Illinois Compiled Statutes
215 ILCS 5/ - Illinois Insurance Code.
Article XIXA - Long-Term Care Insurance

(215 ILCS 5/Art. XIXA heading)

 
(215 ILCS 5/351A-1) (from Ch. 73, par. 963A-1)
Sec. 351A-1.
Definitions.
Unless the context requires otherwise, in this
Article:
(a) "Long-term care insurance" means any accident and health insurance
policy or rider advertised, marketed, offered or designed to provide
coverage for not less than 12 consecutive months for each covered person on
an expense incurred, indemnity, prepaid or other basis, for one or more
necessary or medically necessary diagnostic, preventive, therapeutic,
rehabilitative, maintenance, or personal care services, provided in a
setting other than an acute care unit of a hospital. Such term includes
group and individual annuities and life insurance policies or riders which
provide directly or which supplement long-term care insurance. The term also
includes a policy or rider that provides for payment of benefits based upon
cognitive impairment or the loss of functional capacity. The term shall also
include qualified long-term care insurance contracts. Long-term
care insurance may be issued by insurers, fraternal benefit societies,
nonprofit health, hospital, and medical service corporations, prepaid
health plans, health maintenance organizations or any similar organization
to the extent they are otherwise authorized to issue life or health
insurance. Long-term care insurance shall not include any insurance policy
which is offered primarily to provide basic Medicare supplement coverage,
basic hospital expense coverage, basic medical-surgical expense coverage,
hospital confinement indemnity coverage, major medical expense coverage,
disability income protection coverage, accident only coverage, specified
disease or specified accident coverage, or limited benefit health coverage.
Long-term care insurance may include benefits for care and treatment in
accordance with the tenets and practices of any established church or
religious denomination which teaches reliance on spiritual treatment
through prayer for healing.
(b) "Applicant" means:
(c) "Certificate" means, for the purposes of this Article, any
certificate issued under a group long-term care insurance policy, which
policy has been delivered or issued for delivery in this State.
(d) "Director" means the Director of Insurance of this State.
(e) "Group long-term care insurance" means a long-term care insurance
policy which is delivered or issued for delivery in this State and issued
to one of the following:
(f) "Policy" means, for the purposes of this Article, any policy, contract,
subscriber agreement, rider or endorsement delivered or issued for delivery
in this State by an insurer, fraternal benefit society, nonprofit health,
hospital, or medical service corporation, prepaid health plan, health
maintenance organization or any similar organization.
(g) "Qualified long-term care insurance contract" or "federally
tax-qualified long-term care insurance contract" means an individual or group
insurance contract that meets the requirements of Section 7702B(b) of the
Internal Revenue Code of 1986, as amended, as follows:
"Qualified long-term care insurance contract" or "federally tax-qualified
long-term care insurance contract" also means the portion of a life insurance
contract that provides long-term care insurance
coverage by rider or as part of the contract and that satisfies the
requirements of Sections 7702B(b) and 7702B(e) of the Internal Revenue Code of
1986,
as amended.

(Source: P.A. 92-148, eff. 7-24-01.)
 
(215 ILCS 5/351A-2) (from Ch. 73, par. 963A-2)
Sec. 351A-2.
Group policy issued in another state.
No group long-term
care insurance coverage may be offered to a resident of this State under a
group policy issued in another state to a group described in paragraph (4)
of subsection (e) of Section 351A-1, unless the Director determines that
this State or another state having statutory and regulatory long-term care
insurance requirements substantially similar to those adopted in this State
has made a determination that such requirements have been met.

(Source: P.A. 85-1172; 85-1174; 85-1440.)
 
(215 ILCS 5/351A-3) (from Ch. 73, par. 963A-3)
Sec. 351A-3.
Disclosures.
The Director may adopt rules that include
standards for full and fair disclosure setting forth the manner, content,
and 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, preexisting
conditions, termination of insurance, continuation or conversion,
probationary periods, limitations, exceptions, reductions, elimination
periods, requirements for replacement, recurrent conditions, and
definitions of terms.

