Employer Group Long Term Care Insurance
Issue Ages: 18 through 69
The Benefit Bank represents the lifetime dollar benefit amount available to you. Your Benefit Bank balance is reduced by any benefits paid to you or on your behalf.
Monthly Benefit Payout Structure:
When you become eligible for benefits, you can choose between the payout options below (in accordance with your Plan of Care):
• OPTION 1: Receive reimbursement for qualified long term care services, up to your Monthly Benefit for Covered Expenses. Covered expenses include care at home through a home care agency or independent provider, in an assisted living facility, in an adult daycare center, or in a nursing home. Hospice care is also covered.
• OPTION 2: Elect to receive a cash payout, equal to your Cash Alternative Monthly Benefit amount. The cash benefits can be used to pay an informal caregiver, such as a family member or friend — or used for other purposes unique to your care situation.
Note: The choice between the two options can be made on a monthly basis. Any un-used Monthly Benefit dollars will remain in your Benefit Bank and extend the life of your policy.
Home Modification and Supplemental Products Benefit:
This benefit provides coverage for services and products that are required for you to live more securely and independently at home (in accordance with your Plan of Care). These expenses are reimbursable up to 1X your Monthly Benefit for Covered Expenses over the life of your policy. Payouts made under this benefit will reduce your Benefit Bank amount.
Examples of services and products that are eligible for reimbursement include:
• Home Modifications – equipping your home for greater safety or access related to your long term care impairment. Examples include building or installing an access ramp to your home, widening doorways, and installing grab bars in the bathroom.
• Assistive Devices or Technology – adaptive tools, devices or technology that help you function independently in your home. Examples include specially adaptive eating or dressing devices, emergency medical response systems, or other technology devices used to monitor movement and personal safety in your home.
• Durable Medical Equipment – medical equipment that you buy or rent, and is designed to assist you in living at home. Examples include walkers, hospital-style beds, crutches, and wheelchairs.
The Home Modification and Supplemental Products Benefit can be received in addition to other reimbursable Covered Expenses or the Cash Alternative in a given month.
You are eligible for benefits if you have been certified as Chronically Ill within the last 12 months by a Licensed Health Care Practitioner. This means that you are unable to perform at least two Activities of Daily Living (bathing, dressing, toileting, transferring, continence and eating) for a period that is expected to last at least 90 days, or you require Substantial Supervision to protect your health and safety due to a Severe Cognitive Impairment.
Benefit Wait Period:
90 Calendar Days (once you are verified as Chronically Ill), unless your condition is triggered suddenly by an Accidental Injury or Stroke, in which case the Benefit Wait Period will be completely waived (0 days).
Waiver of Premium:
Your premiums are waived beginning on the first day you start receiving benefits. As long as you continue to receive benefits, additional premiums will not be required.
If you and your spouse/partner both apply for coverage at the same time, a 10% premium discount will apply to each policy. To qualify for the discount, both individuals must apply for the same policy form series (LS-LTC-0006).
Optional Benefit Riders
Compound Inflation Benefit (1%, 3% or 5%):
If you elect this optional benefit, we will automatically increase your current Monthly Benefit and your remaining Benefit Bank by 1%, 3% or 5% each year. The increase will be effective on each anniversary of your policy and rider, even while you are receiving benefits.
If this rider is in force for at least three full years, and your policy then terminates due to non-payment of premium, this optional benefit allows you to retain a reduced paid-up amount of coverage. You will have a revised Benefit Bank equal to the greater of: (a) 100% of the sum of all premiums paid by you; or (b) one times your Monthly Benefit. Not applicable if Benefit Bank is exhausted prior to lapse.
Policy Limitations and Exclusions
This Policy will not pay benefits for care, treatment, services or charges: for a loss that occurs while this Policy is not in force; or for alcoholism or drug addiction (except for an addiction to a prescribed medication administered on the advice of a Physician); or due to declared or undeclared war or act of war; or due to participation in a felony, riot or insurrection or involvement in an illegal occupation; or due to suicide, attempted suicide or intentionally self-inflicted injury; or that are reimbursable under Medicare, or would be so reimbursable but for the application of a deductible or coinsurance amount; or that are reimbursable or provided under a governmental program (except Medicaid), any state or federal workers’ compensation, employer’s liability or occupational disease law; or provided outside the United States, Canada or their territories or possessions; or for which no charge is made in the absence of insurance, except as provided under the Cash Alternative Monthly Benefit; or provided by an Immediate Family member (except as provided under the Cash Alternative Monthly Benefit), unless: he or she is a regular employee of an organization which is providing the care, treatment or service; he or she receives no compensation other than the normal compensation for employees in his or her job category; and the organization receives the payment for the care, treatment, service or charge.
*Only available in employer group insurance products