HomeMy WebLinkAboutContract 1868
August 22, 2005
City of Columbia Heights
Ms. Linda Magee
590 40th Avenue NE
Columbia Heights, MN 55425
tr\~
RE: THE MUNICIPAL POOL Long Term Care Plan
Dear Linda:
We are pleased to announce an enhancement to THE MUNICIPAL POOL Long Term
Care Plan now being offered to your employees. Effective January 1, 2006, a third
option will be offered which will permit your employees to enroll in a $150 Daily Benefit
for Nursing Home care with corresponding increases in all related benefits. See the
enclosed Master Application for details.
All you need to do is sign both copies of the enclosed Master Application, return one
of the copies in the enclosed envelope and retain the other for your file along with the
Master Policy and Addendums 1 through 8 "Table of Premium Rates". Note that rates!
have not changed and are now guaranteed to January 1,2009.
I
You'll be receiving new enrollment packets in early September which will includ \
information on all current options plus the new enhanced option. In the meantime, feel
free to give us a call if you have any questions.
Sincerely,
~i / >' '
?Y/ d 'd/ J
,/' /' . /1 ".... ..1
,~"/c' t,i?tfS'i vi'll .
Kathy 9feen
Enclosures
400 ROBERT STREET NORTH, SUITE 1880, SAINT PAUL, MINNESOTA 55101
651-665-3789 · 800-392-7295 · FAX: 651-665-3791
CNA
Policy Number: 10212TQ
Account Number: 0010039TQ
MASTER APPLICATION
FOR
LONG TERM CARE INSURANCE
The Applicant applies to the Continental Casualty Company ('We", "Our" or "Us") for a Group Long Term Care
Insurance Policy ("Master Policy") based on the statements and representations below.
1. NAME AND ADDRESS OF APPLICANT
City of Columbia Heights
590 40th Ave NE
Columbia Heights, MN 55421
2. MASTER POLICY EFFECTIVE DATE
November 1, 2002
3. INITIAL ENROLLMENT PERIOD
Begins:
Ends:
September 1, 2002
September 30, 2002
4. ELIGIBILITY CLASSES
No person may be an Insured under more than one Eligibility Class.
A. Class A - Employees
An Eligible Employee of City of Columbia Heights who is Actively at Work.
Employee means all employees who work 40 hours or more per week. Employees become Eligible
on their date of hire. Temporary and seasonal employees are not eligible.
Actively at Work means the Employee is physically at his or her usual place of business performing
the regular duties of his or her work.
B. Class B - Spouses of Eligible Employees
The Spouse of a member of Class A.
The Spouse must be the current, lawful spouse of the Eligible Employee.
C. Class C - Parents and Grandparents
The Parent, the Parent-in-law, Grandparent, Grandparent-in-Iaw, of a member of Class A.
Parent means a natural parent; an adoptive parent; or any other person who is legally married to a
natural parent or adoptive parent. The spouse of the Parent or Parent-in-law must be the current,
lawful spouse of the Parent or Parent-in law.
Grandparent means a natural grandparent; an adoptive grandparent; or any person who is legally
married to a natural or adoptive grandparent. The spouse of the Grandparent or Grandparent-in-Iaw
must be the current, lawful spouse of the Grandparent or Grandparent-in-Iaw.
SPV1AA
- 1 -
D. Class D - Retirees
A Retiree of City of Columbia Heights.
E. Class E - Spouses of Retirees
The Spouse must be the current, lawful spouse of the Retiree.
5. ENROLLMENT. UNDERWRITING CRITERIA & COVERAGE EFFECTIVE DATE
A. Class A - Employees
(1) An Eligible Employee may enroll/apply for coverage anytime during the year.
(2) The following underwriting criteria shall apply:
a. Coverage shall be granted without demonstrating evidence of insurability if the Eligible
Employee enrolls:
i. During the Initial Enrollment Period, if he or she is Actively at Work;
ii. Within 30 days of his or her return to work, if he or she was not Actively at Work during
the Initial Enrollment Period for his or her location; or
iii. Within 30 days after becoming Eligible.
b. Coverage shall be granted subject to Our approval of evidence of insurability, if the Eligible
Employee applies for coverage at any other time.
(3) The Eligible Employee must be Actively at Work on the Coverage Effective Date for coverage to
take effect. If the Eligible Employee is on a scheduled vacation, he or she will be deemed to be
Actively at Work on the Coverage Effective Date. If the Eligible Employee is on Sabbatical,
Disability, Medical Leave, or other Leave of Absence on the Coverage Effective Date, coverage will
take effect on the first regular scheduled day he or she returns to work.
a. If the Eligible Employee enrolls during the Initial Enrollment Period coverage shall be the
Master Policy Effective Date.
b. If the Eligible Employee enrolls or applies for coverage at any other time:
i. If We receive and process the enrollment form or approve and process the evidence of
insurability on or before the 15th day of the month, the insurance will be effective on the
first day of the month immediately following.
ii. If We receive and process the enrollment form or approve and process the evidence of
insurability after 15th day of the month, the insurance will be effective on the first day of the
second month following.
B. Class B - Spouses of Eligible Employees
(1) The Spouse of an Eligible Employee may elect to apply for coverage at anytime the Eligible
Employee is Actively at Work.
(2) Coverage shall be granted subject to our approval of evidence of insurability.
(3) Coverage shall take effect as follows:
a. If We approve and process the evidence of insurability on or before the 15th day of the month,
the insurance will be effective on the first day of the month immediately following.
b. If We approve and process the evidence of insurability after 15th day of the month, the
insurance will be effective on the first day of the second month following.
SPV1AA -2-
C. Class C - Parents and Grandparents
(1) Parents, Parents-in-law, Grandparents, and Grandparents-in-Iaw, may elect to apply for coverage
at anytime the Eligible Employee is Actively at Work.
(2) Coverage shall be granted subject to Our approval of evidence of insurability.
(3) Coverage shall take effect on the first day of the month that falls on or next following the date We
approve and process the evidence of insurability.
D. Class D and E - Retirees and their Spouses
(1) Retirees and their Spouses my elect to apply for coverage at anytime.
(2) Coverage shall be granted subject to Our approval of evidence of insurability.
(3) Coverage shall take effect on the first day of the month that falls on or next following the date We
approve and process the evidence of insurability.
6. SCHEDULE OF BENEFITS
A. Long Term Care Benefit
(1) Long Term Care Benefit for Nursing Home Care
100% of the Eligible Expense per day of Nursing Home Care or Alternate Care Facility, not to
exceed the Daily Benefit, as determined by the option elected by the eligible person.
(2) Long Term Care Benefit for Assisted Living Care
100% of the Eligible Expense per day of Assisted Living Care, not to exceed 80% of the Daily
Benefit for Nursing Home Care, as elected by the eligible person.
(3) Long Term Care Benefit for Community Based Care
100% of the Eligible Expense per day of Community Based Care, not to exceed the corresponding
monthly limit as elected by the eligible person.
(4) Long Term Care Benefit for Hospice Care Facility
100% of the Eligible Expense per day, not to exceed the Daily Benefit for Nursing Home Care, as
elected by the eligible person.
Option
1
2
3
Daily Benefit
for Nursing
Home Care
$ 80.00
$120.00
$150.00
Corresponding
Daily Benefit for
Assisted Living
Care
$ 64.00
$ 96.00
$120.00
Corresponding
Monthly Benefit
for Community
Based Care
$1,800.00
$2,700.00
$3,375.00
Corresponding
Daily Benefit for
Hospice Care
Facility
$ 80.00
$120.00
$150.00
B. Lifetime Maximum Benefit
1250 times (1250 days) or 1825 times (1825 days) the Daily Benefit for Nursing Home Care, as elected
by the eligible person.
Option
1
2
3
Daily Benefit
for Nursing
Home Care
$ 80.00
$120.00
$150.00
Corresponding
Lifetime Maximum
Benefit 1250 Days
$100,000.00
$150,000.00
$187,500.00
Corresponding
Lifetime Maximum
Benefit 1825 Days
$146,000.00
$219,000.00
$273,750.00
SPV1AA
- 3 -
C. Waiting Period
15 Days of service for Community Based Care
60 Days of service for Nursing Home Care
D. Waiver of Premium Qualification Period
60 Days of Long Term Care.
E. Caregiver Training Benefit
100% of the Eligible Expense per training, not to exceed the corresponding benefit as elected by the
eligible person.
