Exhibit 99.26(d)(14)
LONG TERM CARE AGREEMENT
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This agreement is a part of the policy to which it is attached and is subject to
all its terms and conditions. This agreement is effective as of the policy date
of this policy unless a different effective date is shown on the policy data
pages.
DISCLOSURES
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CAUTION
THE ISSUANCE OF THIS LONG TERM CARE INSURANCE AGREEMENT IS BASED UPON YOUR
RESPONSES TO THE QUESTIONS ON YOUR APPLICATION. A COPY OF YOUR APPLICATION IS
ENCLOSED. IF YOUR ANSWERS ARE INCORRECT OR UNTRUE, THE COMPANY HAS THE RIGHT TO
DENY BENEFITS OR RESCIND THIS AGREEMENT. THE BEST TIME TO CLEAR UP ANY QUESTIONS
IS NOW, BEFORE A CLAIM ARISES! IF, FOR ANY REASON, ANY OF YOUR ANSWERS ARE
INCORRECT, CONTACT THE COMPANY AT THE ADDRESS SHOWN ON YOUR POLICY.
QUALIFIED LONG-TERM CARE TAX OBLIGATION
THIS AGREEMENT IS INTENDED TO BE A TAX QUALIFIED LONG-TERM CARE INSURANCE
BENEFIT UNDER SECTION 7702B(b) OF THE INTERNAL REVENUE CODE, AS AMENDED.
BENEFITS PAID UNDER THIS ACCELERATED BENEFIT AGREEMENT FOR LONG-TERM CARE
COVERAGE MAY BE TAXABLE. IF SO, YOU OR YOUR BENEFICIARY MAY INCUR A TAX
OBLIGATION. AS WITH ALL TAX MATTERS, YOU SHOULD CONSULT YOUR PERSONAL TAX
ADVISOR TO ASSESS THE IMPACT OF THIS BENEFIT.
IF WE ARE REQUIRED TO MAKE A CHANGE TO THIS TAX-QUALIFIED LONG-TERM CARE
AGREEMENT TO CONFORM TO CHANGES IN THE REQUIREMENTS OF THE INTERNAL REVENUE
CODE, WE SHALL NOTIFY YOU OF THE REQUIRED CHANGES. IF YOU REJECT THE CHANGES,
THE AGREEMENT MAY NO LONGER BE TAX-QUALIFIED. YOU SHOULD CONSULT A FINANCIAL
PLANNING PROFESSIONAL TO DISCUSS ANY REQUIRED CHANGES.
RECEIPT OF ACCELERATED DEATH BENEFITS UNDER THIS AGREEMENT MAY ADVERSELY AFFECT
YOUR ELIGIBILITY FOR GOVERNMENTAL BENEFITS OR PUBLIC ASSISTANCE PROGRAMS SUCH AS
MEDICAID.
BRIEF DESCRIPTION
THIS IS A TAX QUALIFIED LONG-TERM CARE INSURANCE AGREEMENT THAT COVERS NURSING
CARE AND HOME AND COMMUNITY BASED CARE AS DEFINED IN THIS AGREEMENT. THIS
AGREEMENT PROVIDES FOR THE PAYMENT OF A MONTHLY BENEFIT FOR QUALIFIED LONG-TERM
CARE SERVICES.
NOTICE TO OWNER
THIS AGREEMENT MAY NOT COVER ALL OF THE COSTS ASSOCIATED WITH LONG-TERM CARE
THAT THE INSURED INCURS. YOU ARE ADVISED TO REVIEW ALL BENEFIT LIMITATIONS
CAREFULLY.
THIS AGREEMENT IS NOT MEDICARE SUPPLEMENT COVERAGE.
IF THE INSURED IS ELIGIBLE FOR MEDICARE, REVIEW THE GUIDE TO HEALTH INSURANCE
FOR PEOPLE WITH MEDICARE AVAILABLE FROM US.
RENEWABILITY
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This agreement is guaranteed renewable. This means that we may not, on our own,
cancel or reduce coverage provided by this agreement. Subject to the termination
provision in the Additional Information section of this agreement, this
agreement will remain in force for as long as the policy remains in force and
there is sufficient accumulation value to cover the charges for this agreement.
We have the right to change the charges for this agreement as provided in the
Charges section of this agreement.
NOTICE OF YOUR RIGHT TO EXAMINE THIS AGREEMENT
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You may return this agreement for any reason within 30 days after its delivery
by taking it or mailing it to us or to any life insurance agent appointed by us.
Immediately upon return to us, this agreement will be deemed void from the
beginning. Any charges assessed for this agreement will be restored to the
accumulation value.
