More About the Long Term Care Plan
PLEASE NOTE: UNUM CANCELLED THE GROUP LONG TERM CARE PLAN ON MARCH 31, 2018
The following section describes the process for claims, benefits, and other important information.
You must provide the insurance company with written notice of a claim in the form of a claim form (available from your Benefits Department). Ideally, you should provide the insurance company written notice of the claim within 30 days of the date you become disabled. If you cannot do so, you must provide written notice as soon as reasonably possible.
To complete your claim filing, UNUM, the claim administrator, must receive claim information it requests from you (or your authorized representative), your attending physician, and your employer. If you or your authorized representative has any questions about what to do, you should contact UNUM directly.
After you have filed a claim, the insurance company may also require you to be examined by a physician or other medical practitioner of the insurance company's choice. The insurance company will pay for the examination. The insurance company can require an examination as often as it is reasonable to do so. The insurance company may require you or your authorized representative to give authorization to obtain additional medical and non-medical information as part of the proof of claim.
No later than 90 days after your elimination period ends, you must send the insurance company proof of your claim. If you cannot send it within 90 days, you must send it as soon as is reasonably possible, and in no event more than one year after the 90th day following the end of your elimination period.
UNUM will notify you of the decision no later than 45 days after the claim is filed. This time period may be extended twice by 30 days if UNUM determines that such an extension is necessary and notifies you of the circumstances requiring the extension and the date that UNUM expects to render a decision. If such an extension is necessary because you did not submit the information necessary to decide the claim, the notice will describe the required information and you have at least 45 days to provide the requested information. If you provide the requested information within the time specified, any 30-day extension period will begin after you have provided that information. If you do not provide the requested information within the time specified, UNUM may decide your claim without that information.
If Your Claim Is Denied
If your claim for benefits is wholly or partially denied, the denial notice will:
- State the specific reason(s) for the decision;
- Reference specific plan provisions on which the decision is based;
- Describe additional material or information necessary to complete the claim and why such information is necessary; and
- Disclose any internal rule, guidelines, protocol, or similar criterion relied on in making the denial (or state that such information will be provided free of charge upon request).
Notice of the decision may be provided in written or electronic form. Electronic notices will be provided in a form that complies with any applicable legal requirements.
Appeal Procedures
You have 180 days from the receipt of notice of an adverse benefit determination to file an appeal. Requests for appeals should be sent to the address specified in the claim denial. A decision on review will be made no later than 45 days following receipt of the written request for review. If UNUM determines that special circumstances require an extension of time for a decision on review, the review period may be extended by an additional 45 days (90 days total). UNUM will notify you in writing if an additional 45-extension is needed.
If an extension is necessary because you did not submit the information necessary to decide the appeal, the notice of extension will specifically describe the required information, and you will have at least 45 days to provide the requested information. If you provide the requested information within the time specified, the 45-day extension of the appeal period will begin after you have provided that information. If you do not provide the requested information with the time specified, UNUM may decide your appeal without that information.
You will have the opportunity to submit written comments, documents, or other information to support your appeal. You will have access to all relevant documents as defined by applicable U.S. Department of Labor regulations. The review of the claim denial will take into account all new information, whether or not presented or available at the initial decision. UNUM will not give deference to the initial claim denial.
The review will be conducted by a representative of UNUM who is neither the person who denied the initial claim or a subordinate of that individual. If a claim is denied on the grounds of a medical judgment, UNUM will consult with a health professional with appropriate training and experience. The health care professional who is consulted on appeal will not be the individual who was consulted during the initial claim denial or a subordinate of that individual. If the advice of a medical or vocational expert was obtained by the plan in connection with the denial of your claim, UNUM will provide you with the names of each such expert, regardless of whether the advice was relied upon.
If your claim is denied on appeal, UNUM will provide a notice containing the following information:
- The specific reason(s) for the denial;
- A reference to the specific plan provisions on which the decision is based;
- A statement disclosing any internal rule, guidelines, protocol, or similar criterion relied on in making the denial (or a statement that such information will be provided free of charge upon request);
- A statement describing your right to bring a lawsuit under Section 502(a) of ERISA if you disagree with the decision;
- The statement that you are entitled to receive upon request, and without charge, reasonable access to or copies of all documents, records, or other information relevant to the determination; and
- The statement that "You or your plan may have voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency."
Notice of the appeal decision may be provided in written or electronic form. Electronic notices will be provided in a form that complies with any applicable legal requirements.
Unless there are special circumstances, the administrative appeal process must be completed before you begin any legal action regarding your claim.