Option
1
2
3
Daily Benefit for
Nursing Home Care
$ 80.00
$120.00
$150.00
Corresponding Monthly
Benefit for Community
Based Care
$1,800.00
$2,700.00
$3,375.00
Corresponding Benefit
for Caregiver Training
$180.00
$270.00
$337.50
F. Temporary Bed Holding Benefit
100% of the Eligible Expense per day, not to exceed the Daily Benefit for Nursing Home Care, as elected
by the eligible person, with a maximum Annual Benefit of 21 calendar days.
Option
1
2
3
Daily Benefit for
Nursing Home Care
$ 80.00
$120.00
$150.00
Corresponding Daily
Benefit for Temporary Bed
Holding
$ 80.00
$120.00
$150.00
Corresponding Annual
Temporary Bed Holding
Benefit
$1,680.00
$2,520.00
$3,150.00
G. Emergency Alert Benefit
100% of the Eligible Expense per month for rental or lease of Emergency Alert equipment, not to exceed
the corresponding benefit as elected by the eligible person.
Option
1
2
3
Daily Benefit for
Nursing Home Care
$ 80.00
$120.00
$150.00
Corresponding Monthly
Benefit for Community
Based Care
$1,800.00
$2,700.00
$3,375.00
Corresponding Monthly
Emergency Alert
Benefit
$ 60.00
$ 90.00
$112.50
H. Care Assist Benefit
100% of the Eligible Expense per day, not to exceed the Daily Benefit for Nursing Home Care, as elected
by the eligible person, with a maximum Annual Benefit of 14 days per calendar year.
Option
1
2
3
Daily Benefit for
Nursing Home Care
$ 80.00
$120.00
$150.00
Corresponding Daily
Care Assist Benefit
$ 80.00
$120.00
$150.00
Corresponding Calendar
Year Maximum
$1,120.00
$1,680.00
$2,100.00
SPV1AA
-4-
I. Refund of Premium at Death
If the Insured dies on or before reaching age 65, We will return 100% of the premium paid, less any
Benefits paid or payable. After the Insured reaches age 65, the amount of premium returned, less any
Benefits paid or payable, will be as follows:
Premium Returned
Age at Death (less any Benefits paid)
65 and younger 100%
66 90%
~ 00%
68 70%
69 60%
70 50%
71 40%
72 30%
73 20%
M 10%
75 and older 0
Coverage must be in effect at the time of death in order for any premium to be refunded.
J. Benefit Account (Optional Benefit)
If the Insured stops paying premiums after three (3) years of continuous coverage, Long Term Care
coverage will be continued. Daily Benefit levels remain the same; however, the Lifetime Maximum
Benefit will be reduced to the greater of the total premiums paid or 30 times the Daily Benefit for Nursing
Home Care.
K. Inflation Protection (Insured selects one)
(1) Lifetime Automatic Benefit Increase Option
If elected by the eligible person, the Benefit Levels and Lifetime Maximum will be increased by five
percent (5%) of the prior year's amount each year on the anniversary of the Insured's Certificate
Effective Date.
(2) Guaranteed Benefit Increase Option
Insureds will be offered opportunities to increase the Maximum Daily Benefit Levels and Lifetime
Maximum on the third anniversary of the Effective Date of the Master Policy, and each third
anniversary thereafter. The offered increase will be not less than a compounded annual five percent
(5%) rate. Insureds are not obligated to purchase additional coverage in order for their policies to
remain in effect.
Employees who are actively-at-work and their spouses may refuse any number of benefit increase
offers without forfeiting the right to accept future offers on a guarantee issue basis.
7 PREMIUM PAYMENT MODES
A. For Actively at Work Employees and their Spouses, Premiums are payable by deductions from a payroll
account.
B. For all other Insureds, including former Actively at Work Employees and Spouses on continuation
policies, Premiums are payable on a quarterly, semi-annual, or annual direct-billed basis, or via monthly
Electronic Funds Transfer, unless We agree to another mode of payment.
SPV1AA
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8. PREMIUM DUE DATES
A. I nitial Premium Due Date:
(1) For Actively at Work Employees and their Spouses under payroll deduction, the initial Premium
Due Date is 50 days after the Master Policy Effective Date.
If, at any time, the Employer chooses not to administer payroll deductions and notifies Us in writing,
actively at work Employees and their Spouses will pay premiums on a quarterly, semi-annual, or
annual direct-billed basis, or via monthly Electronic Funds Transfer, unless We agree to another
mode of payment.
(2) For all other Insureds, the initial Premium Due Date is the Insured's Certificate Effective Date.
B. Subsequent Premium Due Dates:
(1) For Actively at Work Employees and their Spouses under payroll deduction, subsequent Premium
Due Dates will be monthly, as billed.
(2) For all other Insureds, including former Actively at Work Employees and Spouses on continuation
policies, subsequent Premium Dues Dates will be monthly, quarterly, semi-annually, or annual, as
billed, depending upon the Premium Payment Mode selected Insured.
9. RENEWAL UNDERWRITING STANDARDS
None.
10. CHANGES AND CANCELLATIONS BY THE INSURED
A. Requests to increase the Benefits Level may be made at any time in writing to Us. Increases to the
Benefits Level shall be granted subject to Our approval of evidence of insurability.
B. Requests to reduce the Benefits Level may be made at any time in writing to Us.
C. Requests to cancel coverage may be made at any time in writing to Us.
11. PREMIUM RATES
See Addendum 1 through 8 attached to this Master Application.
12. CONTRACT TYPE
This contract is intended to be a Qualified Long Term Care contract as defined under section 7702B(b) of the
Internal Revenue Code of 1986.
13 MISCELLANEOUS
A. Initial Renewal Period:
B. Subsequent Renewal Periods:
C. Period of Notice for Non-Renewal:
D. Initial Premium Rate Guarantee Period:
E. Period of Notice of Premium Rate Changes:
36 months (3 Years)
12 months ( 1 Year)
60 days
36 months (3 Years)
60 days
SPV1AA
- 6 -
14 EFFECTIVE DATE
This Master Application is attached to and made a part of Group Long Term Care Policy Number 10212TQ.
The Master Policy is Effective November 1, 2002, if We accept the Master Application. This Master
Application cancels and replaces any prior Master Applications attached to the Master Policy. The Effective
Date of the Master Application is November 1, 2002.
City of Columbia Heights, in agreement with The Municipal Pool offered through Ochs,
Inc.
BY:
w!lJ;;/UJ
(signature) .