TABLE OF CONTENTS
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DEFINITIONS. . . . . . . . . . . . . . . . . . . . . 2
PROVISIONS. . . . . . . . . . . . . . . . . . . . . . 4
EXCLUSIONS AND LIMITATIONS. . . . . . . . . . . . . . 5
PRE-EXISTING CONDITION LIMITATIONS . . . . . . . . . . 5
ICC12-932 Long Term Care Agreement Minnesota Life Insurance Company
CHARGES. . . . . . . . . . . . . . . . . . . . . . . . 5
CLAIM PROCEDURES. . . . . . . . . . . . . . . . . . . 6
PAYMENT OF BENEFITS. . . . . . . . . . . . . . . . . . 7
EFFECT OF BENEFIT PAYMENTS. . . . . . . . . . . . . . 7
ADDITIONAL INFORMATION. . . . . . . . . . . . . . . . 8
ELIGIBILITY FOR THE PAYMENT OF BENEFITS
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Benefits are eligible for payment under the agreement if the insured is a
Chronically Ill individual, which means that within the previous 12 months the
insured has been certified by a Licensed Health Care Practitioner as being
unable to perform, without Substantial Assistance, at least two Activities of
Daily Living for an expected period of at least 90 days, or be cognitively
impaired.
The activities of daily living (ADLs) refer to those activities that measure the
insured's ability for self care. The six (6) ADLs that are used for
determination of eligibility for benefits under this agreement are:
(1) Bathing: Washing oneself by sponge bath; or in either a tub or shower,
including the task of getting into or out of the tub or shower.
(2) Continence: The ability to maintain control of bowel and bladder
function; or, when unable to maintain control of bowel or bladder
function, the ability to perform associated personal hygiene (including
caring for a catheter or colostomy bag).
(3) Dressing: Putting on and taking off all items of clothing and any
necessary braces, fasteners or artificial limbs.
(4) Eating: Feeding oneself by getting food into the body from a receptacle
(such as a plate, cup or table) or by a feeding tube or intravenously.
(5) Toileting: Getting to and from the toilet, getting on and off the toilet,
and performing associated personal hygiene.
(6) Transferring: Moving into or out of a bed, chair or wheelchair.
DEFINITIONS
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ADULT DAY CARE
A state licensed or certified program of services provided during the day to
chronically ill individuals in a community group setting through an adult day
care center that includes:
(1) care for a specified number of individuals; and
(2) social or health-related or both types of services; and
(3) maintenance or personal care services.
The purpose of such a program is to support frail, impaired elderly or other
disabled adults who can benefit from care in a group setting outside the home.
ADULT DAY CARE CENTER
A facility licensed or certified under state law, if any, to provide Adult Day
Care to adults who do not require 24-hour institutional care, but are not
capable of full-time, independent living.
All services and facilities required to be available in the state where the
agreement was issued will be covered even If the state does not require a
provider of such services to be licensed, certified or registered, or if the
state licenses, certifies or registers the provider of services under another
name.
ALTERNATIVE PLAN OF CARE
An alternative plan of care is one which may be employed at some point in the
future to pay for services not specifically shown as being available under this
agreement.
ASSISTED LIVING FACILITY
A place which:
(1) is licensed or certified under state law, where licensing is required, to
perform the services it is providing; and
(2) has at least one trained staff member on duty 24 hours per day; and
(3) provides continuous room and board; and
(4) provides maintenance or personal care services required by residents due
to their inability to perform two or more of the activities of daily
living or due to a severe cognitive impairment.
Assisted living facilities do not include hospitals. Unless otherwise excluded
in this agreement, assisted living facilities include facilities otherwise
named, which meet the above criteria, including secure Alzheimer's units.
All services and facilities required to be available in the state where the
agreement was issued will be covered even If the state does not require a
provider of such services to be licensed, certified or registered, or if the
state licenses, certifies or registers the provider of services under another
name.
CHRONICALLY ILL INDIVIDUAL
An insured who has been certified by a Licensed Health Care Practitioner within
the preceding twelve-month period as:
(1) being unable to perform, without substantial assistance from another
person, at least two (2) Activities of Daily Living due to a loss of
functional capacity. In addition, this loss of functional capacity must,
at first, be expected to exist for a period of at least 90 days; or
ICC12-932 Long Term Care Agreement Minnesota Life 2
(2) requiring substantial supervision to protect the person from threats to
health and safety due to Severe Cognitive Impairment.
ELIMINATION PERIOD
The elimination period is the required period of time for which no benefits are
payable following the date the insured is determined to be eligible for
benefits.
(1) The elimination period is 90 days.
(2) The elimination period starts on the first day that qualified long-term
care services are received.
(3) The 90 days need not be continuous; however, if the gap in continuous
days exceeds 180 days, the 90-day elimination period will start over.
