Utah Code 31A-22-2004. Disclosure and performance standards for limited long-term care insurance
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(1) A limited long-term care insurance policy may not:
Terms Used In Utah Code 31A-22-2004
- Applicant: means :(1)(a) when referring to an individual limited long-term care insurance policy, the person who seeks to contract for benefits; and(1)(b) when referring to a group limited long-term care insurance policy, the proposed certificate holder. See Utah Code 31A-22-2002
- Application: means a document:
(10)(a)(10)(a)(i) completed by an applicant to provide information about the risk to be insured; and(10)(a)(ii) that contains information that is used by the insurer to evaluate risk and decide whether to:(10)(a)(ii)(A) insure the risk under:(10)(a)(ii)(A)(I) the coverage as originally offered; or(10)(a)(ii)(A)(II) a modification of the coverage as originally offered; or(10)(a)(ii)(B) decline to insure the risk; or(10)(b) used by the insurer to gather information from the applicant before issuance of an annuity contract. See Utah Code 31A-1-301- Certificate: means evidence of insurance given to:
(23)(a) an insured under a group insurance policy; or(23)(b) a third party. See Utah Code 31A-1-301- Contract: A legal written agreement that becomes binding when signed.
- Direct response solicitation: means an offer for life or accident and health insurance coverage that allows the individual to apply for or enroll in the insurance coverage on the basis of the offer. See Utah Code 31A-1-301
- Employee: means :
(57)(a) an individual employed by an employer; or(57)(b) an individual who meets the requirements of Subsection (55)(b). See Utah Code 31A-1-301- Endorsement: means a written agreement attached to a policy or certificate to modify the policy or certificate coverage. See Utah Code 31A-1-301
- Form: means one of the following prepared for general use:
(74)(a)(i) a policy;(74)(a)(ii) a certificate;(74)(a)(iii) an application;(74)(a)(iv) an outline of coverage; or(74)(a)(v) an endorsement. See Utah Code 31A-1-301- Group limited long-term care insurance: means a limited long-term care insurance policy that is delivered or issued for delivery:
(3)(a) in this state; and(3)(b) to an eligible group, as described under Subsection31A-22-701 (1). See Utah Code 31A-22-2002- Individual: means a natural person. See Utah Code 31A-1-301
- Insurance: includes :
(96)(b)(i) a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;(96)(b)(ii) a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and(96)(b)(iii) a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301- Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy and includes:
(103)(a)(i) a policyholder;(103)(a)(ii) a subscriber;(103)(a)(iii) a member; and(103)(a)(iv) a beneficiary. See Utah Code 31A-1-301- Limited long-term care insurance: includes a policy or rider described in Subsection (4)(a) that provides for payment of benefits based on cognitive impairment or the loss of functional capacity. See Utah Code 31A-22-2002
- Long-term care insurance: includes :
(121)(b)(i) any of the following that provide directly or supplement long-term care insurance:(121)(b)(i)(A) a group or individual annuity or rider; or(121)(b)(i)(B) a life insurance policy or rider;(121)(b)(ii) a policy or rider that provides for payment of benefits on the basis of:(121)(b)(ii)(A) cognitive impairment; or(121)(b)(ii)(B) functional capacity; or(121)(b)(iii) a qualified long-term care insurance contract. See Utah Code 31A-1-301- Outline of coverage: means a summary that explains an accident and health insurance policy. See Utah Code 31A-1-301
- Person: includes :
(146)(a) an individual;(146)(b) a partnership;(146)(c) a corporation;(146)(d) an incorporated or unincorporated association;(146)(e) a joint stock company;(146)(f) a trust;(146)(g) a limited liability company;(146)(h) a reciprocal;(146)(i) a syndicate; or(146)(j) another similar entity or combination of entities acting in concert. See Utah Code 31A-1-301- Policy: includes a service contract issued by:
(150)(b)(i) a motor club under Chapter 11, Motor Clubs;(150)(b)(ii) a service contract provided under Chapter 6a, Service Contracts; and(150)(b)(iii) a corporation licensed under:(150)(b)(iii)(A) Chapter 7, Nonprofit Health Service Insurance Corporations; or(150)(b)(iii)(B) Chapter 8, Health Maintenance Organizations and Limited Health Plans. See Utah Code 31A-1-301- Policyholder: means a person who controls a policy, binder, or oral contract by ownership, premium payment, or otherwise. See Utah Code 31A-1-301
- Preexisting condition: means a condition for which medical advice or treatment is recommended:
(5)(a) by, or received from, a provider of health care services; and(5)(b) within six months before the day on which the coverage of an insured person becomes effective. See Utah Code 31A-22-2002- Premium: includes , however designated:
(156)(b)(i) an assessment;(156)(b)(ii) a membership fee;(156)(b)(iii) a required contribution; or(156)(b)(iv) monetary consideration. See Utah Code 31A-1-301- producer: means a person licensed or required to be licensed under the laws of this state to sell, solicit, or negotiate insurance. See Utah Code 31A-1-301
- Rider: means an endorsement to:
(173)(a) an insurance policy; or(173)(b) an insurance certificate. See Utah Code 31A-1-301- State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
- Waiting period: means the time an insured waits before some or all of the insured's coverage becomes effective. See Utah Code 31A-22-2002