~,~~/ K r;tS!!-
(name printed)
Cifv ~hr:24e/'r'
Title (please print) t
9 him
Date . ( I
SPV1 M
-7-
ADDENDUM NO.1
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights
POLICY NUMBER: 10212TQ
OPT!ONAL BENEF!TS: Guaranteed Benefit Increase
AGE ON EFFECTIVE
DATE OF COVERAGE
Aae
<25
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
LIFETIME
MAXIMUM:
MONTHLY PREMIUM
FOR DAILY BENEFIT SELECTED
$80
5.38
6.12
6.23
6.39
6.60
6.80
7.01
7.28
7.59
8.01
8.50
9.05
9.66
10.29
10.95
11.64
12.37
13.15
13.95
14.79
15.64
16.53
17.53
18.65
19.84
21.06
22.41
24.03
25.95
28.24
30.77
33.57
36.63
39.95
43.68
47.69
51.96
56.28
60.47
64.22
67.66
71.16
SPV1AA
- 8 -
$120
8.07
9.19
9.34
9.59
9.90
10.21
10.51
10.92
11.39
12.01
12.74
13.58
14.48
15.44
16.43
17.46
18.54
19.72
20.94
22.18
23.46
24.80
26.29
27.98
29.75
31.60
33.62
36.04
38.93
42.37
46.16
50.34
54.95
59.93
65.51
71.55
77.94
84.41
90.71
96.33
101.50
106.75
1250 x
$150
10.10
11.48
11.67
12.00
12.38
12.77
13.15
13.65
14.25
15.02
15.92
16.97
18.10
19.30
20.55
21.83
23.18
24.65
26.17
27.73
29.32
31.00
32.88
34.97
37.20
39.50
42.02
45.05
48.67
52.97
57.70
62.93
68.70
74.93
81.90
89.45
97.43
105.53
113.40
120.43
126.87
133.45
ADDENDUM NO.1
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights
POLICY NUMBER: 10212TQ
OPT!ONAL BENEF!TS: Guaranteed Benefit Increase
LIFETIME
MAXIMUM:
MONTHLY PREMIUM
FOR DAILY BENEFIT SELECTED
AGE ON EFFECTIVE
DATE OF COVERAGE
Aae
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
$80
75.46
80.89
87.16
93.88
101.55
110.74
122.07
135.63
151.04
167.65
185.88
205.18
225.37
246.65
269.21
293.46
319.10
347.10
377.32
408.64
439.97
470.63
499.74
528.40
556.80
SPV1AA
-9-
$120
113.18
121.34
130.73
140.82
152.33
166.10
183.11
203.43
226.55
251.48
278.81
307.77
338.07
369.98
403.82
440.19
478.65
520.66
565.97
612.95
659.96
705.95
749.60
792.60
835.21
1250 x
$150
141.47
151.68
163.40
176.02
190.42
207.62
228.90
254.30
283.20
314.35
348.53
384.70
422.60
462.4 7
504.77
550.25
598.33
650.83
707.47
766.20
824.95
882.45
937.00
990.75
1,044.03
ADDENDUM NO.2
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights
POLICY NUMBER: 10212TQ
OPTIO"'~AL BEf'-JEFITS: Guaranteed Benefit Increase & Benefit Account
AGE ON EFFECTIVE
DATE OF COVERAGE
Aae
<25
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
LIFETIME
MAXIMUM:
MONTHLY PREMIUM
FOR DAILY BENEFIT SELECTED
$80
5.97
6.80
6.91
7.10
7.32
7.55
7.84
8.15
8.51
8.97
9.53
10.14
10.82
11.53
12.26
13.04
13.96
14.85
15.77
16.71
17.67
18.85
19.98
21.27
22.62
24.01
25.78
27.64
29.85
32.48
35.38
38.93
42.49
46.34
50.67
55.33
60.79
65.85
70.75
75.12
79.16
83.97
SPV1AA
- 10-
$120
8.95
10.21
10.37
10.64
10.98
11.33
11.77
12.23
12.78
13.46
14.29
15.21
16.22
17.30
18.39
19.55
20.95
22.28
23.65
25.07
26.50
28.27
29.98
31.90
33.93
36.02
38.66
41.45
44.78
48.72
53.07
58.41
63.73
69.52
76.00
82.99
91.18
98.77
106.13
112.69
118.75
125.96
1250 x
$150
11.18
12.77
12.98
13.30
13.73
14.18
14.72
15.30
15.98
16.82
17.85
19.03
20.28
21.63
23.00
24.45
26.20
27.85
29.57
31.35
33.13
35.35
37.48
39.88
42.43
45.03
48.32
51.82
55.97
60.90
66.35
73.00
79.68
86.90
95.00
103.75
113.98
123.47
132.68
140.88
148.45
157.45
ADDENDUM NO.2
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights
POLICY NUMBER: 10212TQ
LIFETIME
MAXIMUM:
OPT!ONAL BENEF!TS: Guaranteed Benefit Increase & Benefit Account
AGE ON EFFECTIVE
DATE OF COVERAGE
Aae
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
MONTHLY PREMIUM
FOR DAILY BENEFIT SELECTED
$80
89.05
95.46
102.85
110.79
119.84
130.68
144.05
160.03
178.22
197.82
219.34
242.10
265.95
288.59
314.97
340.41
370.15
402.65
437.69
469.93
505.97
541.22
569.69
597.09
629.19
$120
133.56
143.19
154.27
166.18
179.76
196.01
216.08
240.05
267.33
296.73
329.01
363.16
398.92
432.87
472.46
510.61
555.23
603.96
656.53
704.89
758.95
811.84
854.54
895.63
943.78
SPV1AA
- 11 -
1250 x
$150
166.95
179.00
192.85
207.73
224.70
245.03
270.10
300.08
334.15
370.93
411.27
453.95
498.65
541.10
590.57
638.27
694.05
754.95
820.67
881.13
948.70
1,014.80
1,068.17
1,119.55
1,179.73
ADDENDUM NO.3
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights
POLICY NUMBER: 10212TQ
nCTln....AI CC....CC'IT~.
....,. . .""'.,,,,... .............. I' ""_
AGE ON EFFECTIVE
DATE OF COVERAGE
Aae
<25
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
SPV1AA
Lifetime Compound Automatic Benefit Increase
LIFETIME
MAXIMUM:
MONTHLY PREMIUM
FOR DAILY BENEFIT SELECTED
$80
16.14
18.39
18.67
19.17
19.76
20.31
20.85
21.58
22.42
23.51
24.81
26.25
27.79
29.34
30.83
32.29
33.76
35.34
36.98
38.70
40.44
42.28
44.32
46.65
49.02
51 .44
54.11
57.26
61.00
65.31
69.88
74.81
80.15
85.90
92.51
99.64
107.08
114.35
120.95
125.98
129.85
133.42
- 12 -
$120
24.20
27.58
28.02
28.75
29.64
30.47
31.29
32.37
33.63
35.27
37.21
39.38
41.68
44.01
46.25
48.44
50.63
53.01
55.47
58.05
60.65
63.43
66.48
69.97
73.53
77.16
81.16
85.89
91.51
97.96
104.81
112.22
120.23
128.85
138.77
149.46
160.63
171.53
181.42
188.97
194.77
200.15
1250 x
$150
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
ADDENDUM NO.3
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights
POLICY NUMBER: 10212TQ
OPTIONAL BENEFITS: Lifetime Compound Automatic Benefit Increase
AGE ON EFFECTIVE
DATE OF COVERAGE
Aae
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
LIFETIME
MAXIMUM:
MONTHLY PREMIUM
FOR DAILY BENEFIT SELECTED
$80
138.39
145.62
154.61
164.58
176.19
190.25
207.53
227.85
250.71
274.95
301.13
328.28
356.10
384.77
414.59
446.05
478.66
513.71
550.89
588.44
624.76
658.89
689.63
718.63
746.12
SPV1AA
- 13 -
$120
207.59
218.42
231.92
246.87
264.30
285.38
311.30
341.78
376.07
412.42
451.69
492.42
534.16
577.16
621.87
669.08
717.97
770.57
826.33
882.65
937.15
988.33
1034.45
1077.94
1119.18
1250 x
$150
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
ADDENDUM NO.4
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights
POLICY NUMBER: 10212TQ
nDTln"'^1 DCII.ICCITC::.
'"'I . .""...~.... ..........,..... I........
