOSURE STATEMENT FOR [ACCELERATED BENEFITS] [EARLY
				WITHDRAWALS ON ANNUITY PROCEEDS]
[The disclosure statement shall be substantially similar to the
				following form.]
[(for accelerated benefit products only)
Limitations of the Accelerated Benefit:
The accelerated benefit in this life insurance product may
				provide benefits to pay for long-term care services, but it is NOT part of a
				long-termcare or nursing home insurance policy and the amount this product pays
				you may not be enough to cover your medical, nursing home or other bills. You
				may use the money you receive from this product for any purpose, unless you
				qualify for benefits because of Chronic Illness only. If you qualify for
				benefits because of Chronic Illness only, you may use the benefits to pay for
				Qualified Long-Term Care Services only. Unlike conventional life insurance
				proceeds, accelerated benefits payable under this product rider COULD BE
				TAXABLE IN SOME CIRCUMSTANCES. We recommend that you contact a tax advisor when
				making tax-related decisions about electing to receive and use benefits from an
				accelerated benefit product.]
A.
			 Consequences of This Benefit
Receipt of [accelerated benefits][early withdrawals on annuity
				proceeds]
MAY AFFECT MEDICAID and SUPPLEMENTAL SECURITY INCOME
				("SSI") ELIGIBILITY
. The mere fact that you own a policy with [an
				accelerated benefit product][an option to make an early withdrawal on annuity
				proceeds without a surrender charge] may affect your eligibility for these
				government programs. In addition, exercising the option to [accelerate death
				benefits][make an early withdrawal on annuity proceeds] and receiving those
				benefits before you apply for these programs, or while you are receiving
				government benefits, may affect your initial or continued eligibility. Contact
				the Medicaid Unit of your local Division of Medical Assistance and the Social
				Security Administration for more information.
B. Medical Condition(s) enabling
			 [accelerating of life benefit][waiver of surrender charge for early
			 withdrawals]:
[Use whichever are included in the policy.]
[__(1)
Terminal
			 Illness
which means a condition that a physician
			 certifies willreasonablybe expected to result in a drastically limited life
			 span as specified in the contract.
___(2)
Chronic
			 Illness
which means a condition because of which an
			 individual has been certified by a licensed health care practitioner as:
(a) being unable to perform (without
			 substantial assistance from another individual) at least two Activities of
			 Daily Living for a period of at least 90 days due to a loss of functional
			 capacity;
(b) having a level of
			 disability similar to the level of disability described above; or
(c) requiring substantial supervision to
			 protect such individual from threats to health and safety due to severe
			 cognitive impairment.
___(3) a medical condition, including but not
			 limited to one of the following specifically named or described conditions,
			 which the insured's physician certifies has required or willrequire
			 extraordinary medical intervention without which the insured would have died,
			 or will die:
(a) Acquired Immune Deficiency
			 Syndrome;
(b) Coronary artery
			 disease resulting in acute infarction or requiring surgery;
(c) End-Stage Renal Disease;
(d) Major organ transplant;
(e) Medical condition requiring continuous
			 life support;
(f) Permanent
			 neurological deficit resulting from cerebral vascular accident; or
___(4) [other qualifying
			 conditions approved by the Commissioner for this policy. (list
			 condition)____________________________________________]