(4) Benefits will not be paid until the elimination period is satisfied.
(5) Benefits will not be paid retroactively for services received during the
elimination period.
(6) The elimination period has to be satisfied only once while this agreement
is in effect.
(7) For each day of qualified service received, one day of the elimination
period is satisfied.
HANDS-ON ASSISTANCE
Hands-on assistance is the physical assistance of another person without which
the insured would be unable to perform an activity of daily living.
HIPAA
The federal Health Insurance Portability and Accountability Act of 1996 amended
2003.
HOME AND COMMUNITY BASED CARE
Home and community based care includes qualified long term care services
provided to the insured through adult day care or home health care.
HOME HEALTH CARE
Home health care is a program of medical and non-medical services provided to
ill, disabled or infirm persons in their residences through a home health care
provider licensed in the state, including:
(1) professional nursing care by, or under the supervision of, a registered
nurse; or
(2) care by a home health aide; or
(3) therapeutic care services by or under the supervision of a speech,
occupational, physical, or respiratory therapist licensed or certified
under state law, if any, or a registered dietician; or
(4) homemaker services.
Home health care is provided in a setting other than a hospital, nursing care
facility or assisted living facility. It refers to the insured receiving medical
or non-medical services from a licensed home health care provider in the
insured's private home or an adult day care center.
HOME HEALTH CARE PROVIDER
A licensed home health care provider or licensed adult day care center or home
health care giver. This also includes an employee of a hospital acting in the
capacity of providing care in a private home.
All services and facilities required to be available in the state where the
agreement was issued will be covered even If the state does not require a
provider of such services to be licensed, certified or registered, or if the
state licenses, certifies or registers the provider of services under another
name.
HOMEMAKER SERVICES
Homemaker services are necessary services provided in a home as required
pursuant to a plan of care for a chronically ill individual.
HOSPITAL
A hospital is an institution or facility that is licensed as a hospital by the
proper authority of the state in which it is located; or accredited as a
hospital by the Joint Commission on Accreditation of Hospitals.
INFORMAL CARE
Qualified long-term care services provided by non-licensed providers or persons
who may or may not be paid for their services but are part of the approved plan
of care.
IMMEDIATE FAMILY
Immediate family is the insured's or your spouse, child, parent, grandparent,
grandchild, brothers and sisters and their spouses.
LICENSED HEALTH CARE PRACTITIONER
A licensed health care practitioner is any physician, as defined in Section
1861(r)(1) of the Social Security Act, registered professional nurse, or
licensed social worker, or other individual who meets requirements prescribed by
the Secretary of the Treasury.
A licensed health care practitioner does not include you, the insured, or a
member of your or the insured's immediate family.
LONG TERM CARE (LTC) AMOUNT
The LTC amount is an amount that represents the maximum total amount of benefits
available under this agreement. The LTC Amount is shown on the policy data
pages.
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MAINTENANCE OR PERSONAL CARE SERVICES
Maintenance or personal care services are any services provided primarily to
give needed assistance to the insured as a result of being a chronically ill
individual.
MEDICARE
The name given to coverage under the federal Health Insurance for the Aged Act,
Title XVIII of the Social Security Amendments of 1965 as then constituted or
later amended.
NURSING CARE
Nursing care is providing qualified-long term care services to the insured in a
nursing care facility or assisted living facility, or providing maintenance or
personal care services in an assisted living facility.
NURSING CARE FACILITY
A facility or institution, other than a hospital,
that:
(1) is licensed or certified by the state in which it is located; and
(2) is a separate facility or a distinct part of another health care
facility, including an area or unit of a hospital not providing acute
care; and
(3) provides 24-hour per day nursing care under the supervision of a
registered nurse (RN) or physician; and
(4) maintains a daily record on each patient.
All services and facilities required to be available in the state where the
agreement was issued will be covered even If the state does not require a
provider of such services to be licensed, certified or registered, or if the
state licenses, certifies or registers the provider of services under another
name.
PERSONAL CARE
Personal care is the hands-on, physical assistance of another person without
which the insured would be unable to perform an activity of daily living.
PLAN OF CARE
A written plan for qualified long-term care services prescribed by a licensed
health care practitioner based upon an assessment indicating the insured is a
chronically ill individual. This plan of care must specify the type, frequency,
and most appropriate types of providers of all the services the insured person
requires.
PROOF OF LOSS
Proof of loss means detailed written documentation satisfactory to us which
describes and confirms the insured is chronically ill and is receiving care that
is covered by this agreement. This documentation includes, but is not limited
to:
(1) the completed proof of loss forms; and
(2) confirmation of the certification of chronic illness by a licensed health
care practitioner; and
(3) copies of medical records; and
(4) copies of the licensed health care practitioner's daily notes of care;
and
(5) copies of itemized bills for the insured's care and services or
documentation that informal care is being received; and
(6) copies of the insured's original and current plan of care.