AGE ON EFFECTIVE
DATE OF COVERAGE
Aae
<25
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
SPV1AA
LIFETIME
MAXIMUM:
1250 x
Lifetime Compound Automatic Benefit Increase & Benefit Account
MONTHLY PREMIUM
FOR DAILY BENEFIT SELECTED
$80
17.92
20.41
20.74
21.28
21.92
22.54
23.35
24.17
25.11
26.34
27.79
29.40
31.11
32.86
34.54
36.17
38.15
39.93
41.80
43.73
45.69
48.21
50.53
53.17
55.89
58.64
62.22
65.86
70.16
75.10
80.35
86.79
92.97
99.65
107.32
115.58
125.29
133.79
141.51
147.40
151.92
157.45
- 14 -
$120
26.87
30.62
31.09
31.91
32.90
33.81
35.02
36.26
37.66
39.51
41.68
44.10
46.67
49.29
51.80
54.26
57.21
59.90
62.69
65.60
68.54
72.32
75.79
79.76
83.83
87.96
93.32
98.79
105.24
112.65
120.54
130.18
139.45
149.47
160.97
173.37
187.93
200.69
212.26
221 . 1 0
227.88
236.17
$150
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
ADDENDUM NO.4
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights
POLICY NUMBER: 10212TQ
LIFETIME
MAXIMUM:
1250 x
t"\DTln~I^1 DCI\IC'I:'IT~. I ;f:_+:-._ 1"-......-....._.._..1 A.....____...:_ D___";'" 1__..____ tJ 0___4=:'" A___.._'"
'-'I 11""'1,."".... u............. II '-'_ .........LIIIIG VUlllfoIUUllU r\.ULUlllaLlv Ll1;;IIt;;'IIL IIn..,.IGQ;;:IlV'.... Ut;;'llvllL """,",UUIIL
AGE ON EFFECTIVE
DATE OF COVERAGE
Aae
66
67
68
69
70
71
72
73
74
75
76
ii
78
79
80
81
82
83
84
85
86
87
88
89
90
MONTHLY PREMIUM
FOR DAILY BENEFIT SELECTED
$80
163.31
171.83
182.44
194.19
207.91
224.50
244.89
268.87
295.83
324.43
355.32
387.37
420.20
450.19
485.06
517.43
555.24
595.90
639.03
676.70
718.47
757.72
786.18
812.05
843.11
SPV1AA
- 15 -
$120
244.95
257.74
273.66
291.30
311 .86
336.75
367.33
403.29
443.76
486.65
532.99
581.05
630.30
675.28
727.59
776.13
832.85
893.86
958.53
1015.05
1077.71
1136.57
1179.26
1218.07
1264.67
$150
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
ADDENDUM NO.5
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights
POLICY NUMBER: 10212TQ
OPTIOt"AL BEt~EFITS: Guaianteed Benefit Increase
LIFETIME
MAXIMUM:
MONTHLY PREMIUM
FOR DAILY BENEFIT SELECTED
AGE ON EFFECTIVE
DATE OF COVERAGE
Aae
<25
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
$80
6.19
7.15
7.29
7.52
7.82
8.09
8.38
8.74
9.17
9.71
10.35
11.04
11.82
12.66
13.48
14.37
15.31
16.32
17.34
18.40
19.46
20.60
21.85
23.28
24.78
26.31
28.04
30.03
32.45
35.27
38.39
41.86
45.65
49.80
54.44
59.48
64.81
70.20
75.44
80.05
84.27
88.58
SPV1AA
- 16 -
$120
9.29
10.74
10.94
11.28
11.72
12.13
12.57
13.10
13.75
14.57
15.51
16.57
17.73
18.99
20.23
21.57
22.97
24.47
26.02
27.59
29.19
30.89
32.78
34.93
37.16
39.47
42.04
45.06
48.69
52.91
57.60
62.79
68.48
74.69
81.66
89.22
97.22
105.30
113.15
120.09
126.40
132.87
1825 x
$150
11.60
13.43
13.67
14.10
14.65
15.17
15.72
16.37
17.20
18.23
19.40
20.73
22.18
23.72
25.30
26.97
28.73
30.60
32.53
34.50
36.50
38.63
40.98
43.68
46.45
49.35
52.55
56.32
60.88
66.15
72.00
78.50
85.60
93.38
102.08
111.53
121.53
131.63
141.45
150.13
158.00
166.10
ADDENDUM NO.5
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights
POLICY NUMBER: 10212TQ
OPTIO~JAL BEf\JEFITS: Guaranteed Benefit Increase
AGE ON EFFECTIVE
DATE OF COVERAGE
Aae
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
LIFETIME
MAXIMUM:
MONTHLY PREMIUM
FOR DAILY BENEFIT SELECTED
$80
93.88
100.70
108.63
117.18
126.93
138.57
152.87
169.92
189.28
210.15
233.03
257.25
282.61
309.32
337.62
368.04
400.23
435.35
473.26
512.55
551.82
590.22
626.64
662.47
697.94
SPV1AA
- 17 -
$120
140.82
151.05
162.94
175.78
190.39
207.87
229.32
254.87
283.91
315.22
349.54
385.87
423.93
463.98
506.42
552.06
600.34
653.02
709.88
768.82
827.72
885.33
939.96
993.71
1046.91
1825 x
$150
176.02
188.83
203.68
219.73
238.00
259.85
286.65
318.60
354.90
394.03
436.92
482.35
529.93
579.98
633.02
690.08
750.43
816.27
887.35
961.03
1,034.65
1,106.68
1,174.95
1,242.15
1,308.65
ADDENDUM NO.6
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights
POLICY NUMBER: 10212TQ
OPTIOl'-JAL BEf'JEFITS: Guaranteed Benefit Increase & Benefit Account
LIFETIME
MAXIMUM:
MONTHLY PREMIUM
FOR DAILY BENEFIT SELECTED
AGE ON EFFECTIVE
DATE OF COVERAGE
Aae
<25
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
$80
6.87
7.94
8.10
8.35
8.67
8.97
9.40
9.78
10.27
10.88
11.58
12.37
13.23
14.18
15.10
16.10
17.30
18.44
19.60
20.79
22.00
23.48
24.92
26.54
28.24
30.00
32.23
34.55
37.32
40.56
44.16
48.56
52.95
57.77
63.16
69.00
75.83
82.13
88.26
93.66
98.60
104.52
SPV1AA
- 18 -
$120
10.31
11.91
12.15
12.52
13.00
13.46
14.09
14.68
15.41
16.31
17.37
18.54
19.85
21.27
22.65
24.16
25.95
27.66
29.41
31.19
32.99
35.22
37.37
39.81
42.37
45.00
48.35
51.82
55.99
60.85
66.24
72.84
79.43
86.65
94.74
103.50
113.75
123.21
132.39
140.50
147.90
156.78
1825 x
$150
12.90
14.90
15.20
15.65
16.25
16.82
17.62
18.35
19.28
20.38
21.73
23.18
24.82
26.60
28.32
30.20
32.45
34.58
36.77
39.00
41.25
44.03
46.70
49.78
52.97
56.25
60.45
64.77
70.00
76.08
82.80
91.05
99.30
108.32
118.42
129.38
142.20
154.03
165.47
175.63
184.88
195.98
ADDENDUM NO.6
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights
POLICY NUMBER: 10212TQ
OPTIONAL BENEFITS: Guaranteed Benefit Increase & Benefit Account
LIFETIME
MAXIMUM:
MONTHLY PREMIUM
FOR DAILY BENEFIT SELECTED
AGE ON EFFECTIVE
DATE OF COVERAGE
Aae
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
$80
110.78
118.82
128.17
138.27
149.79
163.51
180.39
200.49
223.35
247.98
274.98
303.56
333.49
361.91
395.01
426.93
464.26
505.00
548.97
589.43
634.59
678.76
714.38
748.59
788.67
SPV1AA ,
- 19 -
$120
166.17
178.23
192.26
207.41
224.67
245.27
270.59
300.75
335.03
371.96
412.47
455.33
500.23
542.85
592.52
640.40
696.38
757.49
823.47
884.14
951.89
1018.14
1071.57
1122.90
1183.01
1825 x
$150
207.73
222.80
240.33
259.27
280.85
306.60
338.23
375.95
418.80
464.95
515.60
569.18
625.30
678.57
740.65
800.50
870.47
946.87
1,029.35
1,105.17
1,189.87
1,272.67
1,339.45
1,403.62
1,478.77
ADDENDUM NO.7
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights
POLICY NUMBER: 10212TQ
nCTlnl\.lAI CII::I\.IJ:C'IT~. I ifofin'lO t"'ntnnnllnrl Allfnn'l",fi", Ronofif In",po",,,,o
"". . .""'............ ............... I....,. .....""......... -"""1"'''_1'- ...--,._._..._.._ __"",",1.. 1'1""1 ""'_'OIOJ''''''
LIFETIME
MAXIMUM:
MONTHLY PREMIUM
FOR DAILY BENEFIT SELECTED
AGE ON EFFECTIVE
DATE OF COVERAGE
AQe
<25
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
$80
18.57
21 .46
21.89
22.56
23.39
24.15
24.95
25.88
27.05
28.50
30.18
32.02
34.01
36.06
37.97
39.91
41.81
43.85
45.96
48.15
50.34
52.67
55.26
58.20
61.20
64.27
67.66
71.58
76.27
81.55
87.20
93.30
99.89
107.07
115.31
124.25
133.57
142.65
150.87
157.06
161.72
166.08
SPV1AA
- 20-
$120
27.85
32.19
32.83
33.84
35.09
36.21
37.43
38.82
40.58
42.75
45.25
48.03
51.01
54.10
56.97
59.86
62.70
65.77
68.95
72.22
75.51
79.01
82.90
87.31
91.81
96.40
101.50
107.37
114.40
122.33
130.80
139.96
149.84
160.62
172.96
186.38
200.36
213.98
226.29
235.60
242.58
249.13
1825 x
$150
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
ADDENDUM NO.7
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights
POLICY NUMBER: 10212TQ
OPTIOi'JAL BENEFITS: Lifetime Compound Automatic Benefit Increase
LIFETIME
MAXIMUM:
MONTHLY PREMIUM
FOR DAILY BENEFIT SELECTED
AGE ON EFFECTIVE
DATE OF COVERAGE
Aae
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
$80
172.17
181.25
192.69
205.42
220.22
238.08
259.89
285.44
314.19
344.64
377.51
411.60
446.54
482.54
519.93
559.44
600.34
644.31
690.95
738.07
783.58
826.32
864.76
900.96
935.25
SPV1 AA
- 21 -
$120
258.26
271.88
289.04
308.12
330.34
357.10
389.84
428.18
471.29
516.96
566.28
617.40
669.81
723.81
779.90
839.16
900.50
966.47
1036.43
1107.11
1175.39
1239.47
1297.14
1351.44
1402.87
1825 x
$150
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
ADDENDUM NO.8
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights
POLICY NUMBER: 10212TQ
OPTIONAL BENEFITS:
AGE ON EFFECTIVE
DATE OF COVERAGE
Aae
<25
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
SPV1AA
LIFETIME
MAXIMUM:
1825 x
I :~_...:__ ,...____.._..1 A.....___...:_ D___&,:'" 1_______ 0' D___&,:'" A___.._...
