Rule 20:06:21:02 Minimum standards for long-term care insurance policies.
20:06:21:02. Minimum standards for long-term care insurance
policies. Long-term care insurance policies shall contain benefits that are
reasonable in relation to the premium charged. Long-term care insurance
policies that require prior hospitalization or institutionalization as a
condition of coverage may not require that the present hospitalization or
institutionalization be for the same condition for which the insured was
previously hospitalized or institutionalized. Long-term care insurance policies
may not require, as a condition of coverage, that rehabilitation received by
the insured demonstrably improve the insured's condition. The elimination
period for any one confinement may not exceed 100 days for a long-term care
insurance policy or one year for a long-term care insurance rider.
An insurer may make application for an
elimination period in excess of 100 days, provided that specific suitability
criteria or underwriting procedures are filed with the application. If the
director finds that the procedures or criteria provide adequate protection for
consumers, the director may approve the application.
Long-term care policies which
condition payment of benefits on the inability to perform activities of daily
living (ADLs) may not be so restrictive that they exclude coverage of services
provided at least at the level of intermediate care and may not be used to
restrict coverage for organic brain disorders, including Alzheimer's disease
and senile dementia. This paragraph also applies to policies basing benefits on
functional incapacity. Long-term care policies or portions thereof that
condition the receipt of benefits on ADLs or functional incapacity may not also
condition benefits on a certain level of care.
16 SDR 208, effective June 3, 1990; 28 SDR 157, effective May 19, 2002.
Authority: SDCL 58-4-1, 58-17B-4, 58-17B-15.
Implemented: SDCL 58-17B-3, 58-17B-6, 58-17B-7.
Intermediate care services, � 67:16:04:18.
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