Alternate Service Benefits
The provisions in the sample long term care insurance policy clearly state the specific
conditions under which benefits will be paid. Most policies contain provisions similar to those
outlined below.
______________
"Alternate Services" means Qualified Long Term Care Services furnished by a
facility or person not defined in this Policy.
We will consider paying for actual charges You incur for covered Alternate Services only
if We determine that the Alternate Services meet ALL of the following requirements:
- The service falls within guidelines We establish as approved Alternate Services;
- It is a type of service described in Your Plan of Care;
- It effectively meets Your long-term care service needs;
- It is, for You, a cost-effective alternative to Primary Services which would have been
covered under the Policy;
- It is not provided by a member of Your Immediate Family; and
- The Alternate Services and benefit amounts must be mutually agreed to, in writing, by
You, Your Licensed Health Care Practitioner, and Us, through an Alternate Services
Agreement.
The Benefits We will pay for each day You receive Alternate Services will be the
lesser of:
- The actual charges You incur for the services received; or
- The Maximum Daily Benefits Amount for the Covered Services We determine to be most
closely related to the Alternate Services received.
We will not pay for any Alternate Services received prior to the date all parties have
signed the Alternate Services Agreement.
An Agreement to receive Alternate Services Benefits will not waive any of Our rights or
any of Your rights under this Policy.
Receipt of Alternate Services as specified in the Alternate Services Agreement
will count toward satisfying the Elimination Period.
COMMENT: Potentially, this is a generous and extremely reasonable provision, but
exactly how generous and reasonable depends upon how it is administered. The provision allows the
insurance company significant discretion in its implementation. For example, the provision
states that the insurance company "will consider paying..." "…if We determine…," among other
things, that the proposed service "falls within guidelines We establish…" and "it effectively
meets Your long term care needs." This gives the insurer the power to determine whether the
proposed service effectively meets your long term care needs. Finally, the proposed
Alternate Services and benefit amounts must be agreed upon in writing with the insurance
company.
Therefore, while it is useful to have such a provision in your long term care policy, its
true value will be determined when you ask the company to consider providing coverage for some
plan of care that is outside the scope of normal coverage under the policy. |
| 
State Law Center | Legal Links | Site Map | Privacy Policy | Media | About Us | Contact Us