2009 Iowa Code
Title 13 - Commerce
Subtitle 1 - Insurance and Related Regulation
CHAPTER 514G - LONG=TERM CARE INSURANCE ACT
514G.105 - DISCLOSURE AND PERFORMANCE STANDARDS FOR LONG-TERM CARE INSURANCE.

        514G.105  DISCLOSURE AND PERFORMANCE STANDARDS FOR
      LONG-TERM CARE INSURANCE.
         1.  Prohibited policy practices.  A long-term care insurance
      policy shall not:
         a.  Be canceled, nonrenewed, or otherwise terminated on the
      grounds of the age or deterioration of the mental or physical health
      of the insured individual or certificate holder.
         b.  Contain a provision establishing a new waiting period in
      the event that existing coverage is converted to or replaced by a new
      or other policy form within the same company, except with respect to
      an increase in benefits voluntarily selected by the insured
      individual, the certificate holder, or the group policyholder.
         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.  Preexisting conditions.
         a.  A long-term care insurance policy or certificate, other
      than a policy or certificate issued to a group as described in
      section 514G.103, subsection 9, shall not use a definition of
      "preexisting condition" that is more restrictive than the
      definition contained in section 514G.103, subsection 15.
         b.  A long-term care insurance policy or certificate, other
      than a policy or certificate issued to a group as described in
      section 514G.103, subsection 9, shall not exclude coverage for a loss
      or confinement that is the result of a preexisting condition unless
      the loss or confinement begins within six months following the
      effective date of coverage of an insured individual.
         c.  The commissioner may extend the limitation periods set
      forth in paragraphs "a" and "b" as to specific age group
      categories in specific policy forms upon finding that such an
      extension is in the best interest of the public.
         d.  The requirements of paragraph "a" do not prohibit an
      insurer from using an application form designed to elicit the
      complete health history of an applicant, and on the basis of the
      answers on that application, underwriting in accordance with that
      insurer's established underwriting standards.  Unless otherwise
      provided in the policy or certificate, a preexisting condition,
      regardless of whether it is disclosed on the application, is not
      required to be covered until the waiting period described in
      paragraph "b" expires.  A long-term care insurance policy or
      certificate shall 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 beyond
      the waiting period described in paragraph "b".
         3.  Prior hospitalization or institutionalization.
         a.  A long-term care insurance policy shall not be delivered
      or issued for delivery in this state if the policy does any of the
      following:
         (1)  Conditions eligibility for any benefits on a prior
      hospitalization requirement.
         (2)  Conditions eligibility for any benefits provided in an
      institutional care setting on the receipt of a higher level of
      institutional care.
         (3)  Conditions eligibility for any benefits other than waiver of
      premium, post-confinement, post-acute care, or recuperative benefits
      on a prior institutionalization requirement.
         b.  A long-term care insurance policy that contains
      post-confinement, post-acute care, or recuperative benefits shall
      contain, in a clearly visible, separate paragraph or the policy or
      certificate entitled "limitations or conditions on eligibility for
      benefits", a description of such limitations or conditions,
      including any required number of days of confinement.
         c.  A long-term care insurance policy or rider that conditions
      eligibility for noninstitutional benefits on the prior receipt of
      institutional care shall not require a prior institutional stay of
      more than thirty days.
         d.  A long-term care insurance policy or rider that provides
      benefits only following institutionalization shall not condition such
      benefits upon admission to a facility for the same or related
      conditions within a period of less than thirty days after discharge
      from the institution.
         4.  Right to return -- free look -- refund.
         a.  A long-term care insurance applicant shall have the right
      to return the long-term care insurance policy or certificate within
      thirty days of its delivery and to have the premium refunded if,
      after examination of the policy or certificate, the applicant is not
      satisfied for any reason.
         b.  A long-term care insurance policy or certificate delivered
      or issued for delivery in this state shall have a notice prominently
      displayed on the first page of the policy or certificate, or attached
      thereto, which states in substance that the applicant has the right
      to return the policy or certificate within thirty days of its
      delivery and to have the premium refunded if, after examination of
      the policy or certificate, other than a certificate issued pursuant
      to a policy issued to a group as described in section 514G.103,
      subsection 9, paragraph "a", the applicant is not satisfied for
      any reason.
         c.  Any premium refund shall be made to the applicant within
      thirty days of the return.
         5.  Denials -- refund.  If an application is denied by an
      insurer, any premium refund shall be made to the applicant within
      thirty days of the denial.
