What Is Not Covered under Long-Term Insurance?

The provisions in the sample long term care insurance policy state the specific conditions under which benefits will not be paid. Most policies contain provisions similar to those outlined below:

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No payment will be made for any of the following:

1. Treatment of alcoholism or drug addiction, unless the addiction was due to drug(s) taken on the advice of a physician.
2. Any care received while in a hospital, except in a unit specifically designated as a nursing home or a hospice facility.
3. Any injury or sickness that results from:
   • any war, or act of war (whether declared or undeclared); or
   • participation in a felony, riot or insurrection.
4. Any intentionally self-inflicted injury.
5. Services performed by a member of your immediate family.
6. Any care or services received outside of the Untied States and its territories, except as described in the International Coverage section.
7. Any service or supply to the extent the expense for it is reimbursable under Medicare, or would be reimbursable but for the application of a deductible, coinsurance or co-payment amount. This exclusion will not apply where Medicare is a secondary under the applicable law.
8. Treatment received in a government facility (unless otherwise required by law); services for which benefits are available under a government program (except Medicaid); or services for which no charge is normally made in the absence of insurance.

There are no limitations or exclusions for pre-existing conditions, or mental and nervous disorders, including Alzheimer’s Disease.

Unlike regular health insurance, there are no limitations or exclusions for pre-existing conditions and mental and nervous disorders.

Coordination of Other Coverages with This Company

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 you have more than one long term care insurance policy or certificate issued or insured with this Company, We will reduce the benefit amounts payable to the extent necessary, so that the combination of benefits under all of these policies and certificates will not exceed one hundred per cent (100%) of the actual charges for covered services.

If you are eligible to receive benefits under this Policy and any other long term care insurance policy or certificate issued or insured by this Company with a coordination of benefits provision, then the policy or certificate with the earliest effective date will be deemed tore be the primary coverage, and any other policy or certificate will be deemed secondary coverage, in order by effective date, from the earliest to the latest. Policies and certificates without a coordination of benefits provision will pay first.

The provision will not apply to policies or certificates which pay Benefits without regard to actual charges you incur.

Case Studies: Exclusions and Limitations in Long-Term Care Insurance

Case Study 1: Pre-Existing Conditions

John, a policyholder of long-term care insurance, seeks coverage for a medical condition that he had prior to obtaining the policy. However, the policy clearly states that there are no limitations or exclusions for pre-existing conditions. As a result, John’s claim is denied based on this exclusion. He is responsible for covering the expenses related to his pre-existing condition.

Case Study 2: Self-Induced Conditions

Susan, another policyholder, develops health issues due to alcoholism. When she files a claim under her long-term care insurance policy, it is denied based on the exclusion for self-induced conditions. The policy explicitly states that conditions caused by self-induced factors such as alcoholism are not covered. Susan must bear the costs of her treatment on her own.

Case Study 3: Immediate Family Services

Mary, a policyholder, requires long-term care services provided by her immediate family members. However, the policy explicitly excludes coverage for services performed by immediate family members, assuming that such services will be provided without charge. As a result, Mary cannot claim reimbursement for the care provided by her family members.

Case Study 4: Coordination of Benefits

Robert has multiple long-term care insurance policies issued by the same company. When he needs to claim benefits, the coordination of benefits provision comes into play. The provision states that the total benefits paid by all policies should not exceed 100% of the actual charges for covered services. As a result, the benefits from Robert’s policies are adjusted accordingly to prevent an overpayment.