(Source: P.A. 85-1172; 85-1174; 85-1440.)
 
(215 ILCS 5/351A-4) (from Ch. 73, par. 963A-4)
Sec. 351A-4.
Limitation.
No long-term care insurance policy may:
(Source: P.A. 92-148, eff. 7-24-01.)
 
(215 ILCS 5/351A-4.5)
Sec. 351A-4.5.
Long-term care; coverages.
Nothing in this Code prohibits
an insurance company from offering a long-term care insurance
policy that provides for (1) reimbursement
of paid premiums in the event of cancellation or (2) reduced benefits in the
event the policyholder discontinues premium payments.

(Source: P.A. 88-290.)
 
(215 ILCS 5/351A-5) (from Ch. 73, par. 963A-5)
Sec. 351A-5.
Preexisting condition.
(a) No long-term care insurance
policy or certificate other than a policy or certificate thereunder issued
to a group as defined in paragraph (1) of subsection (e) of Section 351A-1
shall use a definition of "preexisting condition" which is more restrictive
than the following: Preexisting condition means the existence of symptoms
which would cause an ordinarily prudent person to seek diagnosis, care or
treatment, or a condition for which medical advice or treatment was
recommended by, or received from a provider of health care services, within
6 months preceding the effective date of coverage for an insured person.
(b) No long-term care insurance policy or certificate other than a
policy or certificate thereunder issued to a group as defined in paragraph
(1) subsection (e) of Section 351A-1 may exclude coverage for a loss or
confinement which is the result of a preexisting condition unless such loss
or confinement begins within 6 months following the effective date of
coverage of an insured person.
(c) The Director may extend the limitation periods set forth in
subsections (a) and (b) of this Section as to specific age group categories
in specific policy forms upon finding that the extension is in the best
interest of the public.
(d) The definition of "preexisting condition" does not prohibit an
insurer from using an application form designed to elicit the complete
health history of an applicant, and, on the basis of the answers on that
application, from underwriting in accordance with that insurer's
established underwriting standards. Unless otherwise provided in the
policy or certificate, a preexisting condition, regardless of whether it is
disclosed on the application, need not be covered until the waiting period
described in subsection (b) of this Section expires. No long-term care
insurance policy or certificate may exclude or use waivers or riders of any
kind to exclude, limit or reduce coverage or benefits for specifically
named or described preexisting diseases or physical conditions beyond the
waiting period described in subsection (b) of this Section.

(Source: P.A. 85-1172; 85-1174; 85-1440.)
 
(215 ILCS 5/351A-6) (from Ch. 73, par. 963A-6)
Sec. 351A-6.
Prior hospitalization; institutionalizations.
(a) On and after the effective date of this amendatory Act of 1989, no
long-term care insurance policy may be delivered or issued for delivery in
this State if such policy:
(b) Beginning one year after the effective date of this amendatory Act
of 1989, a long-term care insurance policy containing any limitations or
conditions for eligibility other than those prohibited above in subsection
(a) shall clearly label in a separate paragraph of the policy or
certificate entitled "Limitations or Conditions on Eligibility for
Benefits" such limitations or conditions, including any required number of
days of confinement.
(Source: P.A. 85-1440; 86-384.)
 
(215 ILCS 5/351A-7) (from Ch. 73, par. 963A-7)
Sec. 351A-7.
Right to return.
(a) An individual long-term care
insurance policyholder shall have the right to return the policy within 30
days of its delivery and to have the premium refunded directly to him or
her if, after examination of the policy, the policyholder is not satisfied
for any reason. Long-term care insurance policies shall have a notice
prominently printed on the first page of the policy or attached thereto
stating in substance that the policyholder shall have the right to return
the policy within 30 days of its delivery and to have the premium refunded
if, after examination of the policy, the policyholder is not satisfied for
any reason.
(b) A person insured under a long-term care insurance policy or
certificate issued pursuant to a direct response solicitation shall have
the right to return the policy or certificate within 30 days of its
delivery and to have the premium refunded directly to him or her if, after
examination, the insured person is not satisfied for any reason. Long-term
care insurance policies or certificates issued pursuant to a direct
response solicitation shall have a notice prominently printed on the first
page of the policy or certificate attached thereto stating in substance
that the insured person shall have the right to return the policy or
certificate within 30 days of its delivery and to have the premium refunded
if, after examination of the policy or certificate, the insured person is
not satisfied for any reason. This subsection also applies to denials of
applications, and any refund must be made within 30 days of the return or
denial.

