Long Term Care Extension of Benefits

The provisions in the sample long term care insurance policy clearly state the specific conditions under which benefits will be paid. Most policies contain provisions similar to those outlined below.

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If, as of the date Your Policy Lapses or as of the date We receive a written request to cancel Your policy, You are eligible for Benefits and are confined in a Nursing Home, Hospice facility or Assisted Living Facility, We will extend the payment of Benefits for Covered Services received so long as, without interruption, You remain eligible for Benefits and remain confined. Subject to the Elimination Period and the terms of this Policy, Benefitswill be extended only until the earliest of the date:

1. You are no longer eligible for Benefits; or
2. You are no longer confined in a Nursing Home, Hospice facility or Assisted Living Facility; or
3. Your Total Lifetime Benefit has been paid.

COMMENT: A long term care insurance policy Lapse means the policy has been terminated because of a failure to pay premiums. The policy actually terminates 35 days after the end of the grace period for paying the premium. The grace period is usually 31 days after the premium due date. To summarize, to be eligible for Benefits, you must be certified to be Chronically Ill and you must have a Plan of Care in place, including the Qualified Long Term Care Services. Not only must you be eligible, you must also be confined in one of the three facilities mentioned above, so, if your long term care insurance coverage Lapses OR you request to cancel your policy AND you are eligible for Benefits AND you are confined, the insurance company will continue the payment of Benefits for Covered Services. Covered Services are diagnostic, preventive, therapeutic, curing treating, mitigating and rehabilitative services, and Maintenance or Personal Care Services. Maintenance or Personal Care Services is basically any care that provides needed assistance when you are Chronically Ill, including Custodial Care and assistance with Activities of Daily Living(bathing, dressing, transferring to and from bed or chair, toileting, continence and eating). If you are no longer confined at the facility, your Extended Benefit coverage stops and your coverage under the policy ends. Your Extended Benefits will also end if you are no longer eligible for Benefits. This might happen if you recover sufficiently to no longer be considered Chronically Ill. Finally, if your Total Benefit Limit shown on the Schedule of Benefits page is reached, all of your benefits, including your Extended Benefits, will stop. Extended Benefits are really nothing more than the normal benefits that would be available to you if you were paying the premium. You might wonder why you should keep paying the premium once you are eligible for Benefits and confined in a qualifying facility. If you are certain that you are not going to recover sufficiently to leave the facility or to lose your eligibility for Benefits, you probably should discontinue paying premiums and avail yourself of the Extended Benefits. But if you think you might recover, you would be wise to continue to pay the premium. If you stop, you will be without long term care insurance and will have to re-apply for a new policy when you recover. Any new policy is subject to underwriting, based on your current age and health when you re-apply. A new policy will probably be far more expensive than your current policy – if you can get it at all.

Case Studies: Long Term Care Extension of Benefits

Case Study 1: Sarah’s Continuation of Benefits

Sarah, a policyholder with long-term care insurance, experienced a lapse in her policy due to non-payment of premiums. However, she remained confined in an eligible facility and met the criteria for benefits. As per the policy provisions, the insurance company extended the payment of benefits for covered services, ensuring Sarah continued to receive the care she needed. This case study emphasizes the significance of understanding the conditions for benefit extension, even in the event of a policy lapse.

Case Study 2: Robert’s Limited Eligibility

Robert, another policyholder, had been receiving long-term care services and qualified for benefits. However, his health condition improved, and he was no longer considered chronically ill. Consequently, his eligibility for benefits ceased, and the insurance company discontinued the extension of benefits. This case study highlights the importance of monitoring changes in health status and understanding the conditions under which extended benefits may be terminated.

Case Study 3: Emily’s Total Benefit Limit

Emily, a long-term care policyholder, had been receiving benefits, including the extension of benefits, for covered services. However, she reached the total benefit limit specified in her policy. As a result, all her benefits, including the extended benefits, came to an end. This case study underscores the significance of being aware of the total benefit limit and planning for the potential exhaustion of benefits in long-term care insurance.