§ 58-55-20. Definitions.
§ 58‑55‑20. Definitions.
As used in this Article:
(1) "Applicant"means:
a. In the case of anindividual long‑term care insurance policy, the person who seeks tocontract for benefits; and
b. In the case of agroup long‑term care insurance policy, the proposed certificate holder.
(2) "Certificate"means any certificate issued under a group long‑term care insurancepolicy, which policy has been delivered or issued for delivery in this State.
(3) "Group long‑termcare insurance" means a long‑term care insurance policy that isdelivered or issued for delivery in this State and issued to:
a. One or moreemployers or labor organizations, or to a trust or to the trustees of a fundestablished by one or more employers or labor organizations, or both, foremployees or former employees or both, or for members or former members orboth, of the employers or labor organizations; or
b. Any professional,trade, or occupational association for its members or former or retiredmembers, or all, if such association:
(i) Comprisesindividuals all of whom are or were actively engaged in the same profession,trade, or occupation; and
(ii) Has been maintainedin good faith for purposes other than obtaining insurance; or
c. An association or toa trust or to the trustee or trustees of a fund established, created, ormaintained for the benefit of members of one or more associations. Prior toadvertising, marketing, or offering such policy within this State, theassociation or associations, or the insurer of the association or associations,shall file evidence with the Commissioner that the association or associationshave at the outset a minimum of 100 persons and have been organized andmaintained in good faith for purposes other than that of obtaining insurance;have been in active existence for at least one year; and have a constitutionand bylaws which provide that (i) the association or associations hold regularmeetings not less than annually to further purposes of the members, (ii) exceptfor credit unions, the association or associations collect dues or solicitcontributions from members, and (iii) the members have voting privileges andrepresentation on the governing board and committees. Ninety days after suchfiling the association or associations will be deemed to have satisfied suchorganizational requirements, unless the Commissioner makes a finding that theassociation or associations do not satisfy those organizational requirements.
d. A group other thanas described in subdivisions (3)a., (3)b., and (3)c. of this section, subjectto a finding by the Commissioner that:
(i) The issuance of thegroup policy is not contrary to the best interest of the public;
(ii) The issuance of thegroup policy would result in economies of acquisition or administration; and
(iii) The benefits arereasonable in relation to the premiums charged.
(4) "Long‑termcare insurance" means any policy or certificate advertised, marketed,offered, or designed to provide coverage for not less than 12 consecutivemonths for each covered person on an expense incurred, indemnity, prepaid, orother basis, for one or more necessary or medically necessary diagnostic,preventive, therapeutic, rehabilitative, maintenance, or personal careservices, provided in a setting other than an acute care unit of a hospital."Long‑term care insurance" includes:
a. Group and individualannuities and life insurance policies or riders that supplement or directlyprovide long‑term care insurance.
b. A policy or riderthat provides for payment of benefits based upon cognitive impairment or theloss of functional capacity.
c. Qualified long‑termcare insurance contracts.
d. Group and individualpolicies whether issued by insurers, fraternal benefit societies, nonprofithealth, hospital, and medical service corporations, prepaid health plans,health maintenance organizations, or any similar organization. "Long‑termcare insurance" does not include any policy that is offered primarily toprovide basic Medicare supplement coverage, basic hospital expense coverage,basic medical‑surgical expense coverage, hospital confinement indemnitycoverage, major medical expense coverage, disability income protectioncoverage, accident only coverage, specified disease or specified accidentcoverage, or limited benefit health coverage.
Withregard to life insurance, "long‑term care insurance" does notinclude life insurance policies that accelerate the death benefit specificallyfor one or more of the qualifying events of terminal illness, medicalconditions requiring extraordinary medical intervention or permanentinstitutional confinement, and that provide the option of a lump‑sumpayment for those benefits and where neither the benefits nor the eligibilityfor the benefits is conditioned upon the receipt of long‑term care.
(5) "Policy"means any policy, contract, certificate, subscriber agreement, rider, orendorsement delivered or issued for delivery in this State by an insurer,fraternal benefit society, nonprofit health, hospital or medical servicecorporation, prepaid health plan, health maintenance organization, or anysimilar organization. (1987, c. 331, s. 1; c. 864, s. 68; 2007‑298, s. 4; 2007‑484,s. 43.5.)