Sample Long Term Care Insurance Policy, Page 21

SAMPLE LONG TERM CARE INSURANCE POLICY
Payment of Claims
While You are living, all benefits will be paid to You unless You request and We accept an
assignment of benefits. An assignment of benefits is Your or Your legal representative’s request for payments to be sent to someone other than Yourself. If You have made an assignment of benefits, We will send the payments to Your care provider or the individual You or Your legal representative have designated. You may cancel or change an assignment of benefits at any time. We will not be on notice of any assignment unless it is in writing, nor until a duplicate of the original has been received at Our LTC Administrative Office. We assume no responsibility for the validity or sufficiency of any assignment. Any accrued benefits unpaid at Your death will be paid to Your estate, or any care provider or individual to whom You or Your legal representative has assigned benefits. At Our option, any benefit of $3,000 or less may be paid to an alternative payee who is deemed by Us to be justly entitled to the benefit. We will be fully discharged to the extent of any payment made in good faith under this paragraph.

Appeals
We will notify You in writing if We do not approve Your claim and provide You with a written
explanation of the reasons for the denial. You will then have the right to appeal Our claims decision and request that We make information directly related to such denial available to You. We will provide You with such requested information within 60 days from the date We receive Your written request. You must put this appeal or request for information in writing (no special form is necessary) and send it to:
Sample Life Insurance Company
P.O. Box 22222
Sample, SA 22222
Attn: Director of RLTC Claims Administration.

In Your appeal, You should:
• state why You disagree with Our determination;
• state what other factors (if any) We should take into consideration; and
• identify whom We could contact (including names, addresses, and phone numbers) to gather
any additional pertinent information regarding Your care.
You may authorize someone else to act for You in this appeals process. We have a Claim Appeals Review Board that will consider Your appeal. If the Board needs additional information to objectively evaluate Your appeal, they may use one or more of the following resources at Our expense:
• a Physician who will assess Your condition and report it to Us;
• an on-site geriatric assessment;
• medical records from Your Physician(s) and/or provider(s) of care; or
• other information that is determined to be relevant to address the appeal.

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