L.III;:LIIIII;: uUlllPUUIIU '""uLulllaL.... J;;n:IlCIIL 111"1 ca;:oc IX J;>CIICIIL ,"",,"UUIIL
MONTHLY PREMIUM
FOR DAILY BENEFIT SELECTED
$80
20.62
23.82
24.30
25.03
25.96
26.81
27.95
28.99
30.29
31.91
33.79
35.87
38.09
40.39
42.53
44.70
47.24
49.55
51.94
54.41
56.89
60.06
63.00
66.36
69.78
73.27
77.81
82.33
87.72
93.79
100.28
1 08.24
115.87
124.21
133.76
144.13
156.29
166.90
176.50
183.77
189.21
195.99
- 22-
$120
30.92
35.74
36.45
37.56
38.94
40.21
41.94
43.48
45.45
47.87
50.70
53.79
57.13
60.60
63.81
67.05
70.86
74.33
77.90
81.62
85.33
90.08
94.50
99.53
104.66
109.90
116.73
123.49
131.57
140.68
150.42
162.36
173.80
186.31
200.64
216.19
234.42
250.35
264.76
275.66
283.81
293.98
$150
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
ADDENDUM NO.8
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights
POLICY NUMBER: 10212TQ
LIFETIME
MAXIMUM:
1825 x
OPTIONAL BENEFITS: Lifetime Compound Automatic Benefit Increase & Benefit Account
AGE ON EFFECTIVE
DATE OF COVERAGE
Aae
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
MONTHLY PREMIUM
FOR DAILY BENEFIT SELECTED
$80
203.17
213.88
227.38
242.41
259.87
280.92
306.67
336.83
370.75
406.67
445.47
485.68
526.91
564.57
608.32
648.95
696.38
747.40
801.50
848.78
901.12
950.26
985.83
1018.08
1056.82
SPV1AA
- 23 -
$120
304.75
320.81
341.06
363.60
389.80
421.38
460.00
505.25
556.12
610.02
668.20
728.52
790.37
846.85
912.48
973.41
1044.58
1121.09
1202.26
1273.17
1351.68
1425.38
1478.75
1527.13
1585.23
$150
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Continental Casualty Company
~NA
CNA Plaza A Stock Company
Chicago, Illinois 60685
"We," "Our," and "Us" are used to refer to the Continental Casualty Company.
Holder: City of Columbia Heights
Policy Number: 10212TQ (the "Policy")
Account Number: 0010039TQ
Policy Effective Date: November 1, 2002
THIS POLICY IS A QUALIFIED LONG TERM CARE INSURANCE CONTRACT
AS DEFINED UNDER SECTION 7702(8) (b) OF THE INTERNAL REVENUE CODE OF 1986.
The Policy is issued in consideration of the statements made in the Master Application, any other required evidence of
insurability for participants and the payment of premium. We agree with the Holder to insure eligible persons based on the
statements made in the Master Application. We promise to pay benefits for loss covered by the Policy.
The Policy is not a Medicare Supplement policy. If the Insured is eligible for Medicare, the Medicare Supplement Buyer's
Guide is available from Us for review.
SPS1AA-22-TQ
EFFECTIVE DATE AND TERM
The Policy starts on the Policy Effective Date. The Insured's coverage starts on the Coverage Effective Date stated in the
Master Application and stays in force for the period for which premium has been paid.
We guarantee to renew the Policy at the end of each renewal period. The Initial Renewal Period starts on the Policy
Effective Date. Each Subsequent Renewal Period starts on the day after the preceding period ends. The length of these
periods is stated in the Schedule.
The Holder may elect not to renew the Policy at any time by written notice to Us. Termination of the Policy will be the later
of: (a) The effective date of non-renewal stated in the written notice; or (b) The end of the Period for Notice of Non-
Renewal stated in the Schedule. This period starts on the date We receive the written notice from the Holder.
If the Insured is paying premiums directly to Us, We will notify him or her of any non-renewal by written notice at least 31
days before the Policy terminates.
In the event the Policy is not renewed, each Insured may continue coverage as provided in the Conversion of Coverage
Due to Termination provision.
All insurance periods start and end at 12:01 a.m., Standard Time, at the Holder's address stated in the Master Application.
SPS2BA-22
Signed for the Continental Casualty Company at its Home Office, CNA Plaza, Chicago, Illinois 60685.
~L,
~et~
GROUP LONG TERM CARE POLICY
SR-L TCP-22-TQ
1
TABLE OF CONTENTS
\
DEFI NITIONS ........................ .......................... ................................................................ ...................................................... 3
ELIGIBILITY FOR THE PAYMENT OF BENEFITS...............................................................................................................5
LIMITATIONS OR CONDITIONS ON ELIGIBILITY FOR BENEFITS ...................................................................................6
LONG TERM CARE BENEFIT.............................................................................................................................................. 7
I NTERRUPTI ON I N CARE.................................................................................................................................................. ..7
WAIVER OF PREMiUM..................................... .,........................................................................................................... ........7
ALTERNATE PLAN OF CARE BENEFIT ..............................................................................................................................7
IN DIVI DUAL TERMI NA TI ONS ........................................................................................................ .......................................8
CONTINUATION OF COVERAGE DUE TO TERMINATION ...............................................................................................8
CONTINUATION OF COVERAGE DUE TO DEATH OR DIVORCE OF SPOUSE ..............................................................8
EXTENSION OF BEN EFITS ................................................................................................................................................. 9
REI NST A TEMENT OF COVERAGE................ ..................................................................................................................... 9
CERTIFiCATES.............. ...... ........................ .................... .......... ..................... .......... ..................... .................................... ... 9
CLAIMS........................................................................................................................................................... .......................9
PREMI UM ............................................................................................................................................................. ...............10
THE CONTRACT...................................................................................................................................................... ........... 11
TEMPORARY BED HOLDING BENEFIT ............................................................................................................................11
CAREGIVER TRAI NI NG BENEFIT.................................................................................................................................... .11
EMERGENCY ALERT SYSTEM BENEFIT .........................................................................................................................12
HOSPICE CARE F ACI L1TY BENEFIT.......................................................................................... .......................................12
CARE ASSIST BENEFIT.................................................................................................... ....... .......................................... 12
REFUND OF PREMIUM AT DEATH ...................................................................................................................................13
BEN EFIT ACCOUNT............................................................................................................................................. .............. 13
LIFETIME COMPOUND AUTOMA rlC BENEFIT INCREASE ............................................................................................14
GUARANTEED BENEFIT INCREASE OPTION .................................................................................................................14
SGS2A
2
DEFINITIONS
The terms defined here are capitalized whenever they are used.
SGD1AA
Alternate Care Facility means a facility or other supportive residence which is engaged primarily in providing ongoing
care and related services to residents in one location and meets all of the following criteria:
1. Provides 24 hour care and/or supervision and is able to provide Qualified Long Term Care Services sufficient to
support needs resulting from the Insured being Chronically III;
2. The facility has at least one supervised, trained and ready to respond employee on duty at all times to provide
care;
3. Offers 3 meals a day and accommodates special dietary needs;
4. Is licensed or accredited by the appropriate agency to provide such care, if such licensing or accreditation is
required by the state in which care is received, or, if licensing is not required, has a quality of care program;
5. Maintains specific policies and procedures, consistent with state requirements, for handling medical emergencies
and trains staff to follow those procedures;
6. Maintains accessible files or records for each resident which includes up to date information listing that resident's
physician, dentist and other community based health care providers;
7. Has appropriate methods and procedures for recording, handling and administering drugs and biologicals, as
needed; and
8. If the facility provides dementia care, has a secured physical plant and specialized dementia programs.
Alternate Care Facility does not mean a Long Term Care facility, hospital or clinic, assisted living facility not meeting the
above criteria or a place which operates primarily for the treatment of alcoholics or drug addicts. However, care or
services for assisted living facilities not meeting the Alternate Care Facility definition may be covered subject to the
conditions of the Alternate Plan of Care provision.
