26-38-105. Disclosure and performance standards for long-term care insurance.

(a) The commissioner shall adopt regulations that include standards for full and fair disclosure setting forth the manner, content and required disclosures for the sale of long-term care insurance policies, terms of renewability, initial and subsequent conditions of eligibility, nonduplication of coverage provisions, coverage of dependents, preexisting conditions, termination of insurance, probationary periods, limitations, exceptions, reductions, elimination periods, requirements for replacement, recurrent conditions and definitions of terms.

(b) No long-term care insurance policy shall:

(i) Be cancelled, nonrenewed or otherwise terminated on the grounds of the age or the deterioration of the mental or physical health of the insured individual or certificate holder;

(ii) Contain a provision establishing a new waiting period in the event existing coverage is converted to or replaced by a new or other form within the same company, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder; or

(iii) Contain coverage for skilled nursing care only or contain coverage that provides significantly more skilled care in a facility than coverage for lower levels of care.

(c) No long-term care insurance policy or certificate shall use a definition of "preexisting condition" which is more restrictive than the definition provided in this article.

(d) No long-term care insurance policy shall exclude coverage for a loss or confinement which is the result of a preexisting condition unless the loss or confinement begins within six (6) months following the effective date of coverage of an insured person.

(e) The commissioner may extend the limitation periods set forth in subsections (c) and (d) of this section as to specific age group categories in specific policy forms upon finding that the extension is in the best interest of the public.

(f) The definition of "preexisting condition" does not prohibit an insurer from using an application form designed to elicit the complete health history of an applicant, and, on the basis of the answers on that application, from underwriting in accordance with that insurer's established underwriting standards. Unless otherwise provided in the policy, a preexisting condition, regardless of whether it is disclosed in the application, need not be covered until the waiting period described in subsection (d) of this section expires. No long-term care insurance policy may exclude or use waivers or riders of any kind to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions beyond the waiting period described in subsection (d) of this section.

(g) No long-term care insurance policy may be delivered or issued for delivery in this state if the policy:

(i) Conditions eligibility for any benefits on a prior hospitalization requirement;

(ii) Conditions eligibility for benefits provided in an institutional care setting on the receipt of a higher level of institutional care;

(iii) Conditions eligibility for any benefits, other than waiver of premium, post-confinement, post-acute care or recuperative benefits, on a prior institutionalization requirement; or

(iv) Fails to meet any of the following requirements:

(A) A long-term care insurance policy containing post-confinement, post-acute care or recuperative benefits shall clearly label in a separate paragraph of the policy or certificate entitled "limitations or conditions on eligibility for benefits" the limitations or conditions, including any required number of days of confinement;

(B) A long-term care insurance policy or rider which conditions eligibility of noninstitutional benefits on the prior receipt of institutional care shall not require a prior institutional stay of more than five (5) days;

(C) No long-term care insurance policy or rider which provides benefits only following institutionalization shall condition the benefits upon admission to a facility for the same or related conditions within a period of less than thirty (30) days after discharge from the institution.

(h) The commissioner shall adopt regulations establishing loss ratio standards for long-term care insurance policies provided that a specific reference to long-term care insurance policies is contained in the regulation.

(j) Long-term care insurance policyholders or certificate holders, shall have the right to return the policy or certificate within thirty (30) days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the policyholder or certificate holder is not satisfied for any reason. Long-term care insurance policies and certificates shall have a notice prominently printed on the first page of the policy and certificate or attached thereto stating in substance that the policyholder or certificate holder shall have the right to return the policy within thirty (30) days of its delivery and to have the premium refunded if, after examination of the policy or certificate, other than a certificate issued pursuant to a policy issued to a group defined in W.S. 26-38-103(a)(iv)(A), the policyholder or certificate holder is not satisfied for any reason. The premium shall be refunded within ten (10) days, excluding Saturdays, Sundays and legal holidays, from the date the policy or certificate is returned. If the premium required to be refunded under this subsection is not refunded within the time periods specified it shall draw interest at the maximum rate allowed for a credit service charge under W.S. 40-14-212(b). No company issuing a long-term care insurance policy shall be required to pay any claim under the terms of the policy until the expiration of the thirty (30) day period. If an application for a qualified long-term care contract is denied, the issuer shall refund to the applicant any premium refund within thirty (30) days of the denial.

(k) An outline of coverage shall be delivered to a prospective applicant at the time of the initial solicitation through means which prominently direct the attention of the recipient to the document and its purpose. The commissioner shall prescribe a standard format of the outline of coverage, including style, arrangement, overall appearance and content. In the case of agent solicitations, an agent shall deliver the outline of coverage prior to the presentation of an application or enrollment form. In the case of direct response solicitations, the outline of coverage shall be presented in conjunction with any application or enrollment form. In the case of a group policy, the outline shall be delivered to certificate holders when the certificate is delivered. The outline of coverage shall include:

(i) A description of the principal benefits and coverage provided in the policy;

(ii) A statement of the principal exclusions, reductions and limitations contained in the policy;

(iii) A statement of the terms under which the policy or certificate, or both, may be continued in force or discontinued, including any reservation in the policy of a right to change premium. Continuation or conversion provisions of group coverage shall be specifically described;

(iv) A statement that the outline of coverage is a summary only, not a contract of insurance, and that the policy or group master policy contains governing contractual provisions;

(v) A description of the terms under which the policy or certificate may be returned and premium refunded;

(vi) A brief description of the relationship of cost of care and benefits; and

(vii) If the policy or certificate is intended to be a qualified long-term care insurance contract, a statement that discloses to the policyholder or certificate holder that the policy is intended to be a qualified long-term care insurance contract.

(m) Repealed by Laws 1993, ch. 212, § 3.

(n) Repealed by Laws 1993, ch. 212, § 3.

(o) The issuer of a long-term care insurance contract shall deliver to the applicant, policyholder or certificate holder, the contract or certificate of insurance no later than thirty (30) days after the date of approval. At the time of policy delivery, a policy summary shall be delivered for an individual life insurance policy which provides long-term care benefits within the policy or rider. In the case of direct response solicitations, the insurer shall deliver the policy summary upon the applicant's request, but regardless of request shall make the delivery no later than at the time of policy delivery. In addition to complying with all applicable requirements, the summary shall also include:

(i) An explanation of how the long-term care benefit interacts with other components of the policy, including deductions from death benefits;

(ii) An illustration of the amount of benefits, the length of benefits, and guaranteed lifetime benefits if any, for each covered person;

(iii) Any exclusions, reductions and limitations on benefits of long-term care; and

(iv) If applicable to the policy type, the summary shall also include:

(A) A disclosure of the effects of exercising other rights under the policy;

(B) A disclosure of guarantees related to long-term care costs of insurance charges; and

(C) Current and projected maximum lifetime benefits.

(p) If any long-term care benefit, funded through a life insurance vehicle by the acceleration of the death benefit, is in benefit payment status, a monthly report shall be provided to the policyholder. The report shall include:

(i) Any long-term care benefits paid out during the month;

(ii) An explanation of any changes in the policy, including, but not limited to, death benefits or cash values, due to long-term care benefits; and

(iii) The amount of long-term care benefits existing or remaining.

(q) If a claim under a long-term care insurance contract is denied, the issuer shall, within sixty (60) days of the date of a written request by the policyholder, or certificate holder or an authorized representative:

(i) Provide a written explanation of the reason for the denial; and

(ii) Make available all information directly related to the denial.