28 Tex. Admin. Code § 3.3830 - Requirements for Application Forms and Replacement Coverage
(a) Individual, direct-response-solicited,
and group long-term care insurance application forms shall include questions
designed to elicit information as to whether, as of the date of application,
the applicant has another long-term care insurance policy or certificate in
force or the proposed insurance is intended to replace any other accident and
sickness or long-term care insurance policy presently in force. A supplementary
application or other form to be signed by the applicant and agent, except where
the coverage is sold without an agent, containing such questions may be used.
With regard to a replacement policy issued to an employer, labor union, or
continuing care retirement community, the following questions may be modified
only to the extent necessary to elicit information about health or long-term
care insurance policies other than the group policy being replaced; provided,
however, that the certificate holder has been notified of the replacement. The
following questions shall be included in the application.
(1) Do you have another long-term care
insurance policy or certificate in force (including health care service
contract, health maintenance organization contract)?
(2) Did you have another long-term care
insurance policy or certificate in force during the last 12 months?
(A) If so, with which company?
(B) If that policy lapsed, when did it
lapse?
(3) Are you
covered by Medicaid?
(4) Do you
intend to replace any of your medical or health insurance coverage with this
policy (certificate)?
(b) Agents shall list any other health
insurance policies and certificates they have sold to the applicant and shall
also:
(1) list policies and certificates sold
which are still in force;
(2) list
policies and certificates sold in the past five years which are no longer in
force.
(c) Agents shall
list any other health insurance policies or certificates the applicant has in
force.
(d) Upon a determination
that a sale will involve replacement, an insurer or its agent, if that insurer
is other than one using direct-response solicitation methods, shall furnish the
applicant, prior to issuance or delivery of the individual long-term care
insurance policy, a notice regarding replacement of accident and sickness or
long-term care coverage. One copy of such notice shall be retained by the
applicant and an additional copy signed by the applicant shall be retained by
the insurer. The required notice shall be provided in the following manner.
(e)
Insurers using direct-response solicitation methods shall deliver a notice
regarding replacement of accident and sickness or long-term care coverage to
the applicant upon issuance of the policy or certificate. The required notice
shall be provided in the following manner.
(f) When
replacement is intended, the replacing insurer shall notify, in writing, the
existing insurer of the proposed replacement. The existing policy or
certificate shall be identified by the insurer, name of the insured, and policy
number or address including zip code. Such notice shall be made within five
working days from the date the application is received by the replacing insurer
at its home office, or the date the policy is issued, whichever is
sooner.
(g) An application for a
long-term care policy or certificate that contains benefits under §
3.3818(b) of
this subchapter (relating to Standards for Eligibility for Benefits) shall in
equal prominence reflect the benefit levels payable for the inability to
perform two activities of daily living, three activities of daily living, and
cognitive impairment.
(h) Life
Insurance policies with a long-term care rider that accelerate benefits for
long-term care shall comply with this section if the policy being replaced is a
long-term care insurance policy. If the policy being replaced is a life
insurance policy, the insurer shall comply with the replacement requirements of
the Insurance Code Chapter 1114 (relating to Replacement of Certain Life
Insurance Policies and Annuities), Subchapter NN of this chapter (relating to
Consumer Notices for Life Insurance Policy and Annuity Contract Replacements),
and any additional rules adopted by the department pursuant to the Insurance
Code Chapter 1114. If a life insurance policy with a long-term care rider that
accelerates benefits for long-term care is replaced by another such policy, the
replacing insurer shall comply with both the long-term care and the life
insurance replacement requirements.
Notes
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