Sec. 38a-528. Long-term care policies.
Sec. 38a-528. Long-term care policies. (a) As used in this section, "long-term
care policy" means any group health insurance policy or certificate delivered or issued
for delivery to any resident of this state on or after July 1, 1986, which is designed to
provide, within the terms and conditions of the policy or certificate, benefits on an
expense-incurred, indemnity or prepaid basis for necessary care or treatment of an injury,
illness or loss of functional capacity provided by a certified or licensed health care
provider in a setting other than an acute care hospital, for at least one year after a reasonable elimination period. A long-term care policy shall provide benefits for confinement
in a nursing home or confinement in the insured's own home or both. Any additional
benefits provided shall be related to long-term treatment of an injury, illness or loss
of functional capacity. "Long-term care policy" shall not include any such policy or
certificate which is offered primarily to provide basic Medicare supplement coverage,
basic medical-surgical expense coverage, hospital confinement indemnity coverage,
major medical expense coverage, disability income protection coverage, accident only
coverage, specified accident coverage or limited benefit health coverage.
(b) No insurance company, fraternal benefit society, hospital service corporation,
medical service corporation or health care center may deliver or issue for delivery any
long-term care policy or certificate which has a loss ratio of less than sixty-five per cent
for any group long-term care policy. An issuer shall not use or change premium rates
for a long-term care insurance policy or certificate unless the rates have been filed with
the Insurance Commissioner. Deviations in rates to reflect policyholder experience shall
be permitted, provided each policy form shall meet the loss ratio requirement of this
section. Any rate filings or rate revisions shall demonstrate that anticipated claims in
relation to premiums when combined with actual experience to date can be expected to
comply with the loss ratio requirement of this section. On an annual basis, an insurer
shall submit to the Insurance Commissioner an actuarial certification of the insurer's
continuing compliance with the loss ratio requirement of this section. Any rate or rate
revision may be disapproved if the commissioner determines that the loss ratio requirement will not be met over the lifetime of the policy form using reasonable assumptions.
(c) No such company, society, corporation or center may deliver or issue for delivery
any long-term care policy without providing, at the time of solicitation or application
for purchase or sale of such coverage, full and fair disclosure of the benefits and limitations of the policy. The provisions of this subsection shall not be applicable to: (1) Any
long-term care policy which is delivered or issued for delivery to one or more employers
or labor organizations, or to a trust or to the trustees of a fund established by one or
more employers or labor organizations, or a combination thereof, for employees or
former employees or a combination thereof or for members or former members or a
combination thereof, or the labor organizations; and (2) noncontributory plans.
(d) The Insurance Commissioner shall adopt regulations, in accordance with chapter 54, which address (1) the insured's right to information prior to his replacing an
accident and sickness policy with a long-term care policy, (2) the insured's right to
return a long-term care policy to the insurer, within a specified period of time after
delivery, for cancellation, and (3) the insured's right to accept by his signature, and prior
to it becoming effective, any rider or endorsement added to a long-term care policy
after the issuance date of such policy, provided (A) any regulations adopted pursuant
to subdivisions (1) and (2) of this subsection shall not be applicable to (i) any long-term
care policy which is delivered or issued for delivery to one or more employers or labor
organizations, or to a trust or to the trustees of a fund established by one or more employers or labor organizations, or a combination thereof or for members or former members
or a combination thereof, of the labor organizations, or (ii) noncontributory plans, and
(B) any regulations adopted pursuant to subdivision (3) of this subsection shall not be
applicable to any group long-term policy. The Insurance Commissioner shall adopt such
additional regulations as he deems necessary in accordance with said chapter 54 to carry
out the purpose of this section.
(e) The Insurance Commissioner may, upon written request by any such company,
society, corporation or center, issue an order to modify or suspend a specific provision
of this section or any regulation adopted pursuant thereto with respect to a specific long-term care policy upon a written finding that: (1) The modification or suspension would
be in the best interest of the insureds; (2) the purposes to be achieved could not be
effectively or efficiently achieved without such modification or suspension; and (3) (A)
the modification or suspension is necessary to the development of an innovative and
reasonable approach for insuring long-term care, (B) the policy is to be issued to residents
of a life care or continuing care retirement community or other residential community
for the elderly and the modification or suspension is reasonably related to the special
needs or nature of such community, or (C) the modification or suspension is necessary
to permit long-term care policies to be sold as part of, or in conjunction with, another
insurance product, whenever the commissioner decides not to issue such an order, he
shall provide written notice of such decision to the requesting party in a timely manner.
(f) Upon written request by any such company, society, corporation or center, the
Insurance Commissioner may issue an order to extend the preexisting condition exclusion period, as established by regulations adopted pursuant to this section, for purposes
of specific age group categories in a specific long-term care policy form whenever he
makes a written finding that such an extension is in the best interest to the public. Whenever the commissioner decides not to issue such an order, he shall provide written notice
of such decision to the requesting party in a timely manner.
(g) The provisions of section 38a-19 shall be applicable to any such requesting party
aggrieved by any order or decision of the commissioner made pursuant to subsections
(e) and (f) of this section.
(P.A. 90-243, S. 112; P.A. 91-276, S. 2; P.A. 93-239, S. 5; P.A. 94-39, S. 6.)
History: P.A. 91-276 substituted 65% for 60% in Subsec. (b) re loss ratio for any individual long-term care policy; P.A.
93-239 added the provision requiring a long-term care policy to provide benefits in the insured's own home or in both a
nursing home and his own home; P.A. 94-39 amended Subsec. (b) by adding provision requiring that issuer not use or
change premium rates for a long-term policy or certificate without the filing and approval of the insurance commissioner,
that any filing or revision of premium rates must comply with the loss ratio requirement for any group long-term care
policy or certificate, that insurer submit annual actuarial certification of its continuing compliance with the loss ratio
requirements, authorized disapproval of rate or revision if the commissioner determines that the loss ratio requirement
will not be met over the lifetime of the policy form and added references to "policies" and "certificates" for statutory
consistency.