31 Pa. Code § 90h.3 - Benefit provisions

(a) Surrender charges.

(1) The form discloses that the surrender charges will be waived when the insured/annuitant receives care from a designated health care facility. The form designates one or more types of health care facilities. The following are types of health care facilities: skilled nursing facility, extended care facility, intermediate care facility, convalescent care facility, personal care facility, home care facility or hospice facility. This is not an all inclusive list of types of health care facilities which may be designated.

(2) The form does or does not provide that the cause for the need of the care from the health care facility is sickness or injury.

(3) The cause for the need of care from the health care facility is not restricted to one or more specific medical condition. A medical condition, except as excluded in accordance with § 90h.4 (relating to exclusions and restrictions) is acceptable.

(4) The form does not provide that the cause may not be sickness.

(5) The form does not provide that the cause may not be injury.

(6) The form does or does not provide that the care from health care facilities is medically necessary. If the form provides that the care from health care facilities is medically necessary, the form contains a definition of "medically necessary."

(b) Benefit provided. The form discloses the benefit provided.

(1) The amount of the benefit is equal to a waiver of 100% of the surrender charge applied to at least 50% of the accumulation value.

(2) The form provides an explanation of how the amount of the waiver is determined.

(3) The form discloses any limitation on the amount of the waiver.

(4) The maximum period for which the waiver is provided is at least 1 year for each occurrence of (continuous) health care facility usage.

(5) Any maximum benefit period for waiver due to home care usage is or is not identical to that applied to other health care facility usage waiver.

(6) The form does or does not provide for a maximum monthly waiver amount.

(7) A maximum benefit amount for waiver due to home care usage is not less than 50% of the benefit that applies to other health care facility usage waiver.

(8) The form does not provide for age or duration requirements as to when the insured is first eligible for the benefit.

(c) Conditions for payment. The form discloses the conditions for payment of the waiver benefit.

(1) The insured/annuitant receives service from a health care facility.

(2) The services are provided during the coverage period.

(3) The services are provided while the rider or the policy alone in the case of a built-in benefit are in force.

(4) The form does or does not require that services be provided while the policy is in full force; for example, not under a nonforfeiture option.

(5) If the payment of the benefit requires that the insured/annuitant enter the health care facility within a period of time from discharge from an institutional confinement, the period of time from discharge is at least 30 days. The original institutional confinement is not required to be greater than 3 days.

(6) The insured/annuitant is or is not required to receive services for a period of time prior to payment of a benefit. This period of time is referred to as an elimination or waiting period and does not exceed 90 days.

(7) A new elimination or waiting period is or is not applied each time an insured/annuitant begins receiving services for a new or nonrelated cause, or for the same cause if services by a health care facility have not been provided to the insured for a period of at least 6 months.

(8) A new elimination or waiting period is not applied each time an insured begins receiving services for the same cause if the services are provided less than 6 months from the last time services were provided.

(9) If the waiver benefit requires that the insured/annuitant receive services for a period of time prior to waiver, the form does not require that the period of time be continuous or without interruption or that the period of time immediately precede the period for which a benefit will be paid unless "continuous," "without interruption" or "immediately preceding" are defined in a manner consistent with paragraphs (7) and (8).

(10) If the form contains a home health care benefit and requires that the insured be confined in a health care facility to establish eligibility for the home health care benefit, the period of confinement is not required to be greater than 30 days.

(11) The owner requests payment of the benefit.

(d) Renewable coverage. If the form provides renewable coverage, the renewability is guaranteed.

(e) Cancellation. The form is not subject to cancellation by the insurer during the coverage period, except as provided in the grace period and nonforfeiture provisions.

(f) Health care facility licensure. If the form provides that the health care facility must be licensed by the jurisdiction in which it is located, clarification is provided in the form that licensing is only required if the jurisdiction actually requires licensing.

(g) Limitations. The form does or does not provide for limitations which apply accumulatively to other policies issued on the insured/annuitant's life by the insurer and affiliated insurers. The accumulative application could be for the purpose of determining the initial eligibility for the benefit or the maximum monthly benefit or maximum lifetime benefit. If a form provides for this, the insurer certifies that a copy of the form will be included in each and every affected policy. As an alternative for policies issued prior to the issuance of the form, the insurer certifies that a certificate listing all the policies eligible for the benefit will be provided to the owner. The form discloses the manner in which the accumulative application affects any conditions, restrictions or benefits of the form.

(h) Accumulative application. The form does not provide for the accumulative application to policies issued on the insured/annuitant by the insurer and nonaffiliated insurers.

(i) Pooling of values.

(1) The form does or does not provide for the pooling of the values of all policies issued on the insured/annuitant's life by the insurer or by the insurer and affiliated insurers. Pooling is for the purpose of determining the initial eligibility for the benefit and the amount and duration of the waiver of surrender benefit. If a form provides for pooling, the insurer certifies that a copy of the form will be included in each affected policy. As an alternative for policies issued prior to the issuance of the form, the insurer certifies that a certificate listing all the policies eligible for the benefit will be provided to the owner. The form discloses the manner in which the pooling affects any conditions, restrictions or benefits in the form.

(2) The form does not provide for the pooling of the values of all policies issued on the insured by the insurer and nonaffiliated insurers.

(j) Waiver benefit denied. If the waiver benefit is denied, the form provides that the surrender proceeds will not be disbursed until the owner is notified of the denial and provided with the opportunity to reapply for the surrender proceeds or to reject the surrender proceeds.

Notes

31 Pa. Code § 90h.3