§ 26-38-105 — Disclosure and performance standards for long- term care insurance

(a) The commissioner shall adopt regulations that include
standards for full and fair disclosure setting forth the manner,
content and required disclosures for the sale of long-term care
insurance policies, terms of renewability, initial and
subsequent conditions of eligibility, nonduplication of coverage
provisions, coverage of dependents, preexisting conditions,
termination of insurance, probationary periods, limitations,
exceptions, reductions, elimination periods, requirements for
replacement, recurrent conditions and definitions of terms.
(b) No long-term care insurance policy shall:
(i) Be cancelled, nonrenewed or otherwise terminated
on the grounds of the age or the deterioration of the mental or
physical health of the insured individual or certificate holder;
(ii) Contain a provision establishing a new waiting
period in the event existing coverage is converted to or
replaced by a new or other form within the same company, except
with respect to an increase in benefits voluntarily selected by
the insured individual or group policyholder; or
(iii) Contain coverage for skilled nursing care only
or contain coverage that provides significantly more skilled
care in a facility than coverage for lower levels of care.
(c) No long-term care insurance policy or certificate
shall use a definition of "preexisting condition" which is more
restrictive than the definition provided in this article.
(d) No long-term care insurance policy shall exclude
coverage for a loss or confinement which is the result of a
preexisting condition unless the loss or confinement begins
within six (6) months following the effective date of coverage
of an insured person.
(e) The commissioner may extend the limitation periods set
forth in subsections (c) and (d) of this section as to specific
age group categories in specific policy forms upon finding that
the extension is in the best interest of the public.
(f) The definition of "preexisting condition" does 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, from underwriting in
accordance with that insurer's established underwriting
standards. Unless otherwise provided in the policy, a
preexisting condition, regardless of whether it is disclosed in
the application, need not be covered until the waiting period
described in subsection (d) of this section expires. No
long-term care insurance policy may 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 subsection (d) of this section.
(g) No long-term care insurance policy may be delivered or
issued for delivery in this state if the policy:
(i) Conditions eligibility for any benefits on a
prior hospitalization requirement;
(ii) Conditions eligibility for benefits provided in
an institutional care setting on the receipt of a higher level
of institutional care;
(iii) Conditions eligibility for any benefits, other
than waiver of premium, post-confinement, post-acute care or
recuperative benefits, on a prior institutionalization
requirement; or
(iv) Fails to meet any of the following requirements:
(A) A long-term care insurance policy containing
post-confinement, post-acute care or recuperative benefits shall
clearly label in a separate paragraph of the policy or
certificate entitled "limitations or conditions on eligibility
for benefits" the limitations or conditions, including any
required number of days of confinement;
(B) A long-term care insurance policy or rider
which conditions eligibility of noninstitutional benefits on the
prior receipt of institutional care shall not require a prior
institutional stay of more than five (5) days;
(C) No long-term care insurance policy or rider
which provides benefits only following institutionalization
shall condition the benefits upon admission to a facility for
the same or related conditions within a period of less than
thirty (30) days after discharge from the institution.
(h) The commissioner shall adopt regulations establishing
loss ratio standards for long-term care insurance policies
provided that a specific reference to long-term care insurance
policies is contained in the regulation.
(j) Long-term care insurance policyholders or certificate
holders, shall have the right to return the policy or
certificate within thirty (30) days of its delivery and to have
the premium refunded if, after examination of the policy or
certificate, the policyholder or certificate holder is not
satisfied for any reason. Long-term care insurance policies and
certificates shall have a notice prominently printed on the
first page of the policy and certificate or attached thereto
stating in substance that the policyholder or certificate holder
shall have the right to return the policy within thirty (30)
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
defined in W.S. 26-38-103(a)(iv)(A), the policyholder or
certificate holder is not satisfied for any reason. The premium
shall be refunded within ten (10) days, excluding Saturdays,
Sundays and legal holidays, from the date the policy or
certificate is returned. If the premium required to be refunded
under this subsection is not refunded within the time periods
specified it shall draw interest at the maximum rate allowed for
a credit service charge under W.S. 40-14-212(b). No company
issuing a long-term care insurance policy shall be required to
pay any claim under the terms of the policy until the expiration
of the thirty (30) day period. If an application for a qualified
long-term care contract is denied, the issuer shall refund to
the applicant any premium refund within thirty (30) days of the
denial.
(k) An outline of coverage shall be delivered to a
prospective applicant at the time of the initial solicitation
through means which prominently direct the attention of the
recipient to the document and its purpose. The commissioner
shall prescribe a standard format of the outline of coverage,
including style, arrangement, overall appearance and content. In
the case of agent solicitations, an agent shall deliver the
outline of coverage prior to the presentation of an application
or enrollment form. In the case of direct response
solicitations, the outline of coverage shall be presented in
conjunction with any application or enrollment form. In the
case of a group policy, the outline shall be delivered to
certificate holders when the certificate is delivered. The
outline of coverage shall include:
(i) A description of the principal benefits and
coverage provided in the policy;
(ii) A statement of the principal exclusions,
reductions and limitations contained in the policy;
(iii) 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 premium. Continuation or conversion provisions of
group coverage shall be specifically described;
(iv) A statement that the outline of coverage is a
summary only, not a contract of insurance, and that the policy
or group master policy contains governing contractual
provisions;
(v) A description of the terms under which the policy
or certificate may be returned and premium refunded;
(vi) A brief description of the relationship of cost
of care and benefits; and
(vii) If the policy or certificate is intended to be
a qualified long-term care insurance contract, a statement that
discloses to the policyholder or certificate holder that the
policy is intended to be a qualified long-term care insurance
contract.
(m) Repealed by Laws 1993, ch. 212, § 3.
(n) Repealed by Laws 1993, ch. 212, § 3.
(o) The issuer of a long-term care insurance contract
shall deliver to the applicant, policyholder or certificate
holder, the contract or certificate of insurance no later than
thirty (30) days after the date of approval. At the time of
policy delivery, a policy summary shall be delivered for an
individual life insurance policy which provides long-term care
benefits within the policy or rider. In the case of direct
response solicitations, the insurer shall deliver the policy
summary upon the applicant's request, but regardless of request
shall make the delivery no later than at the time of policy
delivery. In addition to complying with all applicable
requirements, the summary shall also include:
(i) An explanation of how the long-term care benefit
interacts with other components of the policy, including
deductions from death benefits;
(ii) An illustration of the amount of benefits, the
length of benefits, and guaranteed lifetime benefits if any, for
each covered person;
(iii) Any exclusions, reductions and limitations on
benefits of long-term care; and
(iv) If applicable to the policy type, the summary
shall also include:
(A) A disclosure of the effects of exercising
other rights under the policy;
(B) A disclosure of guarantees related to
long-term care costs of insurance charges; and
(C) Current and projected maximum lifetime
benefits.
(p) If any 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:
(i) Any long-term care benefits paid out during the
month;
(ii) An explanation of any changes in the policy,
including, but not limited to, death benefits or cash values,
due to long-term care benefits; and
(iii) The amount of long-term care benefits existing
or remaining.
(q) If a claim under a long-term care insurance contract
is denied, the issuer shall, within sixty (60) days of the date
of a written request by the policyholder, or certificate holder
or an authorized representative:
(i) Provide a written explanation of the reason for
the denial; and
(ii) Make available all information directly related
to the denial.
(r) Long-term care insurance premium rate increases shall
be based on accepted actuarial principles and practices. All
long-term care insurance premium rate increases shall be subject
to the approval of the commissioner.