376.1109. Policies, content requirements, provisions prohibited--rules authorized.
Policies, content requirements, provisions prohibited--rulesauthorized.
376.1109. 1. The director may adopt regulations that includestandards for full and fair disclosure setting forth the manner, contentand 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, preexistingconditions, termination of insurance, continuation or conversion,probationary periods, limitations, exceptions, reductions, eliminationperiods, requirements for replacement, recurrent conditions and definitionsof terms. Regulations adopted pursuant to sections 376.1100 to 376.1130shall be in accordance with the provisions of chapter 536, RSMo.
2. No long-term care insurance policy may:
(1) Be canceled, nonrenewed or otherwise terminated on the grounds ofthe age or the deterioration of the mental or physical health of theinsured individual or certificate holder; or
(2) Contain a provision establishing a new waiting period in theevent existing coverage is converted to or replaced by a new or other formwithin the same company, except with respect to an increase in benefitsvoluntarily selected by the insured individual or group policyholder; or
(3) Provide coverage for skilled nursing care only or providesignificantly more coverage for skilled care in a facility than for lowerlevels of care.
3. No long-term care insurance policy or certificate other than apolicy or certificate thereunder issued to a group as defined in paragraph(a) of subdivision (4) of subsection 2 of section 376.1100:
(1) Shall use a definition of preexisting condition which is morerestrictive than the following: "Preexisting condition" means a conditionfor which medical advice or treatment was recommended by, or received from,a provider of health care services, within six months preceding theeffective date of coverage of an insured person;
(2) May exclude coverage for a loss or confinement which is theresult of a preexisting condition unless such loss or confinement beginswithin six months following the effective date of coverage of an insuredperson.
4. The director may extend the limitation periods set forth insubdivisions (1) and (2) of subsection 3 of this section as to specific agegroup categories in specific policy forms upon findings that the extensionis in the best interest of the public.
5. The definition of preexisting condition provided in subsection 3of this section does not prohibit an insurer from using an application formdesigned to elicit the complete health history of an applicant, and, on thebasis of the answers on that application, from underwriting in accordancewith that insurer's established underwriting standards. Unless otherwiseprovided in the policy or certificate, a preexisting condition, regardlessof whether it is disclosed on the application, need not be covered untilthe waiting period described in subdivision (2) of subsection 3 of thissection expires. No long-term care insurance policy or certificate mayexclude or use waivers or riders of any kind to exclude, limit or reducecoverage or benefits for specifically named or described preexistingdiseases or physical conditions beyond the waiting period described insubdivision (2) of subsection 3 of this section.
6. No long-term care insurance policy may be delivered or issued fordelivery in this state if such policy:
(1) Conditions eligibility for any benefits on a priorhospitalization requirement; or
(2) Conditions eligibility for benefits provided in an institutionalcare setting on the receipt of a higher level of institutional care; or
(3) Conditions eligibility for any benefits other than waiver ofpremium, post-confinement, post-acute care or recuperative benefits on aprior institutionalization requirement.
7. A long-term care insurance policy containing post-confinement,post-acute care or recuperative benefits shall clearly label in a separateparagraph of the policy or certificate entitled "Limitations or Conditionson Eligibility for Benefits" such limitations or conditions, including anyrequired number of days of confinement.
8. A long-term care insurance policy or rider which conditionseligibility of noninstitutional benefits on the prior receipt ofinstitutional care shall not require a prior institutional stay of morethan thirty days.
9. No long-term care insurance policy or rider which providesbenefits only following institutionalization shall condition such benefitsupon admission to a facility for the same or related conditions within aperiod of less than thirty days after discharge from the institution.
10. The director may adopt regulations establishing loss ratiostandards for long-term care insurance policies provided that a specificreference to long-term care insurance policies is contained in theregulation.
11. Long-term care insurance applicants shall have the right toreturn the policy or certificate within thirty days of its delivery and tohave the premium refunded if, after examination of the policy orcertificate, the applicant is not satisfied for any reason. Long-term careinsurance policies and certificates shall have a notice prominently printedon the first page or attached thereto stating in substance that theapplicant shall have the right to return the policy or certificate withinthirty days of its delivery and to have the premium refunded if, afterexamination of the policy or certificate, other than a certificate issuedpursuant to a policy issued to a group defined in paragraph (a) ofsubdivision (4) of subsection 2 of section 376.1100, the applicant is notsatisfied for any reason. This subsection shall also apply to denials ofapplications and any refund must be made within thirty days of the returnor denial.
(L. 1990 S.B. 765 § 5, A.L. 2002 H.B. 1568 merged with S.B. 1009)*Transferred 2002; formerly 376.955