§ 31–3601. Definitions.

For the purposes of this chapter, the term:

(1) “Applicant” means:

(A) In the case of an individual long-term care insurance policy, the person who seeks to contract for benefits; and

(B) In the case of a group long-term care insurance policy, the proposed certificate holder.

(2) “Certificate” means any certificate issued under a group long-term care insurance policy, which policy has been delivered or issued for delivery in the District of Columbia.

(3) “Commissioner” means the Commissioner of the Department of Insurance, Securities, and Banking.

(4) “Group long-term care insurance” means a long-term care insurance policy which is delivered or issued for delivery in the District of Columbia and issued to one of the following groups:

(A) One or more employers or labor organizations, a trust or the trustees of a fund established by one or more employers or labor organizations, or a combination thereof, for employees or former employees, or a combination thereof or for members or former members, or a combination thereof, of the labor organizations;

(B) Any professional, trade, or occupational association for its members, former or retired members, or combination thereof, if such association:

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

(ii) Has been maintained in good faith for purposes other than obtaining insurance;

(C) An association, trust, or the trustee of a fund established, created, or maintained for the benefit of members of one or more associations;

(D) Any other group; provided that, the Commissioner finds the following:

(i) The issuance of the group policy is not contrary to the best interest of the public;

(ii) The issuance of the group policy would result in economies of acquisition or administration; and

(iii) The benefits are reasonable in relations to the premiums charged.

(5)(A) “Long-term care insurance” means any 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 diagnostic, preventive, therapeutic, rehabilitative, maintenance or personal care services provided in a setting other than an acute care unit of a hospital. “Long-term care insurance” includes group and individual annuities and life insurance policies or riders which provide directly, or which supplement, long-term care insurance. “Long-term care insurance” also includes a policy or rider which provides for payment of benefits based upon cognitive impairment or the loss of functional capacity as well as qualified long-term care insurance contracts.

(B) “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 or related asset-protection coverage, accident only coverage, specified disease or specified accident coverage, or limited benefit health coverage. With regard to life insurance, “long-term care insurance” shall not include life insurance policies which accelerate the death benefit specifically for one or more of the qualifying events of terminal illness, medical conditions requiring extraordinary medical intervention, or permanent institutional confinement and which provide the option of lump-sum payment for those benefits and in which neither the benefits nor the eligibility for the benefits is conditioned upon the receipt of long-term care.

(6) “Nonforfeiture benefit” means a benefit provided to a policyholder in the event of nonpayment of a premium due.

(7) “Policy” means any policy, contract, subscriber agreement, rider or endorsement delivered or issued for delivery in the District of Columbia by an insurer; fraternal benefits society; nonprofit health, hospital, or medical service corporation; prepaid health plan, health maintenance organization, or any similar organization.

(8)(A) “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, approved August 21, 1996 (110 Stat. 259; 26 U.S.C. § 7702B(b)), and the following:

(i) The only insurance protection provided under the contract is coverage of qualified long-term care services; provided, that a contract shall not fail to satisfy the requirements of this sub-subparagraph by reason of payments being made on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate;

(ii) The contract does not pay or reimburse expenses incurred for services or items to the extent that the expenses incurred for services or items are reimbursable under Title XVIII of the Social Security Act, approved July 30, 1965 (79 Stat. 291; 42 U.S.C. § 1395 et seq.), or would be so reimbursable but for the application of a deductible or coinsurance amount; provided, that the requirements of this sub-subparagraph shall not apply to expenses that are reimbursable under Title XVIII of the Social Security Act, approved July 30, 1965 (79 Stat. 291; 42 U.S.C. § 1395 et seq.), only as a secondary payor; provided further, that a contract shall not fail to satisfy the requirements of this sub-subparagraph by reason of payments being made on a per diem or other periodic basis without regard to expenses incurred during the period to which the payments relate;

(iii) The contract is guaranteed renewable, within the meaning of section 7702B(b)(1)(C) of the Internal Revenue Code of 1986, approved August 21, 1996 (110 Stat. 259; 26 U.S.C. § 7702B(b)(1)(C));

(iv) The contract does not provide for a cash surrender value or other money that can be paid, assigned, pledged as collateral for a loan, or borrowed except as provided by sub-subparagraph (v) of this subparagraph;

(v) All refunds of premiums, and all policyholder dividends or similar amounts, under the contract are to be applied as a reduction in future premiums or to increase future benefits; provided, that a refund in the event of death of the insured or a complete surrender or cancellation of the contract cannot exceed the aggregate premiums paid under the contract; and

(vi) The contract meets the consumer protection provisions set forth in section 7702B(g) of the Internal Revenue Code of 1986, approved August 21, 1996 (110 Stat. 259; 26 U.S.C. § 7702B(g)).

(B) “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 requirements of section 7702B(b) and (e) of the Internal Revenue Code of 1986, approved August 21, 1996 (110 Stat. 259; 26 U.S.C. § 7702B(c) and (e)).

(May 23, 2000, D.C. Law 13-121, § 2, 47 DCR 2038; Oct. 1, 2002, D.C. Law 14-190, § 502(a), 49 DCR 6968; June 11, 2004, D.C. Law 15-166, § 4(v), 51 DCR 2817.)

Section References

This section is referenced in § 31-3604, § 31-3605, § 31-3606, § 31-3610, and § 47-1803.03.

Effect of Amendments

D.C. Law 14-190, in par. (5)(A), substituted “loss of functional capacity as well as qualified long-term care insurance contracts” for “loss of functional capacity”; and added par. (8).

D.C. Law 15-166, in par. (3), substituted “Commissioner of the Department of Insurance, Securities, and Banking” for “Commissioner of the District of Columbia Department of Insurance and Securities Regulation”.

Emergency Legislation

For temporary (90-day) amendment of section, see § 2(a) of the Long-Term Care Insurance Emergency Amendment Act of 2000 (D.C. Act 13-312, April 7, 2000, 47 DCR 2738).

For temporary (90-day) amendment of section, see § 2(a) of the Long-Term Care Insurance Congressional Review Emergency Amendment Act of 2000 (D.C. Act 13-370, July 10, 2000, 47 DCR 5838).

For temporary (90 day) amendment of section, see § 502(a) of Fiscal Year 2003 Budget Support Emergency Act of 2002 (D.C. Act 14-453, July 23, 2002, 49 DCR 8026).

For temporary (90 day) amendment of section, see § 4(v) of Consolidation of Financial Services Emergency Amendment Act of 2004 (D.C. Act 15-381, February 27, 2004, 51 DCR 2653).

Temporary Legislation

For temporary (225 day) amendment of section, see § 2(a) of Long-Term Care Insurance Temporary Amendment Act of 2000 (D.C. Law 13-147, July 18, 2000, law notification 47 DCR 6097).

Short Title

Short title of title V of Law 14-190: Section 501 of D.C. Law 14-190 provided that title V of the act may be cited as the Long-Term Insurance Conformity Amendment Act of 2002.