Format for outline of coverage:
(ADDRESS - CITY & STATE)
SHORT TERM CARE INSURANCE
OUTLINE OF COVERAGE
(Except for policies that are guaranteed issue, the following
caution statement, or language substantially similar, shall appear as follows
in the outline of coverage.)
Caution: The issuance of this short term care insurance policy
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 policy. 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 policy is an individual policy of
insurance that was issued in Connecticut.
2. PURPOSE OF OUTLINE OF COVERAGE. This
outline of coverage provides a very brief description of the important features
of the policy. You should compare this outline of coverage to outlines of
coverage for other policies available to you. This is not an insurance
contract, but only a summary of coverage. Only the individual policy contains
governing contractual provisions. This means that the policy sets 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 POLICY CAREFULLY!
TERMS UNDER WHICH THE POLICY MAY BE
RETURNED AND PREMIUM REFUNDED.
(a) (Provide a
brief description of the right to return-"free look" provision of the
(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.)
THIS IS NOT MEDICARE SUPPLEMENT COVERAGE.
If you are eligible for Medicare, review the "Guide to Health Insurance For
People With Medicare" available from the insurance company.
(a) (For producers) Neither (insert company
name) nor its agents represent Medicare, the federal government or any state
(b) (For direct
response) (insert company name) is not representing Medicare, the federal
government or any state government.
5. THIS IS NOT A LONG TERM CARE POLICY. IT IS
NOT TAX QUALIFIED AND DOES NOT PROVIDE ASSET PROTECTION.
SHORT 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 for a limited time.
This policy provides coverage in the form of a fixed dollar
indemnity benefit for covered short term care expenses, subject to policy
(limitations) (waiting periods) and (coinsurance) requirements (Modify this
paragraph if the policy is not an indemnity policy.)
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
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 are used to determine an
insured's eligibility for benefits then these shall be explained.)
pre-existing conditions provision;
(b) Non-eligible facilities or providers
(e.g., unlicensed providers, care or treatment provided by a family
(c) Non-eligible levels of
(d) Exclusions and
(This section should provide a brief specific description of
any policy provisions that limit, exclude, restrict, reduce, delay, or in any
other manner operate to qualify payment of the benefits described in (6)
THIS POLICY MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH YOUR
SHORT TERM CARE NEEDS.
RELATIONSHIP OF COST OF CARE AND BENEFITS.
Because the costs of short 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:
That the benefit level will not increase over time;
(b) Any automatic benefit adjustment
(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
(d) If there is such a
guarantee, whether additional underwriting or health screening will be
required, the frequency and amounts of the upgrade options, and any significant
restrictions or limitations; and
(e) Whether there will be any additional
premium charge imposed, and describe how that is to be calculated.)
TERMS UNDER WHICH THE POLICY
MAY BE CONTINUED IN FORCE OR DISCONTINUED.
(Describe policy renewability provisions);
(b) (Describe waiver of premium provisions,
including whether the insured is entitled to a refund of unearned premium in
the event of a waiver);
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
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
(a) "State the total annual premium for the
(b) (If the premium varies
with an applicant's choice among benefit options, indicate the portion of
annual premium that corresponds to each benefit option.)
(a) "Indicate whether medical underwriting is
(b) (Describe other
important features of the policy.)