Utah Admin. Code R590-148-12 - Requirements for Application Forms and Replacement Coverage

(1) An application or enrollment form for a policy or certificate, except those that are guaranteed issue, shall contain clear and unambiguous questions designed to ascertain the health condition of the applicant.

(2)

(a) If an application or enrollment form contains a question that asks whether the applicant has had medication prescribed by a physician, it must also ask the applicant to list the prescribed medication.

(b) If the prescribed medications listed in the application are known by the insurer, or should have been known at the time of application, to be directly related to a medical condition for which coverage would otherwise be denied, then the policy or certificate may not be rescinded for that condition.

(3) An application or enrollment form shall clearly state the payment plan selected by the applicant.

(4) Except for a policy or certificate that is guaranteed issue:

(a) the following language shall be set out conspicuously and in close conjunction with the applicant's signature block on an application or enrollment form, "Caution: If your answers on this application are incorrect or untrue, (company) has the right to deny benefits or rescind your policy."; and

(b) the following language, or language substantially similar to the following, shall be set out conspicuously on the policy or certificate at the time of delivery, "Caution: The issuance of this long-term care insurance (policy) (certificate) was based upon your responses to the questions on your application. A copy of your (application) (enrollment form) (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)."

(5) Before issuing a policy or certificate to an applicant age 80 or older, the insurer shall obtain:

(a) a report of a physical examination;

(b) an assessment of functional capacity;

(c) an attending physician's statement; or

(d) copies of medical records.

(6) A copy of the completed application or enrollment form shall be delivered to the insured with the policy or certificate, unless it was provided to the applicant at the time of application.

(7)

(a) An application or enrollment form shall include questions designed to elicit information as to whether, as of the date of the application:

(i) the applicant currently has another long-term care insurance policy or certificate in force; or

(ii) the long-term care policy or certificate is intended to replace any other accident and health insurance or long-term care insurance policy or certificate currently in force.

(b) A supplementary application or other form signed by the applicant and producer may be used, except when the coverage is sold without a producer.

(c) For a replacement policy issued to a group, other than an employee or labor union group, the questions may be modified to the extent necessary to elicit information about other accident and health insurance or long-term care insurance other than the group policy being replaced, provided that the certificate holders have been notified of the replacement.

(d) The questions in Subsection (7)(a) shall include:

(i) "Do you have another long-term care insurance policy or certificate in force, including health care service contract, health maintenance organization contract?";

(ii) "Did you have another long-term care insurance policy or certificate in force during the last 12 months?

If so, with which company?

If that policy lapsed, when did it lapse?";

(iii) "Are you covered by Medicaid?"; and

(iv) "Do you intend to replace any of your medical or health insurance coverage with this policy/certificate?".

(8) A producer shall list all other accident and health insurance policies they have sold to the applicant, including a list of each policy sold:

(a) that is still in force; and

(b) in the past five years, that is no longer in force.

(9)

(a) An insurer using a solicitation method other than direct response shall, upon determining that a sale involves a replacement, provide to the applicant, before issuance or delivery of the individual policy, a notice regarding replacement of accident and health insurance or long-term care insurance.

(b) A copy of the notice shall be provided to the applicant and an additional copy signed by the applicant shall be retained by the insurer.

(c) The required notice shall be provided in a manner substantially similar to the Notice to Applicant Regarding Replacement of Individual Accident and Sickness or Long-Term Care Insurance.

(10)

(a) An insurer using a direct response solicitation method shall deliver a notice regarding replacement of accident and health insurance or long-term care insurance to the applicant upon issuance of the policy.

(b) The required notice in Subsection (10)(a) shall be provided in a manner substantially similar to the Notice to Applicant Regarding Replacement of Accident and Sickness or Long-Term Care Insurance.

(11)

(a) If replacement is intended, the replacing insurer shall notify the existing insurer in writing of the proposed replacement, identifying the insurer, the insured, and the policy number or address including zip code.

(b) The notice shall be made within five working days from the date the application is received by the insurer or the date the policy or certificate is issued, whichever is sooner.

(12)

(a) A life insurance policy or certificate that provides long-term care benefits shall comply with this section if the policy being replaced is a long-term care insurance policy.

(b) If the policy being replaced is a life insurance policy, the insurer shall comply with the replacement requirements of Rule R590-93.

(c) If a life insurance policy that provides long-term care benefits is replaced by another similar policy, the replacing insurer shall comply with both the long-term care insurance and the life insurance replacement requirements in Subsections (12)(a) and (12)(b).

(13) A requirement under a group policy that a signature of an insured be obtained by a producer or an insurer is satisfied if:

(a) consent is obtained by telephonic or electronic enrollment by the group policyholder or insurer;

(b) verification of enrollment information is provided to the enrollee; and

(c) telephonic or electronic enrollment provides necessary and reasonable safeguards to assure:

(i) accuracy, retention, and prompt retrieval of records; and

(ii) the ongoing confidentiality of individually identifiable information and privileged information under Section 63G-2-202.

Notes

Utah Admin. Code R590-148-12

Adopted by Utah State Bulletin Number 2024-21, effective 10/22/2024