Required certifications regarding activities of daily living and cognitive
impairment shall be performed by the following licensed or certified
professionals: physicians, registered nurses, licensed social workers, or other
individuals who meet requirements prescribed by the Secretary of the Treasury.
QUALIFIED LONG-TERM CARE SERVICES
Qualified long-term care services are services that meet the requirements of
Section 7702B(c)(1) of the Internal Revenue Code of 1986, as amended and provide
necessary diagnostic, preventative, therapeutic, curing, treating, mitigating
and rehabilitative services, and maintenance or personal care services,
including approved informal care, which are required by the insured when
chronically ill, and are provided pursuant to a plan of care prescribed by a
licensed health care practitioner.
SEVERE COGNITIVE IMPAIRMENT
A severe cognitive impairment is the deterioration or loss of intellectual
capacity, which requires substantial assistance by another person to protect the
insured or others from threats to health and safety. It is measured by clinical
evidence and standardized tests that reliably measure the insured's impairment
in short or long term memory; the insured's orientation as to person (such as
who he or she is), place (such as his or her location) and time (such as day,
date and year); and deductive or abstract reasoning. Severe cognitive impairment
includes Alzheimer's disease and similar forms of irreversible dementia.
STAND-BY ASSISTANCE
Stand-by assistance is the presence of another person within arm's reach of the
insured person that is necessary to prevent, by physical intervention, injury to
the insured person while performing any activity of daily living.
SUBSTANTIAL ASSISTANCE
The hands-on or stand-by physical assistance of another person to protect the
insured person or others from threats to health or safety (such as may result
from wandering) or help with performing the activities of daily living; or the
presence of another person within arm's reach that is necessary to prevent, by
physical intervention, injury to the insured person while he or she is
performing necessary tasks.
ICC12-932 Long Term Care Agreement Minnesota Life 4
WE, US, OUR
Minnesota Life Insurance Company
YOU, YOUR
The owner of the policy to which this agreement is attached and made a part.
PROVISIONS
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WHAT DOES THIS AGREEMENT PROVIDE?
This agreement provides for the payment of a monthly benefit for qualified
long-term care services received from nursing care or home and community based
care.
The benefit is an acceleration of the death benefit of the policy to which this
agreement is attached. The benefit will reduce the policy death benefit and
accumulation value.
WHAT IS THE MONTHLY BENEFIT AMOUNT?
The monthly benefit amount is equal to the lesser of:
(1) the monthly benefit percentage as shown on the policy data pages
multiplied by the LTC amount; or
(2) the per diem amount allowed by the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) times the number of days in the month.
WHAT HAPPENS TO THE LTC AMOUNT IF THE FACE AMOUNT OF THE POLICY IS REDUCED?
If the face amount of the policy is reduced, the LTC amount is set equal to the
lesser of the LTC amount that existed immediately prior to the change in the
face amount and the new face amount.
WHAT HAPPENS TO THE LTC AMOUNT IF A PARTIAL SURRENDER IS TAKEN?
If a partial surrender occurs, the LTC amount is set equal to the LTC amount
that was in effect immediately prior to the partial surrender, multiplied by the
ratio of the death benefit of the policy (without regard to policy loan) after
the partial surrender to the death benefit of the policy (without regard to
policy loan) immediately prior to the partial surrender.
WHAT HAPPENS TO THE LTC AMOUNT IF WE MAKE A PAYMENT AS A RESULT OF THE EXERCISE
OF THE ACCELERATED DEATH BENEFIT AGREEMENT?
If your policy has the Accelerated Death Benefit Agreement attached and you
exercise the payment of an accelerated death benefit, the LTC amount will be
recalculated. At the point of such payment the LTC amount is determined by
taking the lesser of:
(1) the LTC amount that existed immediately prior to the accelerated death
benefit payment, and
(2) the death benefit (without regard to policy loan) immediately prior to
the payment of the accelerated death benefit payment, minus the
accelerated death benefit payment from that amount.
WHAT ARE THE ELIGIBILITY REQUIREMENTS FOR THE PAYMENT OF BENEFITS?
In order for benefits to be payable, the following requirements must be met.
(1) The insured must be certified by a licensed health care practitioner as
being a chronically ill individual, and expected to remain so for at
least 90 calendar days; and
(2) The insured must be receiving qualified long-term care services covered
under this agreement which are specified in a plan of care; and
(3) The plan of care must be submitted to us; and
(4) The elimination period must be satisfied.