Other Rights
UNUM, for itself and as claims fiduciary for the plan, is entitled to legal and equitable relief to enforce its right to recover any benefit overpayments caused by your receipt of deductible sources of income from a third party. This right of recovery is enforceable even if the amount you receive from the third party is less than the actual loss suffered by you but will not exceed the benefits paid you under the policy. UNUM and the plan have an equitable lien over such sources of income until any benefit overpayments have been recovered in full.
Discretionary Acts
The plan, acting through the plan administrator, delegates to UNUM and its affiliate UNUMProvident Corporation discretionary authority to make benefit determinations under the plan. UNUM and UNUMProvident Corporation may act directly or through their employees and agents or further delegate their authority through contracts, letters, or other documentation or procedures to other affiliates, persons, or entities. Benefit determinations include determining eligibility for benefits and the amount of any benefits, resolving factual disputes, and interpreting and enforcing the provisions of the plan. All benefit determinations must be reasonable and based on the terms of the plan and the facts and circumstances of each claim.
Once you are deemed to have exhausted your appeal rights under the plan, you have the right to seek court review under Section 502(a) of ERISA of any benefit determinations with which you disagree. The court will determine the standard of review it will apply in evaluating those decisions.
You are eligible for a monthly long term care benefit after:
- You become disabled, and
- A physician has certified that you are unable to perform (without substantial assistance from another individual) two of six activities of daily living (ADL) for a period of at least 90 days, or that you require substantial supervision by another individual to protect you and others from threats to health and safety due to severe cognitive impairment. You (or your legal representative) will be required to submit a physician certification every 12 months.
You are required to satisfy a one-time 90-day elimination period before the plan pays any benefits. This one-time elimination period can apply to all of the benefits included in the coverage you have elected. For example, if you are in a residential care facility for 90 consecutive days, you are then eligible for facility benefits. If you return home and later require home care, such as visiting nurse services, home care benefits will be available immediately.
To satisfy the elimination period, you must be disabled (as defined by the plan) and receiving care in a facility or receiving home care services for 90 consecutive days. If you are receiving home care during the elimination period, and you do not receive home care for at least one day, the elimination period will begin again.
The amount of your monthly facility benefit will be based on the facility coverage options you choose. You will receive a lump sum payment from the insurance company to cover the period between the day you became eligible for monthly benefit payments and the day you were approved for these payments. You will receive a payment each month for the number of days you were eligible to receive benefits during the prior month. Benefit payments will stop as described under "When Benefit Payments End" below.
You will continue to receive monthly benefit payments until the earliest of the following dates:
- The date you are no longer disabled as defined by the plan
- The expiration of your physician certification
- The date you are no longer eligible for a monthly benefit under the plan of coverage you choose
- The date your total benefit payments equal the lifetime maximum amount (if applicable)
- The date you die
If you have general questions about your insurance, you can call UNUM's Customer Information Call Center at 1-800-421-0344 or write to:
UNUM Life Insurance Company of America
2211 Congress Street
Portland, ME 04122
If a complaint arises about your insurance, you can call UNUM's Compliance Center Complaint Line at 1-800-321-3889 (option 2) or write to:
UNUM Life Insurance Company of America
Customer Relations Department
2211 Congress Street
Portland, ME 04122
Note: When calling or writing to the insurance company, please provide the following identification number (policy number): 538619.
You can also contact the California Department of Insurance if discussions with the insurance company, its representatives, or both, have failed to produce a satisfactory solution to the problem.
Portability of Coverage
If you leave the Company, or if the Company or the insurance company discontinues the group long term care plan, you have the option of continuing your long term care coverage on your own without having to satisfy evidence of insurability. To continue coverage, you must make an election within 31 days of the date your group long term care coverage ends, and pay the required premiums directly to the insurance company.
Reinstatement
If your coverage terminates because a premium is not paid by the end of the grace period, you may request to reinstate your coverage at any time until six months from the coverage termination date. In order to reinstate your coverage, the following requirements must be met:
- You must complete a reinstatement application,
- The insurance company must approve the application, and
- You must pay all unpaid premium.
If the insurance company approves your reinstatement application, reinstatement will take effect on the date your coverage was terminated for non-payment of premium.
Extension of Benefits
Termination of coverage will not affect any benefits payable if disability began while your long term care insurance was in force, and continues without interruption after termination. This extension of benefits will be limited to the duration of the payment of the lifetime maximum amount.
Activities of Daily Living
(ADL) is used to describe six types of daily activities as follows:
- Bathing—giving oneself a sponge bath, or washing in either a tub or shower, including the act of getting into or out of the tub or shower.
- Dressing—putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs.
- Toileting—getting to and from the toilet, getting on and off the toilet and performing associated personal hygiene.
- Transferring—the ability to move into and out of a bed, a chair or wheelchair, or the ability to walk or move around inside or outside the home, regardless of the use of a cane, crutches or braces.