SGDAC1AA
Assisted Living Care means Qualified Long Term Care Services provided by a living arrangement in a facility other than
an Alternate Care facility for Insureds whose condition is such that it precludes total independent living, but which does not
require the level of care available in a Nursing Home. The facility must charge separately for room charges and board/rent
charges.
SGDH3CA
Community Based Care consists of the categories of care listed and defined below.
(a) Home t1ealth Care means the following types of care when received from a Home Health Care Provid~r at the
Insured's Residence: -
(1) Occupational, physical, respiratory or speech therapy, or nutritional services;
(2) Nursing care performed by a registered nurse (RN), a licensed practical nurse (LPN), or a licensed vocational
nurse (L VN);
(3) Personal Care Services provided by a home health care aide or by a medical social worker;
(4) Maintenance Services provided by a home health care aide or homemaker; or
(5) Hospice care.
A Home Health Care Provider is an entity which:
(1) Has an agreement as a provider of Home Health Care under Medicare; or
(2) Is certified or licensed by the state in which it is located as a provider of such care; or
(3) Is accredited as a provider of such care by the National League of Nursing, American Public Health
Association or Joint Commission on Accreditation of Healthcare Organizations.
A Home Health Care Provider may also be an RN, LPN or LVN working within the scope of his or her license.
SGDH1 CB-TQ
3
(b) Adult Day Care means a community based group program of health, social and related support services for 6 or more
individuals provided during the day in a community group setting. Services must be provided for the sole purpose of
supporting impaired elderly or other disabled adults who can benefit from care in a group setting outside of the home.
It does not include 24-hour care. The facility providing this type of care must meet the certification or licensing
requirements, if any, of the state in which it is located. If the state does 'not certify or license adult day care centers,
the facility must be certified by a recognized accrediting agency.
SGDH2AA-22
(c) Adult Foster Care means a facility providing 24 hour care other than a Nursing Home for Insureds whose condition is
such that they cannot live alone, but whose needs can be met in a private home. The provider of this type of care
must be certified or licensed by the state in which it is located.
SGDH4AA-22
Disability means any disorder resulting in the Insured being Chronically III.
SGD28AA-TQ
Eligible Expense means the actual expense incurred by the Insured for Long Term Care and other services covered by
the Policy. For Community Based Care, it does not include the cost of transportation (except for Adult Day Care), supplies
and rent or those costs which the Insured would incur regardless of whether the Insured is Chronically III.
SGD2AA-TQ
Hospice Care means care designed to alleviate the physical, emotional, social and spiritual discomforts resulting from the
last stages of a terminal disease and to provide emotional support to the primary caregiver and family.
SGD20AB
Informal Caregiver means a person who:
(1) Is approved by Us as being experienced in or trained to provide Informal Care; and
(2) Is physically capable of providing Informal Care to the Insured.
SGD13AA
Insured means the eligible person whose coverage is in force under the Policy.
SGD3AA
Insured's Residence means wherever the Insured lives, except a hospital or Nursing Home.
SGD4AA
Licensed Health Care Practitioner means any physician, registered professional nurse (RN) or licensed social worker,
acting within the scope of his or her license.
SGD24AA-TQ
.. .
Lifetime Maximum Benefit means the most We will pay in benefits due to the Insured who has been certified to be
Chronically III. This maximum is stated in the Schedule. All amounts paid to the Chronically III Insured, under any benefit
provision in or attached to the Policy, including the Alternate Plan of Care Benefit, count towards the maximum.
SGD5AA-TQ
Long Term Care means Qualified Long Term Care Services providing Nursing Home Care, Community Based Care,
Assisted Living Care and Alternate Care Facility care.
SGD6IA-TQ
Loss of Functional Capacity means requiring the substantial assistance of another person to perform the prescribed
Activities of Daily Living.
SGD34AA-22
Maintenance Services means any care which is received due to the Insured having a Disability, including the protection
from threats to health and safety due to a severe Cognitive Impairment. This may include homemaker services such as
cooking, cleaning, laundering, organizing bills for payment and running errands.
SGD29AA-22- TQ
4
Master Application means the Holder's application attached to the Policy when issued.
SGD7 AA
Nursing Home means a place which:
(1) Is licensed as a nursing home under Chapter 144A of Minnesota Statutes Annotated;
(2) Is licensed as a boarding care home under Sections 144.50 to 144.56 of Minnesota Statutes Annotated and
certified as an intermediate care facility for purposes of the medical assistance program; and
(3) In states other than Minnesota, meets licensing and certification standards comparable to those that apply to the
facilities described in clauses 1. and 2.
SGDN1AA-22
Nursing Home Care means care received in a Nursing Home.
SGDN2AA-22
Personal Care Services means assistance with Activities of Daily Living or similar personal assistance such as walking,
using a wheelchair, walking with braces or walker, a cane or other walking aid device.
SGD25AA-TQ
Plan of Care means a program of care and treatment initiated by and approved in writing by a Licensed Health Care
Practitioner.
SGD26AA-TQ
Qualified Long Term Care Services means necessary diagnostic, preventive, therapeutic, curing, treating, mitigating and
rehabilitative services and Maintenance or Personal Care Services, which:
1. are required by a Chronically III Insured, and
2. are provided pursuant to a Plan of Care prescribed by a Licensed Health Care Practitioner.
SGD27 AA-22-TQ
Schedule means the schedule of benefits.
SGD8AA
Waiting Period means the number of days of Long Term Care, stated in the Schedule, which the Insured must receive
due to the same or related condition before the Long Term Care Benefit becomes payable.
SGD9AA
Waiver of Premium Qualification Period means the number of days of Long Term Care, stated in the Schedule, which
the Insured must receive before We start to waive premiums.
SGD10Af\ .
ELIGIBILITY FOR THE PAYMENT OF BENEFITS
SGDE1AA
Chronically III means an Insured who has been certified by a Licensed Health Care Practitioner as being unable to
perform (without substantial assistance from another individual) at least 2 Activities of Daily Living for a period of 90 days,
due to a Loss of Functional Capacity or requiring Substantial Supervision to protect the Insured from threats to health and
safety due to a Severe Cognitive Impairment.
The Insured will not be considered Chronically III unless within the preceding 12 months a Licensed Health Care
Practitioner has certified that the Insured meets the above requirements.
SGD23BA-22- TQ
Activities of Daily Living Impairment means the Insured's inability to perform without human assistance or substantial
supervision from another person at least two of the Activities of Daily Living listed and defined below.
SGD22AA-TQ
Bathing. Washing oneself by sponge bath; or in either a tub or shower, including the task of getting into or out of the
tub or shower.
SGDQ2CA-9
5
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 a catheter or
colostomy bag.
SGDQ2BA-6 .
Dressing. Putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs.
SGDQ2BA-2 .
Eating. Feeding oneself by getting food into the body from a receptacle (such as a plate, cup or table) or by a feeding
tube or intravenously.
SGDQ2BA-1
Toileting. Getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.
SGDQ2BA-3 .
Transferring. Moving into or out of a bed, chair or wheelchair.
SGDQ2BA-8
Severe Cognitive Impairment means a loss or deterioration in the Insured's intellectual capacity that is measured by
clinical evidence and standardized tests that reliably measures impairment in the following areas:
1. Short term or long term memory,
2. Orientation as to people, places or time, and
3. Deductive or abstract reasoning
SGDQ3EA
Substantial Supervision means continual supervision, which may include cueing by verbal prompting, gestures, or other
demonstrations, by another person that is necessary to protect the severely cognitively impaired Insured from threats to his
or her safety.
SGD32AA
LIMITATIONS OR CONDITIONS ON ELIGIBILITY FOR BENEFITS
Exclusions - We will not pay benefits for the following:
SGL2AA
1. Loss due to or resulting from war or an act of war whether declared or undeclared.
SGL2AA-1
2.- Long Term Care toths extent that benefits are payable under Workers' Compensatiof'l, the Occup3tional Disease Act
or Law, or a group health plan. However, the days on which Long Term Care is received will count towards satisfying
the Waiting Period and Waiver of Premium Qualification Period, subject to the provisions of the Policy.