EXCLUSIONS AND LIMITATIONS
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You are not eligible to receive benefits if your long-term care service needs
are caused directly or indirectly by, result in whole or in part, from or
during, or there is contribution from:
(1) committing or attempting to commit a felony; or
(2) alcoholism or drug addiction, including prescription medication; or
(3) active service in the armed forces or units auxiliary thereto; or
(4) war or any act of war, whether declared or undeclared; or
(5) any intentionally self-inflicted injury or suicide attempt (whether sane
or insane); or
(6) any condition for which the insured received treatment outside of the
United States, its territories or Canada.
PRE-EXISTING CONDITION LIMITATIONS
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Pre-existing conditions limitations refers to any condition or disease for which
the insured received medical advice or treatment within six (6) months preceding
the effective date of this agreement for that same condition or disease or a
related condition or disease. There does not need to be a specific diagnosis for
the condition or disease for it to be considered a pre-existing condition.
We will not pay benefits for qualified long-term care services needed in total
or in part from a pre-existing condition or disease which is not disclosed in
the application. Days of services received by the insured for a pre-existing
condition during the first six (6) months that this agreement is in force will
not be counted toward the satisfaction of the elimination period.
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CHARGES
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IS THERE A CHARGE FOR THIS AGREEMENT?
Yes. There is a monthly charge for this agreement assessed against the policy
accumulation value. The charge for this agreement is equal to the LTC cost of
insurance rate multiplied by the LTC net amount at risk. The maximum monthly LTC
cost of insurance rate for this agreement is shown on the policy data pages. The
LTC net amount at risk will equal the greater of zero and the LTC amount minus a
proportionate amount of the policy accumulation value. The proportion is equal
to the LTC amount divided by the policy face amount.
Charges for this agreement are subject to change. Any change made to the monthly
rate will not exceed the maximum monthly LTC rate shown on the policy data
pages. Any such change will be on a uniform basis for insureds of the same
gender, risk class, and age when this agreement became effective. We will send
you a notice 60 days in advance of any change in the rate for this agreement.
This notice will be sent to your last known address, and to any assignee or
designated third party shown in our records.
CLAIM PROCEDURES
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HOW DO YOU NOTIFY US OF A CLAIM?
Written notice of claim must be sent to us at our Home Office in St. Xxxx,
Minnesota within 30 days after such covered loss starts and the elimination
period has been satisfied. The notice should include your name, the insured's
name and policy number. If it was not reasonably possible to give written notice
in the time required, we shall not reduce or deny the claim for this reason if
notice is given as soon as reasonably possible. In any event, the proof required
must be given no later than one year from the time specified unless you were
legally incapacitated.
WHAT FORMS MUST BE SUBMITTED TO FILE A CLAIM?
Once notice of claim is received, we will send you forms for filing proof of
loss. If these forms are not sent to you within 15 days of our receipt of
written notice of claim, you may submit the proof of loss requirements. You may
submit these by giving us a written statement of the nature and extent of the
loss within the time limit stated in the question below "Is there a time limit
on providing proof of loss".
Each month we will require proof of loss be submitted to us. Monthly benefit
payments will not be made if proof of loss is not received.
Recertification by a licensed health care practitioner that the insured is a
chronically ill individual will be required at a minimum annually. We will not
rescind the certification provided by the licensed health care practitioner. At
the end of the 90 day elimination period, recertification by a licensed health
care practitioner that the insured is a chronically ill individual will be
required. We will require an update to the plan of care at a minimum annually,
but never more frequently than every 90 days.
A revised plan of care must be provided to us within 30 days if the insured's
condition changes and the plan of care is revised. We will require an update to
the revised plan of care at a minimum annually, but no more frequently than once
every 90 days. Only one plan of care may be in effect at a time. We will not
rescind any certification provided by the licensed health care practitioner.
You must notify us in writing immediately if the insured's plan of care
indicates the insured is no longer eligible for qualified long-term care
services.
IS THERE A TIME LIMIT ON PROVIDING PROOF OF LOSS?
Yes. Proof of loss must be given to us at our Home Office in St. Xxxx, Minnesota
within 90 days after such loss begins and the elimination period has been
satisfied. If it was not reasonably possible to give written proof in the time
required, we shall not reduce or deny the claim for this reason. In any event,
the proof required must be given no later than one year from the time specified
unless you are legally incapacitated.
IS THERE A TIME LIMIT ON LEGAL ACTION?
Yes. No legal action may be brought to recover under this agreement within 60
days after written proof of loss has been given as required by this agreement.
No such action may be brought after the expiration of the applicable statute of
limitations from the time written proof of loss is required to be given.