- Continence—the ability to maintain control of bowel and bladder function; or, when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including caring for catheter or colostomy bag).
- Eating—feeding oneself by getting food in the body from a receptacle (such as a plate, cup or table) or by a feeding tube or intravenously.
For purposes of this plan, the term disability means:
- You are unable to perform—without substantial assistance from another individual-at least two activities of daily living ("substantial assistance" means standby assistance by another person without which you would not be able to safely and completely perform the ADL), or
- You require substantial supervision by another individual to protect you from threats to health and safety due to severe cognitive impairment.
Elimination Period
is the length of time for which you must suffer a loss of two "activities of daily living" (see above) before receiving benefits. For example, you are required to be in a nursing home facility (resulting from a loss of at least two ADLs) for 90 consecutive days to satisfy the elimination period for that level of care. This one-time elimination period can apply to all of the benefits included in the coverage you have elected, i.e., nursing home care or home care.
Family Home Care Services
are those provided by family members as well as services which include the list under "Home Care Services," below.
Home Care Services
mean services provided under a plan of care. This does not include care or services provided by family members. Home care services include:
- Adult day care—medical or non-medical care on a less than 24-hour basis, provided in an Adult Day Care Facility or a licensed facility outside your residence for persons in need of personal services, supervision, protection or assistance in performing activities of daily living and taking medications.
- Adult day care facility—a facility that provides adult day care and operates under state licensing laws and other laws that apply.
- Home health care—skilled nursing or other professional services in your residence.
- Homemaker services—assistance with activities necessary or consistent with your ability to remain in your residence; services may be provided by a skilled or unskilled worker/provider (excluding family members) under a plan of care.
- Hospice services—outpatient services that are designed to provide palliative care, alleviate the physical, emotional, social and spiritual discomforts of a person who is experiencing the last phases of life due to the existence of a terminal disease and to provide supportive care to the primary caregiver and the family. Care may be provided by a skilled or unskilled worker/provider (excluding family members) under a plan of care.
- Personal care—assistance with activities of daily living (ADL), including the instrumental ADLs, provided by a skilled or unskilled worker/provider (excluding family members) under a plan of care. Instrumental ADLs include using the telephone, managing medications, moving about outside, shopping for essentials, preparing meals, laundry, and light housekeeping.
- Respite care—short term assistance to allow the informal caregiver a break from caregiving responsibilities.
A licensed health care practictioner means any physician, and any registered professional nurse, licensed social worker, or other individual who meets such requirements as may be prescribed by the Secretary of the Treasury.
Nursing Facility
A nursing facility is:
- An institution, or a distinctly separate part of a hospital, that is licensed or certified as a nursing home (if licensing or certification is required) or operates under the law as a nursing home to provide skilled, intermediate, or custodial care and operates under state licensing laws and any other laws that apply;
- Any other institution that meets all of the following tests:
- Is operated as a health care facility under applicable state licensing laws and any other laws,
- Primarily provides nursing care under the orders of a physician,
- Provides patient care under the supervision of a registered nurse or a licensed vocational nurse,
- Regularly provides room and board and continuous 24 hour a day nursing care of sick and injured persons,
- Maintains a daily medical record for each patient who must be under the care of a physician,
- Is authorized to administer medication to patients on the order of a physician, and
- Is not, other than incidentally, a hotel, a domiciliary care home or a residence, or a home for the mentally retarded, the mentally ill, the blind, the deaf, alcoholics or drug abusers, or
- A similar institution approved by the insurance company.
Plan of Care
A Plan of care means a program of treatment or care. It must be developed by your physician or multi-disciplinary team and approved, in writing, by your physician before the start of any home care services. The written plan of care is subject to updating, in writing, no more often than every 60 days. You will be responsible for submitting the physician-approved plan of care, and the periodic updates to such plan.
Residential Care Facility
A residential care facility is:
- An institution that is licensed as a residential care facility by the appropriate licensing agency and operates under state licensing laws and any other laws that apply, or
- A similar institution approved by the insurance company.
Residential Care Facility for the Elderly
means a housing arrangement chosen voluntarily by persons 60 years of age or over, or their authorized representative, where varying levels and intensities of care and supervision, protective supervision, personal care, or health-related services are provided, based on the varying needs, as determined in order to be admitted and to remain in the facility. Persons under 60 years of age with compatible needs may be allowed to be admitted or retained in a residential care facility for the elderly.
Severe Cognitive Impairment
means a severe deterioration or loss in intellectual capacity, as reliably measured by clinical evidence and standardized tests in your short or long term memory; your orientation as to person, place and time; and your deductive or abstract reasoning