Sample Long Term Care Insurance Policy, Page 16

SAMPLE POLICY
The waiver period will start the day after the Elimination Period has been satisfied and will end on the date when benefits are no longer payable. In the event You have already satisfied the Elimination Period, the waiver period will start on the next Date of Service and will end on the date when benefits are no longer payable under this Policy.

Your premium will not be waived if You:
• are only receiving benefits under the Stay at Home Benefit, Respite Care Benefit or the Care Advisory Services Benefit; or

• have exhausted the International Coverage Benefit, unless and until You receive care or
services for which benefits are payable under the Long-Term Care Benefit within the fifty (50) United States or the District of Columbia.

If Your premium has been paid for a period for which premiums are waived, We will refund the premium for such period. In order to keep this Policy in effect after the waiver of premium period ends, payment of premiums must be resumed.

Extension of Benefits
If Your Policy lapses, while You are continuously confined in a Nursing Home, benefits under the Long-Term Care Benefit will be continued until the earlier of the following dates:

• the date You are discharged from the Nursing Home;

• the date Your Policy Limit is exhausted; or

• the date You die.

This Extension of Benefits will be subject to all of the provisions of this Policy.

International Coverage Benefit
If You require care or services which would otherwise be covered by this Policy while You are outside the fifty (50) United States or the District of Columbia, We will pay the International Coverage Benefit if all the following requirements are met:

• We receive Proof of Loss which is satisfactory to Us that You have met Your Elimination
Period and the requirements found in the sections captioned "Eligibility for the Payment of
Benefits" and "Conditions".

• You provide Us (at Your own expense) with the following documentation as described in the "Conditions" section of the Policy:

• the required certification from a Licensed Health Care Practitioner:

• a current Plan of Care and any required updates to that Plan of Care; and

• properly completed claim forms and proof, satisfactory to Us, that You are receiving
covered care and services.

• All required documentation must be provided to Us in English.

• We reserve the right to require that You provide us with updated documentation and
information at reasonable intervals. However, We will not require updates more frequently than monthly. We will pay actual charges incurred for certain Long-Term Care Services up to the International Coverage Benefit Amount as shown on the Policy Schedule.

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