«BANKERS LIFE AND CASUALTY COMPANY 111 E Wacker Dr., Ste 2100, Chicago, Illinois 60601-4508 Telephone 1-312-396-6000 COMPREHENSIVE LONG-TERM CARE ...»
BANKERS LIFE AND CASUALTY COMPANY
111 E Wacker Dr., Ste 2100, Chicago, Illinois 60601-4508
COMPREHENSIVE LONG-TERM CARE INSURANCE POLICY
OUTLINE OF COVERAGE
Policy Form GR-N680
THIS POLICY IS AN APPROVED LONG-TERM CARE INSURANCE POLICY UNDER CALIFORNIA LAW
AND REGULATIONS. HOWEVER, THE BENEFITS PAYABLE BY THIS POLICY WILL NOT QUALIFY
FOR MEDI-CAL ASSET PROTECTION UNDER THE CALIFORNIA PARTNERSHIP FOR LONG-TERMCARE.
THE CONTRACT FOR LONG-TERM CARE INSURANCE IS NOT INTENDED TO BE A FEDERALLY
QUALIFIED LONG-TERM CARE INSURANCE CONTRACT.NOTICE TO BUYER: This policy may not cover all of the costs associated with long-term care incurred by the buyer during the period of coverage. The buyer is advised to review carefully all policy limitations.
1. The policy is an individual policy of insurance.
2. PURPOSE OF OUTLINE OF COVERAGE - This outline of coverage provides a very brief description of the important features of the policy. You should compare this outline of coverage to outlines of coverage for other policies available to you. This is not an insurance contract, but only a summary of coverage. Only the actual policy contains governing contractual provisions. This means that the actual policy sets forth in detail the rights and obligations of both you and the insurance company. Therefore, if you purchase this coverage, or any other coverage, it is important that you READ YOUR POLICY CAREFULLY!
TERMS UNDER WHICH THE POLICY MAY BE RETURNED AND PREMIUM REFUNDED3.
If you're not satisfied with the policy, you may return it to us within 30 days after you receive it for a full refund of any premium paid.
Except for a refund of that part of any premium paid beyond your date of death, the policy does not provide for a refund of unearned premium.
In the event your application for coverage is denied, we'll refund any monies paid within 30 days of our notice to you of the denial.
4. THIS IS NOT MEDICARE SUPPLEMENT COVERAGE - If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from us. Neither Bankers Life and Casualty Company nor its agents represent Medicare, the federal government, or any state government.
5. LONG-TERM CARE COVERAGE - Policies of this category are designed to provide coverage for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services, provided in a setting other than an acute care unit of a hospital, such as in a nursing home, in the community or in the home.
The policy provides coverage for those incurred charges for Long-Term Care services when a Licensed Health Care Practitioner certifies you need such services due to: (a) at least two (2) Impairments in the Activities of Daily Living; or (b) a Cognitive Impairment.
The Elimination Period is the number of days you must receive Facility Care or Home and Community Based Care services before benefits are payable. The Elimination Period has to be satisfied only once.
Days used to satisfy the Elimination Period do not need to be consecutive and may be accumulated under separate claims. Each day of Home and Community-Based Care received will count as three (3) days toward satisfaction of the Elimination Period. The Elimination Period is days.
A. Nursing Facility Care.
The expense incurred, up to the Maximum Daily Benefit amount, for a Nursing Facility confinement (whether for a skilled, intermediate, or custodial level of care). Expenses include, but are not limited to, room, board and care including ancillary services and supplies. “Nursing Facility” a place which (a) if licensing is required, is licensed as a Nursing Facility to provide nursing care (skilled, intermediate or custodial) for persons at their own expense and maintains all appropriate licensing under the laws where it is located to provide such care; or (b) if licensing is not required, meets ALL of the following requirements: (1) provides 24 hour a day care and have beds for patients who need nursing care;(2) has a trained and ready-to-respond employee on duty at all times to provide care;
(3) Provides 3 meals a day and accommodate special dietary needs; and (4) has appropriate methods and procedures for handling and administering drugs and biologicals.
B. Residential Facility Care The actual charges for Qualified Long-Term Care Services received while confined in a Residential Care Facility. Residential Facility Care includes services and supplies provided by the Residential Care Facility; care and services covered under other benefits of the policy; and other Qualified Long Term Care Services needed to assist you with the disabling conditions that caused you to be a Chronically Ill Individual. No payment is made for any day for which a Nursing Facility Care benefit is paid.
ENHANCED SERVICES BENEFIT RIDER - LEVEL TWO - 310A-CAIf this rider is attached to the policy it will provide benefits for Alternate Plan of Care, Home Modifications, Home Monitoring Equipment and Caregiver Training
CASH BENEFIT RIDER LEVEL ONE - 313A-CA If this rider is attached to the policy, for each day you are receiving benefit payments for Covered Expenses that are less than the Maximum Daily Benefit amount for Qualified Long Term Care Services, we will pay an additional cash benefit up to 25% of the Maximum Daily Benefit amount. The total benefits paid per day under the policy and this rider will not exceed the Maximum Daily Benefit amount.
In order for benefits to be payable, you must be receiving benefits under the Facility Care and/or Home and Community-Based Care benefit provisions of the policy. Any benefits payable under the terms of this rider count against the Lifetime Maximum Benefit.
CASH BENEFIT RIDER - LEVEL TWO - 315A-CA If this rider is attached to the policy, for each day you qualify for benefits under this rider, we will pay an additional cash benefit up to 25% of the Maximum Daily Benefit for Nursing Home care amount.
You qualify for benefits under this rider after the Rider Elimination Period has been satisfied and if you continue to to have at least 2 Impairments in the Activities of Daily Living or to be Cognitively Impaired as certified by Licensed Health Care Practitioner.. The Rider Elimination period is equal to the Elimination Period elected for the policy. The total benefits paid for any day will not exceed the Maximum Daily Benefit for Nursing Home care amount. Any benefits payable under the terms of this rider count against the Lifetime Maximum Benefit. Any benefits paid do not count toward satisfying the Elimination Period of the policy.
NONFORFEITURE BENEFIT RIDER 216P(02) If this rider is attached to the policy and the policy lapses for non-payment of premium after the third year, you are eligible for a nonforfeiture benefit in the form of a reduced paid up benefit. This reduced paid up benefit will be an amount equal to the greater of (a) 100% of all premiums you paid for the policy and this rider; and (b) 90 times the Maximum Daily Benefit then in effect at the time the policy lapsed, LESS the total amount of any claims paid under the policy. Additional non-forfeiture benefits for policyholder elected increases in the Maximum Benefit for Any One Period of Expense amount or Maximum Daily Benefit amount will be based on the effective date of such increases. The reduced paid up benefit amount will be the new Maximum Benefit amount for the policy. Expenses for Qualified Long-Term Care Services covered by the policy at time of lapse will be payable until this reduced paid up benefit amount is exhausted.
RESTORATION OF POLICY BENEFITS RIDER 304X-CAIf this rider is attached to the policy, the Lifetime Maximum Benefit will be fully restored when you have not had at least 2 Impairments in the Activities of Daily Living, and have not had a Cognitive Impairment, and have not required or received Prescribed Long Term Care Services, as defined in the policy, for 180 consecutive days. If this policy includes one of the Annual Benefit Increase Options, the Policy's Lifetime Maximum Amount will restore to the amount that would have applied if no benefits had been paid under the Policy. After the Lifetime Maximum Benefit has been fully restored once under the provisions of this rider, the rider will end with no further benefits due.
SURVIVOR MAXIMUM BENEFIT INCREASE RIDER 303AIf this rider is attached to the policy and either you or your spouse die, we will increase the Surviving Spouse's Maximum Lifetime Benefit by fifty percent (50%) of the Lifetime Maximum Benefit in effect for the deceased person' policy as of the last anniversary before his or her death. When benefits have been increased under the terms of this rider, no additional premium will be charged for the increased benefit amount.
PAID-UP SURVIVORSHIP RIDER 226G-CA(02) If this rider is attached to the policy and either you or your spouse die, we will waive the payment of all premiums for the surviving spouse's policy. Premium will be waived after the death of a spouse only if this rider and coverage for both you and your spouse are inforce for at least 10 full years.
SHARED MAXIMUM BENEFIT RIDER 308AIf this rider is attached to the policy and you exhausts the policy’s Lifetime Maximum Benefit, we will continue to pay benefits until the Shared Maximum Benefit is exhausted. The Shared Maximum Benefit is an additional amount of benefits, equal to your Lifetime Maximum Benefit amount, that is available to both you and your spouse. This Shared Maximum Benefit is a single amount which may be shared by both you and your spouse. Benefits will be paid at the same Maximum Daily Benefit and, if applicable, same Maximum Monthly/Weekly Benefit, subject to all the provisions of the policy. If the policy includes a Benefit Increases option, the Shared Maximum Benefit will increase in the same manner as the Maximum Benefit. The Restoration of Benefits provision does not apply to the Shared Maximum Benefit.
If both you and your spouse are eligible to receive benefits from the Shared Maximum Benefit at the same time, we will pay benefits for each spouse until the Shared Maximum Benefit is exhausted.
In the event of the death of You or Your spouse, benefits remaining under this rider, if any, will continue for the surviving spouse for as long as the policy and this rider remain in force.
LIMITED PREMIUM PAYMENT RIDER 242AThis rider offers a payment method where, after you pay premium for either 10 years or 20 years, your policy will continue in force with no further premiums being payable. Premiums waived during the Waiver of Premium period will not count towards satisfaction of the Limited Premium Payment Period.
You may choose to cancel this rider at any time. If you cancel this rider, we will change your Premium Payment Period to non-limited and adjust your premium amount accordingly. The new premium will be based on your age when the policy was issued. When the Limited Premium Payment Period Rider 242A is attached to the policy and the policy lapses after the policy and this rider have been inforce for 3 years, you are eligible for a reduced paid up benefit. This reduced paid up benefit will be an amount equal to 100% of all premiums you paid for the policy. The reduced paid up benefit amount will be the new Maximum Benefit for the policy. The new Maximum Benefit will not be less than 30 times the Maximum Daily Benefit amount then in effect at the time the policy lapsed. Charges incurred for expenses covered by the policy at time of lapse will be payable until this new Maximum Benefit is exhausted.
Cognitive Impairment - means a deterioration or loss in intellectual capacity which requires substantial supervision to protect one’s self from threats to health and safety. Cognitive Impairment is measured by clinical evidence or standardized tests which reliably measure impairment in one’s: (a) short or long term memory; (b) orientation as to people, place, and time; and (c) deductive or
Such loss of intellectual capacity can result from the following covered conditions: Alzheimer's disease, Parkinson's disease, senile dementia or other nervous or mental disorders.
8. RELATIONSHIP OF COST OF CARE AND BENEFITS –Because the costs of long-term care services will likely increase over time, you should consider whether and how the benefits of this plan may be adjusted. A comparison of Long Term Care Benefit levels (nonincreasing vs. increasing) over a 20 year period is shown below.
This policy provides options to increase your maximum benefits.
17635-CA Page 7 of 10 If you select a Compound Increases Benefit Option, your current Maximum Daily Benefit amount and Lifetime Maximum Benefit will increase by the percentage you choose (2%, 3%, 4% or 5%). If you select the Equal Increases Benefit Option, your original Maximum Daily Benefit amount and Lifetime Maximum Benefit will increase by 5%. These increases will take place on each policy anniversary for the time period chosen as long as the policy is in force. Each increased maximum benefit option will be rounded to the next highest multiple of $0.25.
The following graph compares the Compound Increase Benefit Option at 5% annually against the Equal Increases Benefit Option at 5% annually.