Covered Services -- Primary Services and Additional Services—Under Long Term Care Policy
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.
______________
Conditions for Benefit Payments
We will pay for Covered Services only if:
- They are Qualified Long Term Care Services;
- They are received after the Original Coverage Effective Date of this Policy;
- They are received after satisfying any required Elimination Period;
- You are eligible for Benefits; and
- The Total Lifetime Benefit has not been paid.
However, Covered Services do not include any service or supply which is primarily for
personal convenience or companionship.
There are two types of Covered Services under this Policy: Primary Services and
Additional Services.
| COMMENT: These five conditions must be met in order
for the insurance company to pay Benefits. They are self-explanatory. The insurance company
will pay only for the Covered Services listed in the Policy: The Primary
Services of Nursing Home, Assisted Living Facility, Respite Care, Home Care and
Community Care, and the Additional Services of Needs Assessment and Informal Caregiver
Training. These services must be provided for a person who is Chronically Ill
(basically, someone who needs assistance to get through the day) and for whom a Licensed Health Care Practitioner has created a written Plan of
Care. |
Primary Services
On any day, you may receive one or more Primary Services. We will pay up to the
applicable Maximum Daily Benefit Amount shown on the Schedule of Benefits page for actual
charges You incur for Primary Services. However, the most We will pay for any combination
of Primary Services You receive on any day is the highest Maximum Daily Benefit
Amount associated with the
Primary Services You receive that day. Payment of Benefits for Primary
Services will reduce Your Total Lifetime Benefit.
| COMMENT: For example, assume that you have
purchased the following package of Primary Service Benefits under your long term care
insurance policy: |
Benefit
Nursing Home
Assisted Living Facility
Respite Care
Home Care and Community Care
TOTAL LIFETIME BENEFIT
On a given day, you incur the following expenses for long term care:
Home Care
Respite Care
|
Maximum Daily Benefit Amount
$125/day
$100/day
$100/day
$100/day
$150,000
$90
$70 | |
Your Benefit under the Policy would be $125. You would receive credit for the full
$90 of Home Care because that is within the $100 daily limit for Home Care. However, you would
only receive credit for $45 the total Respite Care expense of $70 because the most the insurance
company will pay for any combination of Primary Services is the highest Maximum Daily
Benefit Amount shown on your benefits schedule, which happens to be $125. So the company will
pay the $90 for the Home Care plus the difference between $125 and $70, or $35, toward the Respite
Care. If your Home Care expense for that day was $145 instead of $90, the insurance company
would only pay $100 because that is the daily Home Care maximum. Then $25 would be applied toward
to the Respite Care expense to reach your maximum $125 daily benefit.
Benefit payment for that day reduces your Total Lifetime Benefit to
$149,875. | | 
State Law Center | Legal Links | Site Map | Privacy Policy | Media | About Us | Contact Us