         6.  Outline of coverage.
         a.  A written outline of coverage shall be delivered to a
      prospective applicant for long-term care insurance at the time of the
      initial solicitation for coverage which prominently directs the
      attention of the applicant to the document and its purpose.
         b.  The commissioner shall prescribe, by rule, a standard
      format, including style, arrangement, and overall appearance, and
      content of the outline of coverage.
         c.  In the case of producer solicitations, a producer shall
      deliver the outline of coverage to a prospective applicant prior to
      the presentation of an application or enrollment form.
         d.  In the case of direct response solicitations, the outline
      of coverage shall be presented in conjunction with any application or
      enrollment form.
         e.  In the case of a policy issued to a group as described in
      section 514G.103, subsection 9, paragraph "a", an outline of
      coverage is not required to be delivered to the applicant, provided
      that the information described in subsection 7 of this section,
      paragraphs "a" through "f", is contained in other enrollment
      materials provided.  Upon request, such other enrollment materials
      shall be made available to the commissioner.
         7.  Contents of outline of coverage.  An outline of coverage
      of long-term care insurance shall include all of the following:
         a.  A description of the principal benefits and coverage
      provided in the policy.
         b.  A statement of the principal exclusions, reductions, and
      limitations contained in the policy.
         c.  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 the
      premium.  Continuation or conversion provisions of group coverage
      shall be specifically described.
         d.  A statement that the outline of coverage is a summary of
      coverage only, not a contract of insurance, and that the policy or
      group master policy contains governing contractual provisions.
         e.  A description of the terms under which the policy or
      certificate may be returned and the premium refunded.
         f.  A brief description of the relationship of cost of care
      and benefits.
         g.  A statement that discloses to the policyholder or
      certificate holder whether the policy is intended to be a federally
      tax-qualified long-term care insurance contract under section
      7702B(b) of the Internal Revenue Code.
         8.  Contents of group certificate.  A certificate issued
      pursuant to a group long-term care insurance policy which policy is
      delivered or issued for delivery in this state shall include all of
      the following:
         a.  A description of the principal benefits and coverage
      provided in the policy.
         b.  A statement of the principal exclusions, reductions, and
      limitations contained in the policy.
         c.  A statement that the group master policy determines
      governing contractual provisions.
         9.  Time for delivery.  If an application for a long-term care
      insurance policy or certificate is approved, the issuer shall deliver
      the policy or certificate of insurance to the applicant no later than
      thirty days after the date of approval.
         10.  Individual life insurance -- policy summary.
         a.  A written policy summary shall accompany the delivery of
      an individual life insurance policy that provides long-term care
      benefits within the policy or by rider.  In the case of direct
      response solicitations, the insurer shall deliver a policy summary
      upon the applicant's request or at the time of policy delivery,
      whichever occurs first.
         b.  A policy summary shall include all of the following:
         (1)  An explanation of how the long-term care benefit interacts
      with other components of the policy, including deductions from death
      benefits.
         (2)  An illustration 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 long-term care
      benefits.
         (4)  A statement that a long-term care inflation protection option
      required by 191 IAC 39.10 is not available under this policy.
         (5)  If applicable to the policy type, the summary shall also
      include all of the following:
         (a)  A disclosure of the effect of exercising other rights under
      the policy.
         (b)  A disclosure of guarantees related to long-term care costs of
      insurance charges.
         (c)  Current and projected maximum lifetime benefits.
         c.  The requirements of a policy summary set forth in
      paragraph "b" may be incorporated into the basic illustration
      required to be delivered in accordance with 191 IAC 14, or into the
      life insurance policy summary required to be delivered in accordance
      with 191 IAC 15.4.
         11.  Monthly report.  If a long-term care benefit, funded
      through a life insurance vehicle by the acceleration of the death
      benefit, is in benefit payment status, a monthly report shall be
      provided to the policyholder.  The report shall include all of the
      following:
         a.  Any long-term care benefits paid out during the month.
         b.  An explanation of any changes in the policy, including but
      not limited to changes in death benefits or cash values due to
      long-term care benefits being paid out.
         c.  The amount of long-term care benefits existing or
      remaining.
         12.  Claim denial.  If a claim made under a long-term care
      insurance policy is denied, the issuer, within sixty days of the date
      of receipt of a written request by the policyholder, certificate
      holder, or a representative thereof, shall provide a written
      explanation of the reasons for the denial, and shall make all
      information directly related to the denial available to the
      requestor.
         13.  Compliance.  Any policy or rider advertised, marketed, or
      offered as long-term care insurance or nursing home insurance shall
      comply with the provisions of this chapter.  

         2008 Acts, ch 1175, §6
         Referred to in § 514H.1