§ 27-34.2-4 - Definitions. - Rhode Island Statutes

SECTION 27-34.2-4

   § 27-34.2-4  Definitions. – Unless the context requires otherwise, the following definitions applythroughout the chapter:

   (1) "Applicant" means:

   (i) In the case of an individual long term care insurancepolicy, the person who seeks to contract for benefits; and

   (ii) In the case of a group long term care insurance policy,the proposed certificate holder;

   (2) "Certificate" means, for the purposes of this chapter,any certificate issued under a group long term care insurance policy, whichpolicy has been delivered or issued for delivery in this state, except asprovided for in § 27-34.2-5;

   (3) "Director" means the director of business regulation;

   (4) "Group long term care insurance" means a long term careinsurance policy which is delivered or issued for delivery in this state andissued to:

   (i) One or more employers or labor organizations, or to atrust, or to the trustees of a fund established by one or more employers orlabor organizations, or a combination of employers and labor organizations, foremployees or former employees or a combination of employees and formeremployees, or for members or former members, or a combination of members andformer members, of the labor organizations; or

   (ii) Any professional, trade, or occupational association forits members or former or retired members, or combination of members and formermembers, if that association:

   (A) Is composed of individuals all of whom are or wereactively engaged in the same profession, trade, or occupation; and

   (B) Has been maintained in good faith for purposes other thanobtaining insurance; or

   (iii) An association, a trust, or the trustee(s) of a fundestablished, created, or maintained for the benefit of members of one or moreassociations. Prior to advertising, marketing, or offering that policy withinthis state, the association or associations, or the insurer of the associationor associations, shall file evidence with the director that the association orassociations have at the outset a minimum of one hundred (100) persons and havebeen organized and maintained in good faith for purposes other than that ofobtaining insurance, have been in active existence for at least one year, andhave a constitution and bylaws which provide that:

   (A) The association or associations hold regular meetings notless than annually to further purposes of the members;

   (B) Except for credit unions, the association or associationscollect dues or solicit contributions from members; and

   (C) The members have voting privileges and representation onthe governing board and committees;

   (iv) Thirty (30) days after that filing the association orassociations will be deemed to satisfy those organizational requirements,unless the director makes a finding that the association or associations do notsatisfy those organizational requirements; or

   (v) A group other than as described in paragraphs (i), (ii)and (iii) of this subdivision, subject to a finding by the director that:

   (A) The issuance of the group policy is not contrary to thebest interest of the public;

   (B) The issuance of the group policy would result ineconomies of acquisition or administration; and

   (C) The benefits are reasonable in relation to the premiumscharged;

   (5) "Issuer" means any domestic or foreign insurance companyas defined in this title of these general laws or any other entity legallyauthorized to issue or deliver long term care insurance contracts pursuant tothe provisions of this chapter.

   (6) "Long term care insurance" means any insurance policy orrider advertised, marketed, offered, or designed to provide coverage for notless than twelve (12) consecutive months for each covered person on an expenseincurred, indemnity, prepaid, or other basis, for one or more necessary ormedically necessary diagnostic, preventive, therapeutic, rehabilitative,maintenance, or personal care services provided in a setting other than anacute care unit of a hospital. This term includes group and individualannuities and life insurance policies or riders which provide directly or whichsupplement long term care insurance. This term also includes a policy or riderthat provides for payment of benefits based upon cognitive impairment or theloss of functional capacity. Long term care insurance may be issued byinsurers, fraternal benefit societies, nonprofit health, hospital, and medicalservice corporations, prepaid health plans, health maintenance organizations,or any similar organization to the extent that they are authorized to issuelife or health insurance. Long term care insurance shall not include anyinsurance policy which was offered primarily to provide basic Medicaresupplement coverage, basic hospital expense coverage, basic medical-surgicalexpense coverage, hospital confinement indemnity coverage, major medicalexpense coverage, disability income protection coverage, accident onlycoverage, specified disease or specified accident coverage, or limited benefithealth coverage. This list of excluded coverages is illustrative and is notintended to be all inclusive;

   (ii) With regard to life insurance, this term does notinclude life insurance policies which accelerate the death benefit specificallyfor one or more of the qualifying events of terminal illness, medicalconditions requiring extraordinary medical intervention, or permanentinstitutional confinement, and which provide the option of a lump sum paymentfor those benefits and in which neither the benefits nor the eligibility forthe benefits is conditioned upon the receipt of long term care. Notwithstandingany other provision contained in this chapter, any product advertised,marketed, or offered as long term care insurance shall be subject to theprovisions of this chapter;

   (7) "Policy" means, for the purposes of this chapter, anypolicy, contract, subscriber agreement, rider, or endorsement delivered orissued for delivery in this state by an insurer, fraternal benefit society,nonprofit health, hospital, or medical service corporation, prepaid healthplan, health maintenance organization, or any similar organization.

   (8) "Qualified long-term care insurance contract" or"federally tax-qualified long-term care insurance contract" means an individualor group insurance contract that meets the requirements of § 7702B(b) ofthe Internal Revenue Code of 1986, as amended, et seq., as follows:

   (A) The only insurance protection provided under the contractis coverage of qualified long-term care services. A contract shall not fail tosatisfy the requirements of this subparagraph by reason of payments being madeon a per diem or other periodic basis without regard to the expenses incurredduring the period to which the payments relate;

   (B) The contract does not pay or reimburse expenses incurredfor services or items to the extent that the expenses are reimbursable underTitle XVIII of the Social Security Act (Medicare), as amended, or would be soreimbursable but for the application of a deductible or coinsurance amount. Therequirements of this subparagraph do not apply to expenses that arereimbursable under Title XVIII of the Social Security Act only as a secondarypayor. A contract shall not fail to satisfy the requirements of thissubparagraph by reason of payments being made on a per diem or other periodicbasis without regard to the expenses incurred during the period to which thepayments relate;

   (C) The contract is guaranteed renewable, within the meaningof § 7702B(b)(1)(C) of the Internal Revenue Code of 1986, as amended, etseq.;

   (D) The contract does not provide for a cash surrender valueor other money that can be paid, assigned, pledged as collateral for a loan, orborrowed except as provided in subdivision 27-34.2-4(8)(i)(E);

   (E) All refunds of premiums, and all policyholder dividendsor similar amounts, under the contract are to be applied as a reduction infuture premiums or to increase future benefits, except that a refund on theevent of death of the insured or a complete surrender or cancellation of thecontract cannot exceed the aggregate premiums paid under the contract; and

   (F) The contract meets the consumer protection provisions setforth in § 7702B(g) of the Internal Revenue Code of 1986, as amended, etseq.

   (ii) "Qualified long-term care insurance contract" or"federally tax-qualified long term care insurance contract" also means theportion of a life insurance contract that provides long-term care insurancecoverage by rider or as part of the contract and that satisfied therequirements of § 7702(B)(b) and (e) of the Internal Revenue Code of 1986,as amended, et seq.