However, any legal action brought to recover under this agreement must conform
to the laws of the state in which the agreement was delivered or issued for
delivery.
DO WE HAVE THE RIGHT TO OBTAIN INDEPENDENT MEDICAL VERIFICATION?
Yes. If we require the insured to be medically examined to verify that the plan
of care is appropriate and consistent with generally accepted standards, we may
do this as often as reasonably required while benefits are being considered or
paid.
If we request verification more frequently than on an annual basis, we will do
so at our own expense.
WHAT IS THE PROCESS FOR CLAIM APPEALS?
We will evaluate your claim based on the provisions of this agreement and the
information given by you, the insured, your licensed health care practitioner
and other available sources. We will inform you in writing if we deny your claim
or any part of your claim.
If you do not agree with our claim decision, you or your representative may
appeal the denial. To appeal our claim decision, you must send us a written
request which includes all information that pertains to the claim:
XXX00-000 Xxxx Xxxx Xxxx Xxxxxxxxx Xxxxxxxxx Life 6
(1) Policy number
(2) Claim number
(3) Insured's name, address, telephone number
(4) Owner's name, address, telephone number and relationship to the insured,
if different from the insured's
(5) Reason(s) for disputing the decision by our Claim Department
(6) Documentation to support your request
No special form is needed for this appeal. Your appeal request must be sent to
us within 30 days of your receipt of our decision.
We will make a decision on your appeal within 10 working days of receiving your
written request. Once we have made a decision, we will notify you within three
working days. Our review of your appeal will be consistent with the applicable
laws and regulations of the state where the policy was delivered or issued for
delivery.
WHAT HAPPENS IF BENEFITS ARE OVERPAID?
If benefits are overpaid, we have the right to recover any overpayment of
benefits.
We will recover any overpayment by first offsetting any unpaid benefits.
If there are not sufficient unpaid benefits to allow for full recovery, we will:
(1) withhold any future benefit payments; then
(2) xxxx you for the remaining amount until full recovery has been made.
If at the time of death there is an outstanding overpayment of benefits, you, or
your legal representative, may return the overpayment to us. If the overpayment
is returned to us prior to our payment of the death proceeds, the overpayment
will be included in the death benefit paid to the policy beneficiary. If the
entire overpayment is not returned to us, we will reduce the death benefit by
the amount of the overpayment.
WHAT HAPPENS IF THE INSURED IS NO LONGER RECEIVING BENEFITS FOR CARE THAT IS
COVERED BY THIS AGREEMENT?
You must notify us immediately if the insured is no longer receiving care that
is covered by this agreement. If the insured is not receiving care covered by
this agreement, no benefits will be paid.
PAYMENT OF BENEFITS
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TO WHOM WILL BENEFITS BE PAID?
All benefits will be paid to you provided you are legally competent at the time
of payment. You can validly assign them to a named alternative payee as
designated by you or your legal representative provided you are legally
competent at the time of assignment.
WHEN WILL BENEFITS BE PAID?
Benefits for any loss covered under this agreement will be paid monthly when the
insured satisfies the eligibility requirements and we receive written proof of
loss.
Benefits will be paid under this agreement for similar services obtained in a
state other than the policy's state of issue if benefits for those services
would have been paid in the policy's state of issue, irrespective of any
facility licensing, certification or registration requirement differences
between the states.
WHAT DOES NON-DUPLICATION OF BENEFITS MEAN?
Non-duplication of benefits means benefits are not payable under this agreement
for:
(1) expenses incurred to the extent that such expenses are reimbursable under
Medicare, or would be so reimbursable, but for the application of a
deductible or coinsurance amount; or
(2) any other state or federal workers' compensation plan, or other
governmental program (except Medicaid).
For purposes of satisfying the elimination period, days on which you satisfy the
eligibility for the payment of benefits provision, but coverage is excluded due
to the non-duplication of benefits provision, will count towards satisfaction of
the elimination period.
WHAT HAPPENS IF THE INSURED DIES WHILE RECEIVING BENEFIT PAYMENTS?
The remaining death benefit will be paid according to the provisions of your
policy.
Any benefits paid under this agreement will reduce the death benefit payable to
the beneficiary of the policy.
Any eligible benefits due and payable prior to the insured's death will be paid
if we receive proof of loss within the 15 day period following notice of death.
IS THERE A MINIMUM DEATH BENEFIT PAYABLE?
Yes. The minimum death benefit amount is shown on the policy data pages. If the
policy death benefit (without regard to policy loan) is less than this minimum
death benefit amount, then the minimum death benefit amount less any policy loan
and unpaid policy loan interest is payable at the death of the insured.
ARE POLICY CHANGES AND TRANSACTIONS ALLOWED WHILE BENEFITS ARE BEING PAID?