(Source: P.A. 92-148, eff. 7-24-01.)
 
(215 ILCS 5/351A-8) (from Ch. 73, par. 963A-8)
Sec. 351A-8.
Outline of coverage.
(a) An outline of coverage shall be delivered to a prospective applicant
for long-term care insurance at the time of initial solicitation through
means which prominently direct the attention of the recipient to the
document and its purpose.
(b) The outline of coverage shall include:
(Source: P.A. 92-148, eff. 7-24-01.)
 
(215 ILCS 5/351A-9) (from Ch. 73, par. 963A-9)
Sec. 351A-9.
Disclosure in certificate.
A certificate issued pursuant
to a group long-term care insurance policy, which policy is delivered or
issued for delivery in this State, shall include each of the following:
(1) A description of the principal benefits and coverage provided in
the policy.
(2) A statement of the principal exclusions, reductions and limitations
contained in the policy.
(3) A statement that the group master policy determines governing
contractual provisions.

(Source: P.A. 85-1172; 85-1174; 85-1440.)
 
(215 ILCS 5/351A-9.1) (from Ch. 73, par. 963A-9.1)
Sec. 351A-9.1.
Policy summary and benefit reports.
(a) At the time of policy delivery, a policy summary shall be delivered
for an individual life insurance policy which provides long-term care
benefits within the policy or by rider. In the case of direct response
solicitations, the insurer shall deliver the policy summary upon the
applicant's request, but regardless of request shall make such delivery no
later than at the time of policy delivery. In addition to complying with
all applicable requirements, the summary shall also include:
(b) Any time a long-term care benefit, funded through a life insurance
vehicle by the acceleration of the death benefit, is in benefit payment
status, a monthly report shall be provided to the policyholder. Such
report shall include:
(Source: P.A. 86-384.)
 
(215 ILCS 5/351A-9.2)
Sec. 351A-9.2.
Delivery of policy.
If an applicant for a long-term care
insurance contract or certificate is approved, the issuer shall deliver the
contract or certificate of insurance to the applicant no later than 30 days
after the date of approval.

(Source: P.A. 92-148, eff. 7-24-01.)
 
(215 ILCS 5/351A-9.3)
Sec. 351A-9.3.
Claim denial; explanation.
If a claim under a long-term
care insurance contract is denied, the issuer, within 60 days after
receipt of a written request by a policyholder or certificate holder or a
policyholder's or certificate holder's representative shall:
(Source: P.A. 92-148, eff. 7-24-01.)
 
(215 ILCS 5/351A-10) (from Ch. 73, par. 963A-10)
Sec. 351A-10.

Any policy or rider advertised, marketed or offered as
long-term care or nursing home insurance shall comply with the provisions
of this Article.

(Source: P.A. 85-1440; 86-384.)
 
(215 ILCS 5/351A-11) (from Ch. 73, par. 963A-11)
Sec. 351A-11.
Rules and regulations.
The Director may adopt rules and
regulations establishing minimum standards for marketing practices and
reporting practices, penalties for violating those standards, and loss
ratio standards for long-term care insurance policies, provided that a
specific reference to long-term care insurance policies is contained in the
regulation. Rules adopted pursuant to this Article shall be in accordance
with the provisions of the Illinois Administrative Procedure Act.

(Source: P.A. 87-601.)

Structure Illinois Compiled Statutes