Standard format outline of coverage

(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.)