Sample Long Term Care Insurance Policy, Page 13

SAMPLE LONG TERM CARE INSURANCE POLICY
Charges Not Covered
We will not pay for any of the following: Physician’s charges; hospital and laboratory charges;
prescription or non-prescription medication; medical supplies; durable medical equipment (except as described in the Stay at Home Benefit); transportation; items and services furnished at Your request for beautification, comfort, convenience or entertainment; and charges for care or services which are not included in and/or are inconsistent with Your Plan of Care.

HOW YOUR LONG-TERM CARE BENEFITS ARE PAID
Long-Term Care Benefit
We will pay the actual charges incurred by You for Long-Term Care Services up to the Long-Term Care Benefit Amount as shown in the Policy Schedule if You are eligible for the payment of benefits under this Policy.

Long-Term Care Services mean the following covered care or services:
• Your confinement in a Nursing Home or Assisted Living Facility for Your room, board and care services (such care services being Nursing Care, Custodial Care and Hospice Care);
• Home Health Care, Hospice Care, Respite Care; or
• Attendance at an Adult Day Care Center providing Adult Day Care.
In addition, if Your stay in a Nursing Home or Assisted Living Facility is interrupted for any reason and a benefit is payable under this Policy, We will continue to pay the actual charges for up to 60-days in any calendar year in order to reserve Your bed during Your absence.
Any unused portion of Your Long-Term Care Benefit Amount will remain in the Policy Limit. Any benefit paid under this provision will reduce Your Policy Limit.

Stay at Home Benefit
The Stay at Home Benefit can be used to pay for a variety of Your long-term care expenses while You are living in Your Home that are not otherwise covered under the Policy. Stay at Home Services include:
1. Home Modifications;
2. Emergency Medical Response Systems;
3. Durable Medical Equipment;
4. Caregiver Training;
5. Home Safety Check; and
6. Provider Care Check.

We will pay actual charges incurred for Stay at Home Services up to the Stay At Home Lifetime Benefit Amount so long as all of the following conditions are met:
• the care or services are consistent with Your care needs and are provided pursuant to a Plan of Care approved by a Licensed Health Care Practitioner; and
• You are eligible for the payment of benefits under this Policy.

|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|