(1)(a) be cancelled, nonrenewed, or otherwise terminated because of the age, gender, or the deterioration of the mental or physical health of the insured individual or certificate holder;(1)(b) contain a provision establishing a new waiting period if existing coverage is converted to or replaced by a new or other form within the same insurer, or the insurer’s affiliates, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder; or(1)(c) provide coverage for skilled nursing care only or provide significantly more coverage for skilled care in a facility than coverage for lower levels of care.(2)(2)(a) A limited long-term care insurance policy or certificate may not:(2)(a)(i) use a definition of “preexisting condition” that is more restrictive than the definition under this part; or(2)(a)(ii) exclude coverage for a loss or confinement that is the result of a preexisting condition, unless the loss or confinement begins within six months after the day on which the coverage of the insured person becomes effective.(2)(b) A preexisting condition does not prohibit an insurer from:(2)(b)(i) using an application form designed to elicit the complete health history of an applicant; or(2)(b)(ii) on the basis of the answers on the application described in Subsection (2)(b)(i), underwriting in accordance with the insurer’s established underwriting standards.(2)(c)(2)(c)(i) Unless otherwise provided in the policy or certificate, an insurer may exclude coverage of a preexisting condition:(2)(c)(i)(A) for a time period of six months, beginning the day on which the coverage of the insured person becomes effective; and(2)(c)(i)(B) regardless of whether the preexisting condition is disclosed on the application.(2)(c)(ii) A limited long-term care insurance policy or certificate may not exclude or use waivers or riders of any kind to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions for more than a time period of six months, beginning the day on which the coverage of the insured person becomes effective.(3)(3)(a) An insurer may not deliver or issue for delivery a limited long-term care insurance policy that conditions eligibility for any benefits:(3)(a)(i) on a prior hospitalization requirement;(3)(a)(ii) provided in an institutional care setting, on the receipt of a higher level of institutional care; or(3)(a)(iii) other than waiver of premium, post-confinement, post-acute care, or recuperative benefits, on a prior institutionalization requirement.(3)(b) A limited long-term care insurance policy or rider may not condition eligibility for noninstitutional benefits on the prior or continuing receipt of skilled care services.(4)(4)(a) If, after examination of a policy, certificate, or rider, a limited long-term care insurance applicant is not satisfied for any reason, the applicant has the right to:(4)(a)(i) within 30 days after the day on which the applicant receives the policy, certificate, endorsement, or rider, return the policy, certificate, endorsement, or rider to the company or a producer of the company; and(4)(a)(ii) have the premium refunded.(4)(b)(4)(b)(i) Each limited long-term care insurance policy, certificate, endorsement, and rider shall:(4)(b)(i)(A) have a notice prominently printed on the first page or attached thereto detailing specific instructions to accomplish a return; and(4)(b)(i)(B) include the following free-look statement or language substantially similar: “You have 30 days from the day on which you receive this policy certificate, endorsement, or rider to review it and return it to the company if you decide not to keep it. You do not have to tell the company why you are returning it. If you decide not to keep it, simply return it to the company at its administrative office. Or you may return it to the producer that you bought it from. You must return it within 30 days of the day you first received it. The company will refund the full amount of any premium paid within 30 days after it receives the returned policy, certificate, or rider. The premium refund will be sent directly to the person who paid it. The policy certificate or rider will be void as if it had never been issued.”(4)(b)(ii) The requirements described in Subsection (4)(b)(i) do not apply to a certificate issued to an employee under an employer group limited long-term care insurance policy.(5)(5)(a)(5)(a)(i) An insurer shall deliver an outline of coverage to a prospective applicant for limited long-term care insurance at the time of initial solicitation through means that prominently direct the attention of the recipient to the document and the document’s purpose.(5)(a)(ii) In the case of an agent solicitation, the agent shall deliver the outline of coverage before the presentation of an application or enrollment form.(5)(a)(iii) In the case of a direct response solicitation, the outline of coverage shall be presented in conjunction with any application or enrollment form.(5)(a)(iv)(5)(a)(iv)(A) In the case of a policy issued to a group, the outline of coverage is not required to be delivered if the information described in Subsections (5)(b)(i) through (iii) is contained in other materials relating to enrollment, including the certificate.(5)(a)(iv)(B) Upon request, an insurer shall make the other materials described in this Subsection (5)(a)(iv) available to the commissioner.(5)(b) An outline of coverage shall include:(5)(b)(i) a description of the principal benefits and coverage provided in the policy;(5)(b)(ii) a description of the eligibility triggers for benefits and how the eligibility triggers are met;(5)(b)(iii) a statement of the principal exclusions, reductions, and limitations contained in the policy;(5)(b)(iv) a statement of the terms under which the policy or certificate, or both, may be continued in force or discontinued, including any reservation in the policy of a right to change premium.(5)(b)(v) a specific description of each continuation or conversion provision of group coverage;(5)(b)(vi) a statement that the outline of coverage is a summary only, not a contract of insurance, and that the policy or group master policy contains governing contractual provisions;(5)(b)(vii) a description of the terms under which a person may return the policy or certificate and have the premium refunded;(5)(b)(viii) a brief description of the relationship of cost of care and benefits; and(5)(b)(ix) a statement that discloses to the policyholder or certificate holder that the policy is not long-term care insurance.(6) A certificate pursuant to a group limited long-term care insurance policy that is delivered or issued for delivery in this state shall include:(6)(a) a description of the principal benefits and coverage provided in the policy;(6)(b) a statement of the principal exclusions, reductions, and limitations contained in the policy; and(6)(c) a statement that the group master policy determines governing contractual provisions.(7) If an application for a limited long-term care insurance contract or certificate is approved, the issuer shall deliver the contract or certificate of insurance to the applicant no later that 30 days after the day on which the application is approved. - Application: means a document: