THE CONTRACT
The entire contract between the policyholder and the carrier is as stated in the policy, the policyholder's application and any attached papers. No change in the policy will be effective until approved by one of the carrier's officers. That approval must be noted on, or attached to, the policy. NO agent may change the policy or waive any of its provisions.

TIME LIMIT ON CERTAIN DEFENSES
In regard to misstatements in the policyholder's application: After two (2) years from the policy's effective date, only fraudulent misstatements in the application may be used to void the policy or to deny any claim for loss incurred, or disability that starts after the two (2) year period.

MISSTATEMENTS OF AGE
The policyholder's age may have been misstated in the application. In that case, the carrier will pay the benefits that the premiums would have purchased at the policyholder's true age. If, based on the policyholder's true age, the policy would not have become effective, the carrier will only be liable for the refund of all premiums paid on the policy.

CONFORMITY WITH STATE STATUTES
If the policy does not comply with the laws of the state in which the policyholder resides on its effective date, the carrier will treat it as though it had been changed to comply with those laws.

GOVERNING JURISDICTION
The policy is governed by the laws of the state in which the policyholder resides.

TIME PERIODS
All time periods begin and end at 12:01 a.m. at the policyholder's residence.

PERIOD OF CARE
A period of care begins on the first day you receive and are paid for Long-term Care through your Service Plan and ends when you are no longer receiving services or the period specified in your Service Plan has ended.

NONPARTICIPATING
DIVIDENDS NOT PAYABLE: The policyholder does not participate in the carrier's profits or surplus earnings; no dividends will be paid at any time.

TEMPORARY INSURANCE
Temporary insurance, subject to any elimination periods elected by the applicant, begins at 12:01 a.m., standard time, on the date of the application, at the applicant's residence, and is subject to the terms and conditions of the temporary insurance receipt.

GROUP LTC INSURANCE
This type of insurance can be sold through organizations such as the American Association of Retired Persons (AARP). A "Master Contract" is held by the organization that includes the actual provisions and benefits specified. A Certificate of Insurance is usually issued rather than a policy. This insurance can be sold by mail, whereas individual LTC insurance policies are sold by insurance agents.

COVERED PERSON
Means a person who is in the Eligible Group and approved for coverage under the Group Long-term Care Plan.

POLICY TAKING EFFECT
EFFECTIVE DATE AND CONSIDERATION: The policy is issued based on the statements made in the policy- holder's application and payment of the first premium shown in the schedule. The policy then takes effect on the effective date shown in the schedule.

RIGHT TO CANCEL AT ANY TIME
The policyholder may cancel the policy at any time by sending the carrier a written notice.

PREMIUMS PAID BEYOND THE POLICYHOLDER'S DEATH
If the policyholder should die while insured under the policy, the carrier will refund the pro rata part of any premium paid for the period after the policyholder's death.

SURVIVOR BENEFITS
If both spouses have policies, some policies will, on the death of one spouse, convert the policy of the surviving spouse to paid-up status. That is, the surviving spouse need pay no further premiums.

PAYING PREMIUMS
The premium mode shown in the schedule states how often premiums are to be paid. Each premium, after the first premium, is due at the end of the period for which the prior premium was paid.

GRACE PERIOD
If a renewal premium is not paid on or before the date it is due, it may be paid during the following 31 days. The policy will stay in force during the grace period. If the premium is not paid during the grace period, the policy will terminate at the end of the grace period. This is called a lapse.

EXTENSION OF BENEFITS
Termination of the policy will not affect any claim for uninterrupted institutional confinement that begins while the policy is in force and continues beyond the date of termination. The extension of benefits beyond the period the policy is in force is limited to the unexpired duration of the benefit limit and will be subject to the elimination period and all other applicable provisions of the policy. For the purposes of the extension provision, an uninterrupted institutional confinement will include: Being transferred to another nursing home or alternate Long-Term Care facility; receiving another level of care in the same facility; or transfer back to a nursing home or alternate Long-Term Care facility for a temporary or acute hospitalization.

REINSTATEMENT
Once the policy lapses, the carrier may or may not put it back in force (reinstate), at the carrier's option. An acceptance of late premium by the carrier (or by an Agent authorized to accept payment), without requiring an application for reinstatement, will reinstate the policy.

UNEARNED PREMIUM
Means a premium amount paid by you for coverage that extends over a period of time during which your coverage is no longer in force.

UNPAID PREMIUMS
When a claim is paid, any premium due and unpaid will be deducted from the claim payment.

EXCLUSIONS AND LIMITATIONS (WHAT'S NOT COVERED)
The policy will not pay benefits for anything provided by a member of the policyholder's immediate family (unless stated otherwise – policies may vary); or that for which no charge would be made in the absence of insurance; for care provided outside of the United States of America or its possessions; for care provided in a Veteran's Administration or federal government facility, unless the policyholder or the policyholder's estate is charged for the services or confinement; care that results from war or an act of war, whether declared or not; services needed because of an attempted suicide or an intentionally self inflicted injury; any care needed that results from alcoholism or addiction to narcotics (but not addiction which results from the administration of those substances in accordance with the advice and written instructions of a doctor).

THE POLICYHOLDER'S ROLE
Let the carrier know at once. Early awareness by the carrier's claim department will facilitate a timely review of the policyholder's claim.

INFORMING THE CARRIER OF A CLAIM
NOTICE OF CLAIM: The carrier must be notified when the policyholder has a claim for benefits. The notice can be given to the carrier at the home office or to an Agent of the carrier. It must be received with 30 days of the date the covered loss starts, or as soon as reasonably possible. Include in the notice, at least the policyholder's name, policy number and an address where the claim form can be sent.

WHEN TO FILE
PROOF OF LOSS: The carrier must get written proof of loss within 120 days after the end of each month for which benefits may be payable. If it is not reasonably possible to give the carrier written proof in the time required, the carrier shall not reduce or deny a claim for being late if the proof is filed as soon as reasonably possible. Unless the claimant is not legally capable, the required proof must always be given to the carrier no later than one (1) year from the time specified.

CALENDAR YEAR
A twelve-month period that begins on January 1 and ends on December 31.

CARRIER EVALUATION, CRITERIA AND PAYMENT PROCESS
WHEN PROOF OF LOSS IS SATISFACTORY: The carrier will work with the policyholder, the policyholder's doctor and other care givers to obtain information about the policyholder's state of health and the degree to which the policyholder needs care covered by the policy.

COORDINATION OF BENEFITS
If your policy has coordination of benefits, then it will pay benefits only after any other insurance policy or government agency has made payment. It will not make payments in addition to other benefits you receive.

CO-PAYMENT
This is the percentage of the cost of care that you pay, a/k/a coinsurance. Some LTC policies pay a percentage of charges, up to a daily maximum. Typically, this percentage is 80%, meaning your co-payment is 20% of the charges.

PHYSICAL EXAMINATIONS
As part of the carrier's evaluation of the policyholder's claim, the carrier has the right to require a medical examination when a claim is made and at reasonable intervals while the policyholder is claiming continued benefits. If an examination is required, the policyholder will not have to pay for it.

TIME INVOLVED FOR PAYMENT OF CLAIM
After the carrier receives the proper written proof of loss, the carrier will pay any benefits then due, monthly when the loss is expected to result in on- going benefits or immediately when the carrier's liability has ended.

PAYMENT OF CLAIMS
All benefits will be paid to the policyholder. Any benefits not paid at the policyholder's death will be paid to the policyholder's estate. If benefits are payable to the policyholder's estate, the carrier may pay a portion of the benefits (up to $1,000) directly to someone related to the policyholder by blood or marriage, who is deemed by the carrier to be justly entitled to the benefits. The carrier will be discharged to the extent of any such payment made in good faith.

TRUSTS
A trust is a legal instrument created to hold assets. Assets are sometimes placed in trusts to qualify for Medicaid benefits in case long-term care is needed.

IRREVOCABLE TRUSTS
An Irrevocable Trust holds assets, but the donor cannot change the trust once it is established. These trusts have been used to protect assets from Medicaid spend down, but recent changes in law have restricted their use.

REVOCABLE TRUSTS
A Revocable or "Living" Trust is a legal instrument you create to hold assets. You can change the trust or remove assets from it any time.

APPEAL PROCESS
The policyholder will first have been informed in writing that a claim or any part of a claim is denied. If the policyholder believes that the carrier's decision is in error, the carrier will reconsider the claim.

LEGAL ACTION
The policyholder cannot sue on any claim before 60 days after written proof of loss has been given, as required by the policy. The policyholder cannot sue after three (3) years from the time written proof of loss is required to be given.