Sample Long Term Care Insurance Policy, Page 12

SAMPLE LONG TERM CARE INSURANCE POLICY

PART 2 - YOUR LONG-TERM CARE BENEFITS
This part describes when You are eligible for benefits, the benefits available under this Policy and the conditions under which benefits will be paid.

ELIGIBILITY FOR PAYMENT OF BENEFITS

Eligibility for the Payment of Benefits

You are eligible for benefits under this Policy if:
• You need Substantial Assistance to perform at least two of the Activities of Daily Living; or
• You require Substantial Supervision to protect Yourself from threats to health and safety due to the presence of a Cognitive Impairment.

This Policy provides coverage for Long-Term Care Services which are needed due to mental illness, Alzheimer’s Disease and forms of senility and irreversible dementia that result in a Cognitive Impairment subject to the provisions, exclusions and limitations found in this Policy.

LIMITATIONS ON OR CONDITIONS FOR ELIGIBILITY FOR BENEFITS
Conditions

To receive benefits under this Policy:
• Your Elimination Period must have been satisfied unless otherwise provided in this Policy;
• You must receive covered care or services while this Policy is in effect;
• You must receive care or services that are consistent with Your care needs and are covered under this Policy, specified in a Plan of Care and are in accordance with accepted medical and nursing standards of practice; and
• You must submit to Us a current Plan of Care and written Proof of Loss both of which are
acceptable to Us. Because this Policy is intended to be tax-qualified under federal law, You must ALSO provide Us with one of the following written certifications:
• A Licensed Health Care Practitioner must certify that You are unable to perform without
Substantial Assistance from another individual at least two Activities of Daily Living due to the loss of functional capacity for a period expected to last at least 90 days.
• A Licensed Health Care Practitioner must certify that You require Substantial Supervision to protect Yourself from threats to health and safety due to the presence of a Cognitive
Impairment.This written certification must be renewed and submitted to Us every 12 months.

Limitations
We will not pay benefits, except for the Stay at Home Benefit and Care Advisory Services Benefit, in excess of the Policy Limit as shown in the Policy Schedule. We will not pay benefits for charges during the Elimination Period, except as described in the Respite Care Benefit, Care Advisory Services Benefit and the Stay at Home Benefit.

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