Rule 20:06:21:26.01 Notice to claimants -- Temporary leave.
20:06:21:26.01. Notice to claimants -- Temporary leave.
Within 30 days of receiving a claim or other written notice that an insured has
entered a nursing home or assisted living center, the insurer must provide
notice to the insured of the applicable policy or certificate provisions that
would apply should the insured temporarily leave the nursing home or assisted
living center. If benefits are provided through a bed reservation benefit or
other policy provision, the notice must explain the extent of such coverage. If
benefits are excluded, the notice must advise the insured of the scope of the
exclusion and identify any applicable policy or certificate provision. If a
temporary absence from the nursing home or assisted living center affects other
policy or certificate benefits or conditions such as waiver of premium, that
effect must also be explained in the notice. If, as of the effective date of
this rule, an insured had been in a nursing home or assisted living center for
30 or more days and the insurer had received notice of the nursing home or
assisted living center stay, the notice required pursuant to this section must
be provided to that insured. An insurer may satisfy the requirements of this
section by including the notice requirements in other written communications,
including claim communications, sent to the insured. No filing of the notice to
the director is required. The provisions of this section will be effective
October 1, 2005.
The following sample language of
notices may be used by insurers to comply with the notice requirements of this
section provided that it is consistent with the provisions of the policy or
(1) Your [policy] has a bed
reservation benefit. If you leave the nursing home or assisted living center
for a period of not more than [X] days during a 12-month period, those days are
payable subject to other [policy] limitations that may apply.
(2) Your [policy] does not
contain bed reservation benefits. If you leave the nursing home or assisted
living center and are not provided care by that facility, you will not be
covered for the days that your were absent from the
facility. The absence [will/will not] result in your having to again satisfy
the waiver of premium waiting period.
31 SDR 214, adopted June 16, 2005, effective October 1, 2005.
Authority: SDCL 58-17B-4.
Implemented: SDCL 58-17B-4.
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