SGL2AA-2-22- TQ
3. Long Term Care which would be provided without charge in the absence of insurance.
SGL2AA-3
4. Treatment for neurosis, psychoneurosis, psychopathy, psychosis or mental or emotional disease or disorder which is
not of organic origin. Alzheimer's Disease and similar dementias are covered, subject to the provisions of the Policy.
SGL2AA-4
5. Nursing Home Care received in a hospital or clinic or a rehabilitation hospital, except as provided in the definition of
Nursing Home; or in a facility or section of a facility which operates primarily for the treatment of alcoholics or drug
addicts or the mentally ill.
SGL2DB-5
6. Long Term Care received outside the United States and its possessions.
SGL2AA-6
6
7. Long Term Care to the extent that benefits are payable under Medicare or would be so reimbursable for the
application of a deductible or coinsurance amount.
SGL2AA-7-22-TQ
Waiting Period .'The Insured must complete the Waiting Period before the tong Term Care Benefit becomes payable. A
day of Long Term Care which counts toward the Waiting Period for the benefit payable for Nursing Home Care
simultaneously counts toward the Waiting Period for the benefit payable for Community Based Care and vice versa.
SGL3AA
LONG TERM CARE BENEFIT
We will pay the Long Term Care Benefit stated in the Schedule, subject to the conditions below.
(a) The Insured must be certified as Chronically III by a Licensed Healthcare Practitioner.
(b) The Long Term Care Benefit will be paid pursuant to a Plan of Care provided by a Licensed Healthcare
Practitioner.
(c) The Long Term Care must start while the Insured's coverage is in force.
(d) The Lifetime Maximum Benefit must not yet have been reached.
(e) The terms of the Limitations or Conditions on Eligibility for Benefits provision must be met.
SGNH 1 AA-22- TQ
INTERRUPTION IN CARE
We will consider the Long Term Care due to the same or a related condition to be continuing without interruption until 6
months pass during which the Insured receives no Long Term Care due to such condition. When Long Term Care due to
the same or a related condition recurs, the Insured must complete the full Waiting Period and Waiver of Premium
Qualification Period before benefits again become payable and premiums are again waived for Long Term Care due to
such condition.
SGNH2AA
WAIVER OF PREMIUM
We will waive premiums starting with the first premium due after the Insured completes the Waiver of Premium
Qualification Period. We will continue to waive premiums until no benefits have been paid for 6 months.
If premiums are being paid other than monthly, the Insured will be placed on the monthly premium payment mode when
We start to waive premiums. We will then refund any unearned monthly premiums, starting with the premium of the first
full month for which premiums are waived.
,. .' ~ ..,. .
. . " ~
When waiver of premium stops, the Insured's coverage may be continued in force by payment of the first modal premium
due after the date it stops. The modal premium will be the same as in effect prior to the date waiver of premium started,
subject to any change in the premium rates which may have occurred as provided in the Payment of Premium provision.
SGS3AA
ALTERNATE PLAN OF CARE BENEFIT
If the Insured requires Long Term Care, We may pay for alternate services, devices or types of care, pursuant to a written
Alternate Plan of Care, developed by or with a Licensed Healthcare Practitioner.
Any alternate care, including the benefits to be paid, may be adopted, as long as it is mutually agreeable to the Insured,
the Insured's physician and Us. No benefits will be payable under this provision until an agreement is reached.
Agreement to participate in an alternate Plan of Care will waive neither the Insured's nor Our rights.
The Alternate Plan of Care may specify special treatments or different sites or levels of care. Some of the care the
Insured may receive may be different from that otherwise covered by the Policy. In this case, benefits will be paid at the
levels specified and agreed to in the alternate Plan of Care.
SGA 1 AB- TQ
7
INDIVIDUAL TERMINATIONS
The Insured's coverage under the Policy terminates on the earliest of the dates below. Unless termination occurs under
Paragraphs (c), or (d) of this provision, the Insured's coverage may be continued in force as provided in the Continuation of
Coverage Due to Termination provision.
(a) Except as stated in the Continuation of Coverage Due to Death or Divorce of Spouse provision, the date the
Insured is no longer eligible for coverage, as provided in the Master Application.
(b) On the date the Policy terminates.
(c) The end of the grace period of an unpaid premium, unless non-payment is due to a clerical error made by Us or
the Holder. .
(d) The date the Lifetime Maximum Benefit is reached.
SGS4AA
CONTINUATION OF COVERAGE DUE TO TERMINATION
The Insured becomes eligible for continuation of coverage on the date his or her coverage under the Policy terminates as
provided in Paragraphs (a) and (b) of the Individual Terminations provision. Coverage will be continued under a new
group policy (the "continuation policy") subject to the conditions below:
(a) The Insured must remit the first quarterly premium to Us for the continued coverage and We must receive it within
60 days from the date coverage terminates under the Policy or, if a claim started before termination, when waiver
of premium stops. The Insured must remit the first quarterly premium to Us regardless whether a bill has been
sent by Us or received by the Insured. The Insured not receiving a bill for continuation of coverage is not to be
considered a clerical error made by Us or the Holder.
The first quarterly premium for the continued coverage is three times the Insured's monthly premium and is due on
the date coverage terminates under the Policy. The first quarterly premium should be paid by check, made out to
'Continental Casualty Company' and identify the Insured's Certificate Number and Social Security Number. The
remittance should be sent to CNA-GL TC, P.O. Box 946760, Maitland, FL 32794-6760.
(b) Upon receipt of the Insured's remittance of the first quarterly premium for continuation coverage, We will verify that
the Insured is eligible for continuation and provide ongoing billings. All future premiums under the continuation
policy are due quarterly. The Insured must remit them directly to Us. We will consider requests for payment
modes other than quarterly.
(c) Coverage will be continued under the continuation policy with the same benefits and provisions as the Policy, such
that the Insured is left in the sar:ne position as if coverage had not terminated. "
(d) The Insured's coverage under the continuation policy is effective as of the date coverage terminates 'under the
Policy. The Insured will not be covered or receive benefits simultaneously under the Policy and the continuation
policy.
(e) There is no continuation of coverage if Extension of Benefits stops due to the Lifetime Maximum Benefit having
been reached.
SGS5DA
CONTINUATION OF COVERAGE DUE TO DEATH OR DIVORCE OF SPOUSE
If the Insured is no longer eligible for coverage due to the death of, or divorce from, the spouse, the Insured's coverage will
continue in force under the Policy, subject to its provisions. If the Insured's premiums are being deducted from a payroll
account, the Insured must remit the first monthly premium for the continued coverage at the end of the period for which
premium has already been paid or, if later, on the first Premium Due Date after we stop waiving premiums. All future
premiums are due monthly. The Insured must remit them directly to us. We will consider requests for payment modes
other than monthly.
SGS6AA-22
8
EXTENSION OF BENEFiTS
If the Insured's coverage under the Policy terminates, except as provided in (d) of the Individual Terminations provision, we
will recognize the Insured's basis for a claim which started before the date of termination in the same manner as if the
Insured's coverage were still in force. Extension of benefits stops on the earlier of:
(a) The end of a benefit period; or
(b) The date the Lifetime Maximum Benefit is reached.
SGS7 AA-22
REINSTATEMENT OF COVERAG~
If the Insured's coverage terminates for non-payment of premium and if the Insured provides proof of a Cognitive
Impairment or the loss of functional capacity at the time of termination, We will reinstate coverage up to 5 months after the
coverage terminated without requiring evidence of insurability. The reinstated coverage will cover losses from the date
coverage terminates. All premium must be paid in order for coverage to be reinstated. Subsequent reinstatements may
require evidence of insurability.
In all other situations, if the Insured's coverage terminates for non-payment of premium, coverage may be reinstated at
Our option. We may require the Insured to submit an application for reinstatement. If We approve the application,
coverage will be reinstated as of the date of Our approval. If We have accepted premium and issued a conditional
premium receipt, the Insured's coverage will be reinstated no later than 45 days after the date of that receipt, unless We
notify the Insured by written notice prior to that date that the application for reinstatement is not approved. If We do not
require an application for reinstatement, coverage will be reinstated as of the date We accept the Insured's premium.
