20-1691.06. Outline of coverage; certificate

A. An outline of coverage shall be delivered to an applicant for a long-term care insurance policy at the time of initial solicitation through means that prominently direct the recipient s attention to the document and its purpose. In the case of direct response solicitations, the outline of coverage shall be presented in conjunction with an application or enrollment form. In the case of insurance producer solicitations, the insurance producer shall deliver the outline of coverage before the presentation of an application or enrollment form. The outline of coverage shall include all of the following:

1. A description of the principal benefits and coverage provided in the policy.

2. A statement of the principal exclusions, reductions and limitations contained in the policy.

3. A statement of the renewal provisions, including any reservation in the policy of a right to change premiums, and any continuation or conversion provisions of group coverage.

4. A statement that the outline of coverage is a summary of the policy issued or applied for and that the policy should be consulted to determine governing contractual provisions.

5. A description of the terms under which the policy or certificate may be returned and the premium refunded.

6. A description of the relationship of cost of care and benefits.

7. A statement and description of whether the policy constitutes a qualified long-term care insurance contract.

B. For a long-term care policy that is issued to a group as defined in section 20-1691, paragraph 5, subdivision (a), an outline of coverage is not required to be delivered if the information listed in subsection A of this section is contained in other materials related to enrollment. On request, an insurer shall make the other materials available to the director.

C. On delivery of an individual life insurance policy that provides long-term care benefits within the policy or by rider, a policy summary shall be delivered to the policyholder. In the case of direct response solicitations, the insurer shall deliver the policy summary on the applicant's request. If an applicant does not request the delivery of a policy summary, the insurer shall deliver the policy summary no later than at the time the policy is delivered. A policy summary shall include:

1. An explanation of how the long-term care benefits interact with other components of the policy, including deductions from death benefits.

2. An explanation of the amount of benefits, the length of benefits and the guaranteed lifetime benefits, if any, for each covered person.

3. Any exclusions, reductions or limitations on benefits of long-term care.

4. A statement that any long-term care inflation protection option required by state law is not available under the policy.

5. If applicable to the type of policy that is issued:

(a) A disclosure of the effects of exercising other rights under the policy.

(b) A disclosure of guarantees that are related to long-term care costs of insurance charges.

(c) Current and projected maximum lifetime benefits.

6. An explanation of the monthly reporting requirements for life insurance policies with an accelerated death benefits option.

D. The provisions of the policy summary required under subsection C of this section may be incorporated into any required life insurance illustration or policy summary.

E. The insurer shall provide a monthly report to the insured any time a long-term care benefit that is funded through a life insurance vehicle by the acceleration of the death benefit is in benefit payment status and the report shall include:

1. Any long-term care benefits paid out during the month.

2. An explanation of any changes in the policy, including death benefits or cash values, due to long-term care benefits paid out.

3. The amount of long-term care benefits existing or remaining.

F. A certificate issued pursuant to a group long-term care insurance policy that is delivered or issued for delivery in this state shall include all of the following:

1. A description of the principal benefits and coverage provided in the policy.

2. A statement of the principal exclusions, reductions and limitations contained in the policy.

3. A statement that the group master policy should be consulted to determine governing contractual provisions.

G. If an application for a long-term care insurance contract or certificate is approved, the issuer shall deliver the contract or certificate of insurance to the applicant within thirty days of approval.

H. An insurer shall notify a claimant that a claim under a long-term care insurance policy is accepted or denied within fifteen working days of the insurer's receipt of a claim if the insurer has received the documentation it reasonably requires to determine liability. If the insurer requires longer than fifteen working days, the insurer, within the fifteen days, shall notify the claimant of the need for additional time and shall explain why additional time is required. In no case shall the determination exceed sixty days.

I. If an insurer denies a claim under a long-term care insurance policy, the insurer shall:

1. Provide the policyholder, certificate holder or designated representative of the policyholder or certificate holder with a written explanation of the reasons for the denial, including a reference to any specific policy provision, condition or exclusion supporting the denial.

2. Make available all information directly related to the denial to the policyholder, certificate holder or designated representative of the policyholder or certificate holder.