§431:10H-203 - Limitations and exclusions.
§431:10H-203 Limitations and exclusions. (a) A policy may not be delivered or issued for delivery in this State as long-term care insurance if the policy limits or excludes coverage by type of illness, treatment, medical condition, or accident, except as follows:
(1) Preexisting conditions or diseases;
(2) Mental or nervous disorders; however, this shall not permit exclusion or limitation of benefits on the basis of Alzheimer's disease;
(3) Alcoholism and drug addiction;
(4) Illness, treatment, or medical condition arising out of:
(A) War or act of war, whether declared or undeclared;
(B) Participation in a felony, riot, or insurrection;
(C) Service in the armed forces or units auxiliary thereto;
(D) Suicide (sane or insane), attempted suicide, or intentionally self-inflicted injury; or
(E) Aviation (this exclusion applies only to non-fare-paying passengers);
(5) Treatment provided in a government facility (unless required by law), services for which benefits are available under medicare or other governmental program (except medicaid), any state or federal workers' compensation, employer's liability, or occupational disease law, or any motor vehicle insurance law, services provided by a member of the covered person's immediate family, and services for which no charge is normally made in the absence of insurance;
(6) Expenses for services or items available or paid under another long-term care insurance or health insurance policy; or
(7) In the case of a qualified long-term care insurance contract, expenses for services or items to the extent that the expenses are reimbursable under Title XVIII of the Social Security Act or would be so reimbursable but for the application of a deductible or coinsurance amount.
(b) This section is not intended to prohibit exclusions and limitations by type of provider. However, no long-term care issuer may deny a claim because services are provided in a state other than the state of policy issue under the following conditions:
(1) When the state other than the state of policy issue does not have the provider licensing, certification, or registration required in the policy, but where the provider satisfies the policy requirements outlined for providers in lieu of licensure, certification, registration; or
(2) When the state other than the state of policy issue licenses, certifies, or registers the provider under another name.
For purposes of this subsection, "state of policy issue" means the state in which the individual policy or certificate was originally issued.
(c) This section is not intended to prohibit territorial limitations. [L 1999, c 93, pt of §2; am L 2007, c 233, §12]