Sec. 38a-501a-4 - Minimum standards

ยง 38a-501a-4. Minimum standards

No individual insurance policy or subscriber contract shall be advertised, solicited or issued for delivery in this state as a short term care policy that does not meet the following minimum standards. These are minimum standards and do not preclude the inclusion of other provisions or benefits that are not inconsistent with these standards.

(a) Renewability. The terms "guaranteed renewable" and "noncancellable" shall not be used in any individual short term care policy without further explanatory language in accordance with the disclosure requirements of this section.

(1) No individual short term care policy shall contain renewal provisions other than "guaranteed renewable" or "noncancellable."

(2) The term "guaranteed renewable" shall be used only when the insured has the right to continue the short term care insurance in force by the timely payment of premiums and when the insurer has no unilateral right to make any change in any provision of the policy or rider while the insurance is in force, and cannot decline to renew, except that rates may be revised by the insurer on a class basis.

(3) The term "noncancellable" shall be used only when the insured has the right to continue the short term care insurance in force by the timely payment of premiums during which period the insurer has no right to unilaterally make any change in any provision of the insurance or in the premium rate.

(b) A short term care policy shall not deny a claim for loss that occurs or confinement that begins more than six (6) months from the effective date of the policy for a pre-existing condition. The policy or subscriber contract shall not define a pre-existing condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six (6) months before the effective date of coverage.

(c) A short term care policy shall not indemnify against losses resulting from sickness on a different basis from losses resulting from accidents.

(d) Limitations and Exclusions. An individual short term care policy shall not include limitations or exclusions that are more restrictive than the following:

(1) PRE-EXISTING CONDITIONS LIMITATION - This policy does not pay benefits for loss that occurs or confinement that begins within six (6) months after the effective date of the policy as a result of a pre-existing condition.

(2) OTHER EXCLUSIONS - This policy does not cover:

(A) loss that is caused by declared or undeclared war or any act thereof;

(B) loss that is caused by mental disease or disorder without demonstrable organic disease;

(C) loss that is caused by suicide or any attempt thereof (while sane or insane), or intentionally self-inflicted injury;

(D) confinement in a government institution unless a charge is made that the covered person is obligated to pay;

(E) confinement due to alcoholism or drug addiction;

(F) confinement in a hospital;

(G) confinement or care received outside of the United States;

(H) loss that is caused by participation in a felony, riot or insurrection;

(I) services for which benefits are payable under any state or federal workers' compensation, employer's liability or occupational disease law, or any motor vehicle no-fault law;

(J) services provided by the insured's immediate family, unless a benefit specifically states that a member of the insured's immediate family can provide covered care;

(K) services for which no charge is normally made in the absence of insurance;

(L) medications, whether prescription or non-prescription; or

(M) loss that occurs while this policy is not in force.

(3) A policy may provide that its benefits shall not duplicate benefits payable by Medicare or that would be payable by Medicare but for the application of a deductible or coinsurance amount.

(e) No short term care policy shall use waivers to exclude, limit or reduce coverage or benefits for specifically named or described pre-existing diseases or physical conditions.

(f) Short term care policies shall make reasonable provision for waiver of premium. As to benefits for institutional confinement, this requirement is met if the policy provides for a waiver of premium after benefits have been paid for a period not to exceed thirty (30) consecutive days inclusive of any elimination period, and thereafter during the continuance of the consecutive days for which benefits are paid.

(g) Short term care policies, other than those issued pursuant to direct response solicitation, shall have a notice prominently printed on the first page of the policy or attached thereto stating in substance that the policyholder shall have the right to return the policy to the insurer or its agent within thirty (30) days of its delivery and to have the premium refunded if, after examination of the policy, the insured person is not satisfied for any reason. Short term care policies issued pursuant to a direct response solicitation shall have a notice prominently printed on the first page or attached thereto stating in substance that the policyholder shall have the right to return the policy to the insurer within thirty (30) days of its delivery and to have the premium refunded if, after examination of the policy, the insured person is not satisfied for any reason.

(h) Short term care policies shall not condition benefits upon prior hospitalization or institutionalization.

(i) Short term care policies shall include a provision that states that upon notification to the insurer of an insured's death, the insurer will refund on a pro-rata basis any part of a periodic premium paid by such insured that applies to the period after death.

(j) Short term care policies shall not have an elimination period greater than thirty (30) days of confinement.

(k) Short term care policies shall include a provision that the policy shall be incontestable, except for nonpayment of premium, after it has been in force for two (2) years from its date of issue.

(l) Extension of Benefits. Termination of short term care insurance shall be without prejudice to any benefits payable for institutionalization if such institutionalization began while the short term care insurance was in force and continues without interruption after termination. Such extension of benefits beyond the period the short term care insurance was in force may be limited to the duration of the benefit period or to payment of the maximum benefits and may be subject to any policy waiting period, and all other applicable provisions of the policy.

(m) The premiums charged to an insured for short term care insurance shall not increase due solely to either the increasing age of the insured at ages beyond sixty-five (65) or the duration the insured has been covered under the policy.

(n) Payment of Benefits. A short term care policy that provides for the payment of benefits based on standards described as "usual and customary," "reasonable and customary" or words of similar import shall include a definition of such terms and an explanation of such terms in its accompanying outline of coverage.

(o) A short term care policy that only provide benefits for confinement in the insured's own home shall include a statement to that effect on the first page of the policy in bold print.

(p) A short term care insurance policy that provides benefits for home health care shall not limit or exclude such benefits:

(1) by requiring that the insured would need skilled care in a skilled nursing facility if home care services were not provided;

(2) by requiring that the insured first or simultaneously receive nursing or therapeutic services, or both, in a home, community or institutional setting before home health care services are covered;

(3) by limiting eligible services to services provided by registered nurses or licensed practical nurses;

(4) by requiring that a nurse or therapist provide services covered by the policy that can be provided by a home health aide or other home care worker acting within the scope of his or her licensure or certification;

(5) by excluding coverage for personal care services provided by a home health aide;

(6) by requiring that the provision of home health care services be at a level of certification or licensure greater than that required by the eligible service;

(7) by requiring that the insured have an acute condition before home health care services are covered;

(8) by limiting benefits to services provided by Medicare-certified agencies or providers; or

(9) by excluding coverage for adult day care, hospice care, skilled nursing care, or physical, occupational, respiratory or speech therapy.

(q) The application for every individual short term care policy shall include a section inviting the applicant to give the name of an individual who is to receive notice of lapse concurrently with any such notice sent to the policyholder. Along with space for the name and address of such individual, this section shall include a notice to the applicant as follows (or in substantially similar language): YOU WILL RECEIVE NOTICE IF YOUR POLICY IS ABOUT TO LAPSE (TERMINATE) BECAUSE YOU HAVE NOT PAID PREMIUMS. WE WILL BE GLAD TO SEND A COPY OF THIS NOTICE TO ANOTHER PERSON, IF YOU WOULD LIKE. THAT PERSON WILL NOT BE RESPONSIBLE FOR PAYMENT OF THE PREMIUM, AND YOU WILL ALWAYS RECEIVE YOUR OWN COPY OF THE NOTICE. IF YOU WANT AN EXTRA COPY SENT TO ANOTHER PERSON, PLEASE GIVE US THAT PERSON'S NAME AND ADDRESS.

(Effective May 26, 2017)

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