You may choose to decrease the face amount of the policy while benefits are
being paid. You may also request a partial surrender for the purpose of applying
it towards any policy loan on this policy.
ICC12-932 Long Term Care Agreement Minnesota Life 7
The following policy changes and transactions are not allowed while benefits are
being paid.
(1) Changes in risk class; or
(2) Increases in the policy face amount; or
(3) Additions of agreements to your policy; or
(4) Transfers to sub-accounts or indexed accounts, or to a loan account, if
applicable; or
(5) Requests for loans; or
(6) Partial surrenders other than those described previously; or
(7) Changes in death benefit option; or
(8) Changes in account allocations.
EFFECT OF BENEFIT PAYMENTS
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DOES THE PAYMENT OF BENEFITS AFFECT THE POLICY DEATH BENEFIT?
Yes. When a benefit payment is made, the death benefit is reduced by the amount
of the benefit payment.
DOES THE PAYMENT OF BENEFITS AFFECT THE POLICY ACCUMULATION VALUE?
Yes. The accumulation value of the policy is set equal to the accumulation value
immediately prior to the benefit payment multiplied by the new death benefit
(without regard to policy loan), divided by the death benefit (without regard to
policy loan) immediately prior to the benefit payment.
If your policy has a minimum accumulation value, the minimum accumulation value
will be adjusted in the same manner as the policy accumulation value.
DOES THE PAYMENT OF BENEFITS AFFECT THE DEATH BENEFIT GUARANTEE AGREEMENT VALUE?
Yes. If your policy has the Death Benefit Guarantee Agreement attached, the DBGA
Value will be adjusted in the same manner as the policy accumulation value.
DOES THE PAYMENT OF BENEFITS AFFECT THE POLICY LOAN?
Yes. If the policy has an outstanding loan, a portion of the benefit payment
will be applied to repay the loan. The amount of the benefit payment applied to
the policy loan is equal to the lesser of the benefit payment and the result of:
(a) the loan interest due at the time of the benefit payment; plus
(b) the policy loan immediately prior to the benefit payment; multiplied by
one (1) minus the ratio of the new death benefit (without regard to
policy loan) divided by the death benefit (without regard to policy loan)
immediately prior to the benefit payment.
WHAT HAPPENS TO THE ACCUMULATION VALUE IN THE SUB-ACCOUNTS OF THE SEPARATE
ACCOUNT OF THE POLICY WHEN BENEFIT PAYMENTS BEGIN?
If you have accumulation value in sub-accounts of a separate account when
benefit payments begin, we will automatically transfer any value in each
sub-account to the guaranteed interest account.
Once benefits are being paid, no further premium allocations may be made to
sub-accounts of a separate account.
WHAT HAPPENS TO THE ACCUMULATION VALUE OF THE POLICY IN AN INDEXED ACCOUNT
SEGMENT WHEN BENEFIT PAYMENTS BEGIN?
If you have accumulation value in indexed accounts when benefit payments begin,
we will automatically transfer any value in each segment of the indexed accounts
to the fixed account at each segment's next anniversary.
Once benefits are being paid, no further account allocations may be made to the
indexed accounts.
WHAT HAPPENS TO THE POLICY LOAN WHEN BENEFIT PAYMENTS BEGIN?
If you have a policy loan with a variable interest rate, we will automatically
change the loan to a fixed interest rate loan. We will also automatically
transfer accumulation value to the fixed loan account in the amount of the
policy loan plus any unpaid policy loan interest.
WILL THE CHARGES FOR THIS AGREEMENT BE WAIVED IF BENEFITS ARE BEING PAID?
Yes. As long as benefits are being paid, the charge for this agreement will be
waived. All other charges will continue to be assessed against your policy.
WILL OTHER POLICY CHARGES BE WAIVED IF BENEFITS ARE BEING PAID?
No. However, if the policy accumulation value goes to zero while benefits are
being paid, we will waive all policy and agreement charges that would otherwise
be assessed against the policy accumulation value.
WHEN WILL THE PAYMENT OF BENEFITS TERMINATE?
The monthly benefit payments will stop when:
(1) 100% of the LTC amount has been paid; or
(2) the insured is no longer eligible for the benefit; or
(3) the policy is surrendered; or
(4) the policy terminates when the policy loan plus unpaid policy loan
interest exceeds the policy accumulation value; or
(5) we receive your request to cancel this agreement; or
(6) the insured dies
ICC12-932 Long Term Care Agreement Minnesota Life 8
WILL WE PAY BENEFITS UNDER AN ALTERNATIVE PLAN OF CARE?
