415-D:8 Outline of Coverage. –
An outline of coverage shall be delivered to a prospective applicant for long-term care insurance at the time of initial solicitation through means that prominently direct the attention of the recipient to the document and its purpose.
I. The commissioner shall prescribe a standard format, including style, arrangement and overall appearance, and the content of an outline of coverage.
II. In the case of agent solicitations, an agent shall deliver the outline of coverage prior to the presentation of an application or enrollment form.
III. In the case of direct response solicitations, the outline of coverage shall be presented in conjunction with any application or enrollment form.
IV. The outline of coverage shall include:
(a) A description of the principal benefits and coverage provided in the policy.
(b) A statement of the principal exclusions, reductions and limitations contained in the policy.
(c) A statement of the terms under which the policy or certificate, or both, may be continued in force or discontinued, including any reservation in the policy of a right to change premium. Continuation or conversion provisions of group coverage shall be specifically described.
(d) A statement that the outline of coverage is a summary only, not a contract of insurance, and that the policy or group master policy contains governing contractual provisions.
(e) A description of the terms under which the policy or certificate may be returned and premium refunded.
(f) A brief description of the relationship of cost of care and benefits.
(g) A statement that discloses to the policyholder or certificate holder whether the policy is intended to be a federally tax-qualified long-term care insurance contract under Section 7702B(b) of the Internal Revenue Code of 1986, as amended.
V. A certificate issued pursuant to a group long-term care insurance policy that is delivered or issued for delivery in this state shall include:
(a) A description of the principal benefits and coverage provided in the policy.
(b) A statement of the principal exclusions, reductions, and limitations contained in the policy.
(c) A statement that the group master policy determines governing contractual provisions.
VI. If an application for a long-term care insurance contract or certificate is approved, the issuer shall deliver the contract or certificate of insurance to the applicant no later than 30 days after the date of approval.
VII. At the time of policy delivery, a policy summary shall be delivered for an individual life insurance policy that provides long-term care benefits within the policy or by rider. In the case of direct response solicitations, the insurer shall deliver the policy summary upon the applicant's request, but regardless of request shall make delivery no later than at the time of policy delivery. In addition to complying with all applicable requirements, the summary shall also include:
(a) An explanation of how the long-term care benefit interacts with other components of the policy, including deductions from death benefits.
(b) An illustration of the amount of benefits, the length of benefit, and the guaranteed lifetime benefits if any, for each covered person.
(c) Any exclusions, reductions and limitations on benefits of long-term care.
(d) A statement that any long-term care inflation protection option is not available under this policy.
(e) If applicable to the policy type, the summary shall also include:
(1) A disclosure of the effects of exercising other rights under the policy.
(2) A disclosure of guarantees related to long-term care costs of insurance charges.
(3) Current and projected maximum lifetime benefits.
(f) The provisions of the policy summary listed above may be incorporated into a basic illustration required to be delivered in accordance with Ins 309 or into the life insurance policy summary which is required to be delivered in accordance with Ins 301.
VIII. Any time a long-term care benefit, funded through a life insurance vehicle by the acceleration of the death benefit, is in benefit payment status, a monthly report shall be provided to the policyholder. The report shall include:
(a) Any long-term care benefits paid out during the month.
(b) An explanation of any changes in the policy such as death benefits or cash values, due to long-term care benefits being paid out.
(c) The amount of long-term care benefits existing or remaining.
IX. If a claim under a long-term care insurance contract is denied, the issuer shall, within 60 days of the date of a written request by the policyholder or certificate holder, or a representative thereof:
(a) Provide a written explanation of the reasons for the denial; and
(b) Make available all information directly related to the denial.
X. Any policy or rider advertised, marketed, or offered as long-term care or nursing home insurance shall comply with the provisions of this chapter.