Sample Long Term Care Insurance Policy, Page 14

SAMPLE LONG TERM CARE INSURANCE POLICY

The Stay At Home Lifetime Benefit Amount is shown on the Policy Schedule. Any unused portion of this benefit amount may be used for future Stay at Home Services. Benefits paid under the Stay at Home Benefit will not reduce the Policy Limit. You do not have to satisfy the Elimination Period to receive benefits under the Stay at Home Benefit. The days for which You receive only the Stay at Home Benefit do not count toward the Elimination Period. You may receive benefits under the Long-Term Care Benefit and/or Care Advisory Services Benefit while receiving benefits under the Stay at Home Benefit. The Stay at Home Benefit will no longer be available to You on the earliest of the following dates: the date You terminate Your Policy; the date You exhaust Your Policy Limit; the date You exhaust Your Stay at Home Lifetime Benefit Amount; or the date Your Policy goes on nonforfeiture status.

Stay at Home Services Defined:

• Home Modifications mean modifications to Your Home that are primarily being made to
improve Your ability to perform the Activities of Daily Living and allow You to live safely and
independently in Your Home. Examples of Home Modifications include: installation of ramps

accessibility modifications. Home Modification does not include: hot tubs, swimming pools,
home repair or maintenance; or other modifications that may, other than incidentally, increase the value of Your Home.

•Emergency Medical Response System means a communication system that is: installed in
Your Home; and used to call for assistance in the event of a medical emergency. It does not mean a home security system.

• Durable Medical Equipment means equipment that You rent or purchase which is designed to be used in Your Home to assist You in performing the Activities of Daily Living. Examples of Durable Medical Equipment include: walkers; hospital-style beds; crutches; and wheelchairs. Durable Medical Equipment does not include: prescription drugs; athletic equipment; equipment placed in Your body; or items commonly found in a household.

• Caregiver Training means a training program which provides instruction to uncompensated informal caregivers in basic caregiving techniques which will allow You to remain in Your Home. Such training is to help Your caregiver tend to Your specific long-term care needs. The informal caregiver may be a relative or someone chosen by You, but in no event will We pay for training provided to someone who will be paid to care for You.

• Home Safety Check means a written evaluation of Your Home, by a Home Health Agency or other qualified professional agency or individual acceptable to Us, in order to evaluate the safety of Your Home environment. Examples of items in the Home that may be evaluated include: cabinet and appliance height; furniture arrangement; doorway and hallway width; and the need for safety bars in the bathroom.

• Provider Care Check means an independent written evaluation of Your care providers and the care You are receiving, in order to confirm consistent delivery of care being provided to You as defined in Your Plan of Care. This evaluation must be performed by a Home Health Agency or other qualified professional agency or individual acceptable to Us.

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