In order to comply with section
52.54 of this Part, policies of
individual insurance and certificates and policies of group insurance meeting
the definition of section
52.12 or
52.13 of this Part shall use the
following statement only, except that appropriate policy identification may be
included.
(COMPANY NAME) (LONG TERM CARE INSURANCE) OR (NURSING HOME
AND
(HOME CARE INSURANCE) OR (NURSING HOME INSURANCE ONLY) OR
(HOME CARE INSURANCE ONLY)
REQUIRED DISCLOSURE STATEMENT
(Policy Number or Group Master Policy and Certificate
Number)
1. This policy or certificate
is (an individual policy of insurance) (a group policy or certificate) that was
issued in the (indicate jurisdiction in which the policy or certificate was
issued).
2. This disclosure
statement provides a very brief description of the important features of the
policy or certificate. You should compare this disclosure statement to outlines
of coverage for other policies or certificates available to you. This is not an
insurance contract, but only a summary of coverage. Only the individual or
group 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 (OR CERTIFICATE)
CAREFULLY!
3. TERMS UNDER WHICH THE
POLICY OR
CERTIFICATE MAY BE RETURNED AND PREMIUM REFUNDED.
(a) (Provide a brief description of the right
to return - "free look" provision of the policy or certificate.)
4. THIS IS NOT MEDICARE SUPPLEMENT
INSURANCE. If you are eligible for Medicare, review the Medicare Supplement
Buyer's Guide available from the insurance company.
5. LONG TERM CARE INSURANCE. Policies or
certificates of this category are designed to provide coverage for not less
than twenty-four (24) consecutive months for each covered
person on an expense
incurred, indemnity, prepaid or other basis and provides coverage of all levels
of care in a nursing home and home care benefits.
This policy or
certificate
provides coverage in the form of a fixed dollar indemnity benefit for covered
long term care expenses, subject to
policy or
certificate (limitations)
(waiting periods) and (coinsurance) requirements. (Modify this paragraph if the
policy or
certificate is not an indemnity
policy or
certificate.)
OR
NURSING HOME INSURANCE ONLY, HOME CARE INSURANCE ONLY, OR
NURSING HOME AND HOME CARE INSURANCE. Policies or certificates of this category
are designed to provide coverage for not less than twelve (12) consecutive
months for each covered person on an expense incurred, indemnity, prepaid or
other basis and provides at least custodial care services in a nursing home
(and)(or) home care benefits. This policy or certificate provides coverage in
the form of a fixed dollar indemnity benefit for covered expenses, subject to
policy or certificate (limitations) (waiting periods) and (coinsurance)
requirements. (Modify this paragraph if the policy or certificate is not an
indemnity policy or certificate.) THIS POLICY OR CERTIFICATE DOES NOT PROVIDE
LONG TERM CARE INSURANCE AS THAT TERM IS DEFINED BY THE NEW YORK STATE
DEPARTMENT OF FINANCIAL SERVICES. (If for a nursing home insurance only policy
or certificate or a home care insurance only policy or certificate.) (THIS
POLICY)(CERTIFICATE)(DOES NOT PROVIDE COVERAGE FOR NURSING HOME.) (THIS POLICY)
(CERTIFICATE) (DOES NOT PROVIDE COVERAGE FOR HOME CARE.)
6. BENEFITS PROVIDED BY THIS (
POLICY)
(
CERTIFICATE).
(a) (Covered services, related
deductible(s), waiting periods, elimination periods and benefit
maximums.)
(b) (Institutional
benefits, by skill level.)
(c)
(Non-institutional benefits, by skill level.)
(d) Statement that
policy or
certificate
covers Alzheimer's Disease and other organic brain disorders.
(Any qualifying criteria or benefit screens must be
explained in this section. If such criteria or screens differ for different
benefits, explanation of the criteria or screen should accompany each benefit
description. If an attending physician or other specified person must certify a
certain level of functional dependency in order to be eligible for benefits,
this too must be specified. If activities of daily living (ADL's) are used to
measure an insured's need for care, then these qualifying criteria or screens
must be explained.)
7. LIMITATIONS AND EXCLUSIONS.
(Describe:
(a)
Preexisting conditions;
(b)
Exclusions/exceptions;
(c)
Limitations.)
(This section should provide a brief specific description
of any policy or certificate provisions that limit, exclude, restrict, reduce,
delay, or in any other manner operate to qualify payment of the benefits
described in (6) above.)
THIS POLICY OR CERTIFICATE MAY NOT COVER ALL THE EXPENSES
ASSOCIATED WITH YOUR LONG TERM CARE NEEDS.
8. (As applicable, indicate the following:
(a) That the benefit level will not increase
over time;
(b) A description of any
benefit adjustment provisions and whether these are made without regard to
health status;
(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, include whether additional underwriting or health screening will be
required, the frequency and amounts of the upgrade options, and any significant
restrictions or limitations;)
9. TERMS UNDER WHICH THE
POLICY (OR
CERTIFICATE) MAY BE CONTINUED IN FORCE OR DISCONTINUED.
(a) Describe the policy or certificate
renewability provisions;
(b) For
group coverage, specifically describe continuation/conversion provisions
applicable to the certificate and group policy);
(c) For individual coverage, specifically
describe conversion rights.
10. PREMIUM.
(a) State the total annual premium for the
policy or certificate.
(b) State
that the policy or certificate may be subject to future premium rate increases,
describe clearly and concisely each circumstance under which premium may
change, and state that such rate increases shall be subject to the approval or
modification of the superintendent. Include a list of the premium rate history
for the policy or certificate over the previous 10 years. If the company did
not offer the policy or certificate over the previous 10 years, the company
shall use the past premium rate history for policies or certificates offering
similar benefits over the previous 10 years.
(c) Include a statement that the policy or
certificate either does or does not contain provisions providing for a refund
or partial refund of premium upon the death of an insured, surrender of the
policy or certificate, or upon the cancellation of the policy or certificate.
If the policy or certificate contains such provisions, include a description of
their terms.
(d) If the premium
varies with an applicant's choice among benefit options, indicate the annual
premium associated with each benefit option.
(e) Provide directions on how to obtain
information about the department's review of any premium rate filing or
application, contact information for the department, and information on how to
contact the insurer for more information.
(f) State whether there is a period in which
premium will not change, and if so, when that period expires.
(g) Include a description of the options
insureds will have to mitigate any premium increases, and a description of the
options insureds will have if the premium increases and the insured deems it in
the insured's best interest to cancel the policy or certificate.
(h) Include a statement that the insured will
be given at least 90 days' notice before any premium change takes
effect.
(i) Include a statement
that if the insurer seeks to increase the premium rate, the department will
post notice of rate filing on its website prior to any determination by the
department.
(j) Include information
regarding the rights of prospective insureds to submit public comments on any
rate filing or application regarding premium rates on the department's
website.
11. ADDITIONAL
FEATURES.
(a) Nonforfeiture. Describe
nonforfeiture benefits or state policy or certificate does not contain such
benefits.
(b) Describe other
important features.
(c) The
expected benefit ratio for this policy or certificate is percent. This ratio is
the portion of future premiums that the company expects to return as benefits,
when averaged over all people with this policy or certificate.
