Limitations and Exclusions: What is Not Covered Under Long Term Insurance Policy; Coordination of
Benefits
The provisions in the sample long term care insurance policy clearly state the specific
conditions under which benefits will not be paid. Most policies contain provisions similar to
those outlined below.
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No payment will be made for any of the following:
- Treatment of alcoholism or drug addiction, unless the addiction was due to drug(s) taken
on the advice of a Physician.
- Any care received while in a Hospital, except in a unit specifically designated as a
Nursing Home or a Hospice facility.
- Any injury or sickness that results from:
- any war, or act of war (whether declared or undeclared); or
- participation in a felony, riot or insurrection.
- Any intentionally self-inflicted injury.
- Services performed by a member of Your Immediate Family.
- Any care or services received outside of the Untied States and its territories, except as
described in the International Coverage section.
- Any service or supply to the extent the expense for it is reimbursable under Medicare,
or would be reimbursable but for the application of a deductible, coinsurance or co-payment
amount. This exclusion will not apply where Medicare is a secondary under the applicable
law.
- Treatment received in a government facility (unless otherwise required by law); services for
which benefits are available under a government program (except Medicaid); or services for
which no charge is normally made in the absence of insurance.
There are no limitations or exclusions for pre-existing conditions, or mental and nervous
disorders, including Alzheimer's Disease.
COMMENT: Note that many of the exclusions relate to conditions caused by a condition
presumed to be brought on by yourself, in other words, self-induced: alcoholism, drug addiction,
participation in a felony, riot or insurrection, self-inflicted injury.
Services performed by your Immediate Family are not covered because it is presumed
that they will be done by the family for no charge. A charge for a service performed by an
Immediate Family member is not considered to be legitimate. It is regarded as one which
would not be charged if there were no insurance.
If, under the law, Medicare is secondary, that means that your insurance company
pays first. If Medicare is primary, then your insurance company need not pay because Medicare will.
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Unlike regular health insurance, there are no limitations or exclusions for pre-existing
conditions and mental and nervous disorders.
Coordination of Other Coverages with This Company
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.
______________________
If you have more than one long term care insurance policy or certificate issued or insured with
this Company, We will reduce the benefit amounts payable to the extent necessary, so that the
combination of Benefits under all of these policies and certificates will not exceed one
hundred per cent (100%) of the actual charges for Covered Services.
If you are eligible to receive Benefits under this Policy and any other long term care
insurance policy or certificate issued or insured by this Company with a coordination of benefits
provision, then the policy or certificate with the earliest effective date will be deemed tore be
the primary coverage, and any other policy or certificate will be deemed secondary coverage, in
order by effective date, from the earliest to the latest. Policies and certificates without a
coordination of benefits provision will pay first.
| COMMENT: Coordination of benefit provisions can be very complicated to apply because each
policy may have its own priority system for which policy pays first, second, etc. The goal, of
course, is to protect against profiteering. |
The provision will not apply to policies or certificates which pay Benefits without
regard to actual charges you incur.
| COMMENT: For example, if another long term care policy was providing long term care on a
per diem basis (like this Policy pays for International Coverage, for example), coordination of benefits would not
apply. That is because the theory behind coordination of benefits is to keep an individual from
profiting from insurance by buying a bunch of policies that are designed and intended to help
you cover your incurred long term care expenses and collecting, in essence, multiple benefit
payments for the same incurred expenses. This is contrary to the basic insurance concept. A per
diem benefit is not designed to do that. It is priced to pay you a specific daily benefit,
regardless of expenses you incur. |
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