certificate - Summary of policy provisions - Report of benefits status. 1. Long-term care insurance applicants have the right to return the policy or certificate within thirty days of the date of its delivery or within thirty days of its effective date, whichever occurs later, and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason. Long -term care insurance policies and certificates must have a notice prominently printed on the first page or attached thereto stating in substance that the applicant has the right to return the policy or certificate within thirty days of the date of its delivery or within thirty days of its effective date, whichever occurs later, 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 subdivision a of subsection 3 of section 26.1-45-01, the applicant is not satisfied for any reason. 2. a. An outline of coverage must be delivered to a prospective applicant for long -term care insurance at the time of initial solicitation through means that prominently direct the attention of the recipient to the document and its purpose. (1) The commissioner shall prescribe a standard format, including style, arrangement, overall appearance, and the content of an outline of coverage. (2) In the case of insurance producer solicitations, an insurance producer must deliver the outline of coverage prior to the presentation of an application or enrollment form. (3) In the case of direct response solicitations, the outline of coverage must be presented in conjunction with any application or enrollment form. (4) In the case of a policy issued to a group defined in subdivision a of subsection 3 of section 26.1-45-01, an outline of coverage is not required to be delivered, provided that the information described in paragraphs 1 through 7 of subdivision b is contained in other materials relating to enrollment. Upon request, these other materials must be made available to the commissioner. b. The outline of coverage must include: (1) A description of the principal benefits and coverage provided in the policy. (2) A statement of the principal exclusions, reductions, and limitations contained in the policy. (3) 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 must be specifically described. (4) 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 the governing contractual provisions. (5) A description of the terms under which the policy or certificate may be returned and premium refunded. (6) A brief description of the relationship of cost of care and benefits. (7) A statement that discloses to the policyholder or certificate holder whether the policy is intended to be a federally tax-qualified long-term care insurance contract under 7702B(b) of the Internal Revenue Code of 1986, as amended. 3. A certificate issued pursuant to a group long-term care insurance policy which policy is delivered or issued for delivery in this state must include: a. A description of the principal benefits and coverage provided in the policy. b. A statement of the principal exclusions, reductions, and limitations contained in the policy. c. A statement that the group master policy determines governing contractual provisions. 4. If an application for a long -term care insurance contract or certificate is approved and issued, the issuer, directly or through an authorized representative, shall deliver the contract or certificate of insurance to the applicant no later than thirty days after the date of approval. 5. At the time of policy delivery, a policy summary must be delivered for an individual life insurance policy which provides long-term care benefits within the policy or by 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 such delivery no later than at the time of policy delivery. In addition to complying with all applicable requirements, the summary must also include: a. An explanation of how the long-term care benefit interacts with other components of the policy, including deductions from death benefits; b. An illustration on the amount of benefits, the length of benefit, and the guaranteed lifetime benefits, if any, for each covered person; c. Any exclusions, reductions, and limitations on benefits of long-term care; d. A statement as to whether a long -term care inflation protection option is available under this policy; e. If applicable to the policy type, the summary shall also include: (1) A disclosure of the effects of exercising other rights under the policy; (2) A disclosure of guarantees relating to long -term care costs of insurance charges; and (3) Current and projected maximum lifetime benefits; and f. The provisions of the policy summary listed above may be incorporated into a basic illustration or into a life insurance policy summary delivered to the consumer. 6. Any time a 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 must be provided to the policyholder. Such report must include: a. Any long-term care benefits paid out during the month; b. An explanation of any changes in the policy, e.g., death benefits or cash values, due to long-term care benefits being paid out; and c. The amount of long-term care benefits existing or remaining. 7. If a claim under a long -term care insurance contract is denied, the issuer shall, within sixty days of the date of a written request by the policyholder or certificate holder, or a representative thereof: a. Provide a written explanation of the reasons for the denial; and b. Make available all information directly related to the denial.
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