Sample Long Term Care Insurance Policy, Page 20

SAMPLE LONG TERM CARE INSURANCE POLICY
This documentation includes:
• a completed claim form;
• confirmation of provider licensure as required by the jurisdiction in which it is located;
• the required certification from a Licensed Health Care Practitioner;
• itemized bills for charges You incurred for Your care and services; and
• Your Plan of Care. In addition, We may also request copies of medical records (or We may consult with Your primary Physician and provider by telephone at Our option) or Your providers’ daily notes of care. We will send You claim forms within 15 days after having received Your claim notification. If We do not provide You with the claim forms within 15 days after having received Your notification, You will be able to satisfy the Proof of Loss provision by giving Us written proof of the nature and extent of Your loss. Proof of Loss must be given to Us within ninety (90) days after the first Date of Service. Failure to give Us proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible for You to give proof within such time. However, the proof must be given to Us as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required. At time of claim, We will make available to You Our Advantage List Program, if such Program is available in Your state at the time of Your claim notification. The Advantage List will include a listing of long-term care providers that offer discounts to Our policyholders. These discounts can help You extend your long-term care benefits. Any unused portion of Your benefits will remain in the Policy Limit. There is no penalty for using long-term care providers that are not included on this list. Discounts may only relate to certain services or may vary by provider. A provider may be added to, or removed from, this list at such provider’s own or Our request at any time and the discount may be discontinued. We reserve the right to enhance, modify or terminate this Program at any time. Please note that the discounted fees charged by a provider on the Advantage List may not be the least expensive fees available and not all providers may qualify for reimbursement under Your Policy. You should review cost of care and services as well as the providers in Your area. In addition, We do not endorse, sponsor or guarantee the quality of a provider listed on the Advantage List, or the care or
services provided by such provider. It is Your responsibility to choose a provider who will best meet Your long-term care and service needs.

Our Claims Evaluation Process
Upon receiving Your claim forms, We will work with You, Your Physician, Your care providers, or anyone acting on Your behalf, to obtain information about Your health and the care or services You are receiving. We will then make an objective review of all the information We receive to determine whether You qualify for benefits as well as the level of benefits for which You qualify. As part of Our review, We reserve the right to do a telephone interview, perform an on-site nursing or functional/cognitive assessment or require a physical exam when and as often as We may reasonably require while a claim is pending or any time during the claim. We will pay for any interview, assessment or examination that We request.

Time of Payment of Claims
Benefits under this Policy are payable on a monthly basis, after services have been rendered and charges have been incurred for such services.

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