33-22-1125. Benefit triggers. (1) A long-term care insurance policy may not be delivered or issued for delivery in this state unless it complies with the requirements of this section and applicable rules for the triggering of mandatory provision of benefits.

(2) (a) A long-term care insurance policy must condition the payment of benefits on a determination of the insured's inability to perform activities of daily living or on cognitive impairment.

(b) Eligibility for the payment of benefits may not be more restrictive than requiring a deficiency in the ability to perform not more than three of the activities of daily living or requiring the presence of cognitive impairment.

(c) Insurers may use activities of daily living to trigger covered benefits that are in addition to those contained in the definition under 33-22-1107 or rules as long as they are defined in the policy.

(3) An insurer may use additional provisions for the determination of when benefits are payable under a policy. However, the provisions may not restrict or be in lieu of the requirements contained in subsections (1) and (2).

(4) For purposes of this section, the determination of a deficiency may not be more restrictive than:

(a) requiring the hands-on assistance of another person to perform the prescribed activities of daily living; or

(b) if the deficiency is due to the presence of a cognitive impairment, the need for supervision or verbal cueing by another person in order to protect the insured or others.

(5) Assessments of activities of daily living and cognitive impairment must be performed by licensed or certified professionals, such as physicians, nurses, or social workers.

(6) Long-term care insurance policies must include a clear description of the process of appealing and resolving benefit determinations.

History: En. Sec. 49, Ch. 416, L. 1997; amd. Sec. 12, Ch. 32, L. 2007.