Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3823 - Prohibited Policy Provisions; Required Disclosures

Current through Reg. 49, No. 28; July 12, 2024
(a) No long-term care insurance policy may be
					 cancelled, nonrenewed, or otherwise terminated on the grounds of age or the
					 deterioration of the mental or physical health of the insured individual or
					 certificate holder.
(b) No
					 long-term care insurance policy may contain a provision establishing a new
					 waiting period in the event existing coverage is converted to, or replaced by,
					 a new or other form within the same company, except with respect to an increase
					 in benefits voluntarily selected by the insured individual or group
					 policyholder.
(c) No long-term care
					 insurance policy may provide coverage for skilled nursing care only, or provide
					 significantly more coverage for skilled care than coverage for lower levels of
					 care.
(d) No long-term care
					 insurance policy or certificate shall be utilized in such manner as would
					 result in post-claims underwriting.
(1) All
					 applications for long-term care insurance policies or certificates, except
					 those that do not provide the company any rights to deny benefits or to rescind
					 coverage based on answers in the application, shall contain questions designed
					 to ascertain the health condition of the applicant, and such questions shall be
					 clear and unambiguous.
(2) If an
					 application for long-term care insurance contains a question which asks whether
					 the applicant has had medication prescribed by a physician, it must also ask
					 the applicant to list the medication that has been prescribed. If the
					 medications listed in such application were known by the insurer, or should
					 have been known at the time of application, to be directly related to a medical
					 condition for which coverage would otherwise be denied, then the policy or
					 certificate shall not be rescinded for that condition.
(3) Except for policies or certificates which
					 do not provide the company any rights to deny benefits or to rescind coverage
					 based on answers in the application, the following language shall be set out
					 conspicuously in bold print and in close proximity to the applicant's signature
					 block on an application for a long-term care insurance policy or certificate:
					 "Caution: If your answers on this application are incorrect or untrue,
					 (company) may have the right to deny benefits or rescind your
					 coverage."
(4) Except for policies
					 or certificates which do not provide the company any rights to deny benefits or
					 to rescind coverage based on answers in the application, the following
					 language, or language substantially similar to the following, shall be set out
					 conspicuously in bold print on the long-term care insurance policy or
					 certificate at the time of delivery: "Caution: The issuance of this long-term
					 care insurance (policy) (certificate) is based upon your responses to the
					 questions on your application. A copy of your (application) (enrollment form)
					 (is enclosed) (was retained by you when you applied). If your answers are
					 incorrect or untrue, the company may have 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)."
(5) Prior to issuance of a long-term care
					 policy or certificate to an applicant age 80 or older, the insurer shall obtain
					 one of the following:
(A) a report of a
					 physical examination;
(B) an
					 assessment of functional capacity;
(C) an attending physician's statement;
					 or
(D) copies of medical
					 records.
(6) A copy of
					 the completed application (or enrollment form if applicable) shall be delivered
					 to the insured no later than at the time of delivery of the policy or
					 certificate unless it was retained by the applicant at the time of
					 application.