Sample Long Term Care Insurance Policy, Page 17

SAMPLE POLICY

Long-Term Care Services eligible for payment under the International Coverage Benefit include:
• confinement in a Nursing Home or Assisted Living Facility;
• Home Health Care, Adult Day Care and Hospice Care.
No benefits under the International Coverage Benefit, are payable for the Stay at Home Benefit, the Double Coverage for Accident Benefit (if included in Your Policy), or for Respite Care or Care Advisory Services.

The International Coverage Benefit will not be paid in excess of an amount equal to:
• 365-times the Long-Term Care Benefit Amount if You elected the daily Benefit Amount option;
or
• 12-times the Long-Term Care Benefit if You elected the monthly Benefit Amount option.
This Policy will continue in force after the International Coverage Benefit is exhausted so that any remaining benefits may be paid for care and services received in the fifty (50) United States or the District of Columbia. In the event that the International Coverage Benefit is exhausted, premiums will no longer be waived pursuant to the Waiver of Premium provision. In the event that the International Coverage Benefit is exhausted, the benefits remaining for Long-Term Care Services received within the fifty (50) United States or the District of Columbia shall remain in effect. Any benefit paid under this provision will reduce Your Policy Limit. All terms in the Policy will remain in effect. Any benefits paid will be paid in United States currency.

Return of Premium upon Death Benefit
Important Notice - The Return of Premium Benefit is not applicable to You if You are age 65 or older or You elected Family Care.
If You die before Your 65th birthday, We will pay to Your beneficiary a Return of Premium upon Death Benefit if Your Policy is in force on the date of Your death. (That is, Your insurance is not being continued under the provisions of any nonforfeiture benefit.) The Return of Premium upon Death Benefit will be calculated by subtracting the sum of all benefits paid under Your Policy for charges incurred prior to the date of Your death from the sum of all premiums paid for Your Policy (accumulated without interest). In the event the amount of benefits paid exceed the sum of premiums paid for Your Policy, no Return of Premium upon Death Benefit will be payable to Your beneficiary. If We receive a claim for benefits for Long-Term Care Covered Charges after the Return of Premium upon Death Benefit has been paid, benefits for those services will be reduced by the amount of the Return of Premium upon Death Benefit that has been paid.
Your beneficiary for the Return of Premium upon Death Benefit is the individual that You designated as beneficiary in Your application for this Policy. You may change the beneficiary for this benefit at any time. However, such request for a change in beneficiary must be in writing and sent to Our LTC Administrative Office.

Important Notice Regarding Federal Income Tax Law – Please note that the payment of the
Return of Premium Benefit may have Federal Income Tax implications for Your estate or beneficiary. You are advised to review this benefit with a qualified tax professional or attorney to determine any such tax impact.

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