If the insured is chronically ill and satisfies the claim procedures provision,
we will consider paying benefits under an alternative plan of care for qualified
long-term care services not specifically shown as being available under this
agreement.
We must agree that the alternative plan of care must be (1) medically
acceptable; and (2) the most cost effective manner in which to provide benefits
for the insured's claim under this agreement.
ADDITIONAL INFORMATION
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WHAT IF THE INSURED'S AGE IS MISSTATED?
If the insured's age has been misstated on the application, we may at any time
adjust your benefits and/or charges based on the insured's correct age. The
amount payable as a benefit shall be such as the charges assessed would have
purchased at the correct age. If any benefits were underpaid, based on the
insured's correct age, we will make additional payment. Any benefits overpaid to
you based on the insured's correct age must be repaid according to the
provisions of this agreement.
IS THIS AGREEMENT SUBJECT TO THE INCONTESTABILITY PROVISION OF THE POLICY?
Yes. That provision applies to this agreement. The contestable period for this
agreement will be measured from the effective date of this agreement.
If this agreement is issued at a date later than this policy, then this
agreement will be contestable based only on the evidence of insurability which
we required to issue this agreement.
However, a misstatement by you or the insured in any application for the policy
or this agreement may be used to rescind (void) or cancel this agreement or deny
an otherwise valid claim. During the first six (6) months following the policy
date, we may take such action only if the misstatement was material to the
issuance of this agreement. After the first six (6) months, but before the end
of the first twenty-four (24) months, we may take such action only if the
misstatement was material to both the issuance of this agreement and the claim
for which benefits are being sought. After this agreement has been in force for
twenty-four (24) months from the effective date of this agreement, we can take
such action only if we can show you or the insured knowingly and intentionally
misrepresented relevant facts relating to the insured's health.
No benefits will be paid under this agreement if it is rescinded or canceled.
In the event of death of the insured, this provision will not apply to the
remaining death benefit payable under the policy which will be governed by the
incontestability provision in the policy.
DOES THIS AGREEMENT CONFORM TO INTERSTATE INSURANCE PRODUCT REGULATION
COMMISSION STANDARDS?
Yes. This agreement was approved under the authority of the Interstate Insurance
Product Regulation Commission and issued under Commission standards. Any
provision of this agreement which is in conflict with Interstate Insurance
Product Regulation Commission standards for this product type as of that
provision's effective date, is hereby amended to conform to the Interstate
Insurance Product Regulation Commission standards for this product type as of
the provision's effective date.
WHEN DOES THIS AGREEMENT TERMINATE?
This agreement will terminate on the earliest of:
(1) the date this policy is surrendered or terminated; or
(2) the date we receive your request to cancel this agreement; or
(3) the date of the insured's death.
Termination of long-term care insurance shall be without prejudice to any
benefits payable for institutionalization if such institutionalization began
while the long-term care insurance was in force and continues without
interruption after termination. Such extension of benefits beyond the period the
long-term care insurance was in force may be limited to the duration of the
benefit period, if any, or to payment of the maximum benefits and may be subject
to any policy waiting period, and all other applicable provisions of the policy.
WHAT IF YOUR POLICY AND THIS AGREEMENT TERMINATED UNINTENTIONALLY?
You have the right to name at least one person who is to receive the notice of
termination, in addition to yourself. You may designate another person either on
the application to the life insurance policy or on the supplemental application
for this agreement. We will notify you of the right to change this written
designation no less often than once every two years.
The policy and this agreement will not terminate for insufficient accumulation
value to cover the monthly charges unless we, at least 30 days before the
effective date of the termination, have given notice to you and to those persons
you have designated to receive the notice of termination. The notice shall be
given by first class United States mail, postage prepaid; and notice may not be
given until 30 days after a premium is due and unpaid. Notice shall be deemed to
have been given as of five days after the date of the mailing.
ICC12-932 Long Term Care Agreement Minnesota Life 9
CAN YOU REQUEST THAT THIS AGREEMENT BE REINSTATED?
Yes. You can request that this agreement be reinstated if all of the
reinstatement conditions stated in the policy have been satisfied. The effective
date of the agreement will be the same as the effective date of the reinstated
policy.
Alternatively, we will reinstate the policy and this agreement, but no other
agreements, if all of the following conditions are met:
(1) we receive written request for reinstatement from you, or your designated
third party; and
(2) the written request is received within 6 months after the termination
date; and
(3) we receive proof that you were cognitively impaired or a loss of
functional capacity existed prior to the expiration of the grace period;
and
(4) we receive all back charges due plus premium sufficient to keep the
policy in force another 3 months.
/s/ Xxxxxx X. Xxxxxxxxx /s/ Xxxxxx X. Xxxxxxx
Secretary President