The reinstated coverage will cover only losses for conditions that start after the date of reinstatement. In all other aspects,
the Insured's rights and Ours will be the same as before the coverage terminated, unless there are new provisions added
due to the reinstatement. The premium We accept for reinstatement may be used for the period for which premiums were
not paid. We can apply the premium back for as many as 60 days before the date of reinstatement.
SGS8EA-22-TQ
CERTIFICATES
We will issue an individual certificate for the Insured. The certificate describes the benefits, to whom they are payable, the
limits and where the Policy may be inspected.
SGS9AA
CLAIMS
Notice of Claim. Notice must be given to Us within 90 days after a loss. If notice cannot be given within that time, it must
be given as soon as reasonably possible. The notice will be sufficient if it identifies the Insured and the Policy. It musJ be
sent to Us at the following address:
Continental Casualty Company
PO Box 946760
Maitland, FL 32794-6760
SGC1 SA
Claim Forms: After We receive the notice of claim, We will furnish any required forms within 15 days. If We do not, We
will consider the Insured to have met the requirements for written proof of loss if We are given written proof of the extent
and nature of the loss.
SGC2SA
Written Proof of Loss: Written or electronic proof of Eligible Expenses must be given to Us within 90 days after the date
of such loss. If this is not reasonably possible, the claim is not affected if the proof is given to Us as soon as possible.
Unless the Insured is legally incapacitated, written proof must be given within 1 year of the time it is otherwise due.
SGC3DA
Time of Payment of Claim: Benefits for a loss which requires periodic payment will be paid monthly subject to receipt of
due written proof of loss. Any balance unpaid when liability terminates will be paid when We receive due written proof.
SGC4AA
9
Payment of Claim: All benefits are paid to the Insured or the Insured's estate, unless the Insured has assigned them
elsewhere.
If benefits are payable to the estate, We may pay up to $1,000 to any relative of the Insured who We feel is entitled to
them. Any payment We make in good faith discharges Us to the extent of the payment.
SGC5AA
Misstatement of Age: If the Insured's age has been misstated, the benefit will be in an amount that the premiums paid
would have purchased at the Insured's true age. If coverage would not have been issued, We will refund the premium paid
within 90 days of discovering the misstatement.
SGC6AA-22
Physical Examination and Assessment: At Our expense, We may, as often as reasonably necessary while the claim is
pending, have the insured examined or obtain an assessment of the Insured's impairment.
SGC7AA-15-TQ
Claim Denial: If a claim is denied, We will make available to the Insured or the Insured's personal physician, all
information directly related to such denial. We will release such information within 60 days of Our receipt of the written
request unless such disclosure is prohibited under state or federal law.
SGC9AA
Claim Appeal: If the Insured contests the denial, We will request from the Insured, the nature of the dispute in writing and
(if applicable) the amount of money involved. We will then compile all relevant data including evaluations by qualified
individuals independent of Us, if appropriate. The accumulated data will be reviewed by Us. The decision is sent to the
Insured in writing within 60 days.
SGC10AA
PREMIUM
Payment of Premium: Premium is computed as stated in the Master Application. Premiums are payable in United
States currency to us on the Premium Due Dates stated in the Schedule.
We cannot change the Insured's premiums because of age or health. We can, however, change the Insured's premiums
based on his or her premium class on the Policy anniversary date, but only if we change the premiums for all other
Insureds in the same premium class. A change may be made, as provided in the following paragraph, on any Premium
Due Date after the end of the Premium Rate Guarantee Period. The Premium Rate Guarantee Period starts on the Policy
Effective Date. The length of this period is stated in the Schedule of the Master Application.
If we elect to change premium rates, the Insured's premiums change on his or her first Premium Due Date following the
later of: (a) The effective date of the change stated in our written notice to the Holder; or (b) the end of the Period for
Notice of Premium Rate Changes stated in the Schedule of the Master Application. This period starts on the date the
Hokier receives the written notice from us. If the Insured is paying premiums directly to us, we will notify-him or her oUbe ,-
change at least 31 days before the Premium Due Date on which his or her premiums change.
The Premium Rate Guarantee Period does not limit our right not to renew the Policy, as stated in the Effective Date and
Term provision.
SGP1AA-15
Refund of Unearned Premium at Death: If the Insured dies, We will make a pro-rata refund of premium paid for the
period beyond the date of death.
SGP3AA
Unintentional Lapse: The Insured has the right to designate another individual to receive notification of lapse. Upon
notice of nonpayment of premium, We will inform both the Insured and, if chosen, the designated individual at least 30
days before the effective date of lapse. If payment is through a payroll or pension deduction plan, We will inform both the
Insured and, if chosen, the designated individual 60 days after the Insured is no longer on a payroll or pension deduction
plan. The notice will be given by first class United States mail, postage prepaid, to the designated individual no earlier than
30 days after the premium due date. Notice is considered to have been given as of 5 days after the date of mailing. The
Insured will be notified of the right to change the designated person at least once every 2 years.
SGP6AB
10
THE CONTRACT
Entire Contract; Changes: The Policy, the Master Application, the individual applications of the Insureds and any
attached papers make up the entire contract between the parties. No change is valid unless approved in writing on the
Policy by one of Our officers. No agent may change the Policy or waive any' of its provisions.
SGX1AA
Incontestability: Statements the Holder or the Insured makes are, in the absence of fraud, representations and not
warranties. No statement voids the insurance, reduces the benefits or may be used in defense to a claim unless it is in
writing and a copy of it has been furnished to the Holder or the Insured, whoever made the statement.
If the Insured's coverage has been in force for less than 6 months, We may rescind or deny an otherwise valid claim for
any misstatements made by the insured that is material to the acceptance of coverage. After the Insured's coverage has
been in force for at least 6 months but less than 2 years, We may rescind or deny an otherwise valid claim for fraudulent
misstatements made on the application and which pertains to the condition for which benefits are sought. After the
Insured's coverage has been in force for 2 years, only fraudulent misstatements of the Insured who knowingly and
intentionally misrepresented relevant facts relating to his health may be used to void the Insured's coverage. If benefits
have been paid under the Policy, the benefits cannot be recovered by Us in the event coverage is rescinded.
After the Policy has been in force for 2 years, only fraudulent misstatements of the Holder may be used to void the Policy.
SGX2AB-22-TQ
Legal Actions: No action at law or in equity may be brought until 60 days after the date written proof of loss was given. No
action may be brought after 3 years from the date written proof is required.
SGX3AA
Conformity with Statutes: If a provision conflicts with the statutes of the jurisdiction in which the Policy was delivered or
issued, it is automatically changed to meet the minimum requirements of the statute.
SGX4AA
TEMPORARY BED HOLDING BENEFIT
When the Insured is receiving benefit payments for Nursing Home Care, We will pay the Temporary Bed Holding Benefit,
subject to the conditions below, if the Insured is temporarily absent from the Nursing Home due to a hospital stay or other
event. The Temporary Bed Holding Benefit will be paid only if the Insured continues to incur a charge for a bed in the
Nursing Home and that charge would have been assessed even in the absence of insurance.
(a) The benefit will equal the Long Term Care Benefit payable for Nursing Home Care. It will be limited to 21 days per
calendar year. Unused days cannot be carried over into the next calendar year.
(b) The temporary absence must start while the Insured is receiving benefits for Nursing Home Care.
(c) The Lifetime Maxirl1ul11 Benefit must not yet-have been reached. ' - .. .
SGB1AA
CAREGIVER TRAINING BENEFIT
Caregiver Training means training received by the Informal Caregiver to care for the Insured in the Insured's Residence.
Informal Care means Informal Care provided by an Informal Caregiver, making it unnecessary for the Insured to be in a
Nursing Home, or to receive such care in the Insured's Residence from a paid provider.
Informal Caregiver means the person who has the primary responsibility of caring for the Insured in the Insured's
Residence. A person who is paid for caring for the Insured cannot be an Informal Caregiver.
BENEFIT
We will pay the Caregiver Training Benefit stated in the Schedule, subject to the conditions below:
(a) The conditions which must be met for the Long Term Care Benefit to become payable, stated in the Long Term
Care Benefit provision, must also be met for benefits to become payable under this provision. However, there is no
Waiting Period.
(b) The Caregiver Training must be provided by a Home Health Care Provider, Nursing Home or hospital while the
Insured is receiving Long Term Care or Informal Care. If the Insured is in a Nursing Home or in a hospital, the
11
Caregiver Training Benefit will only be payable if the training will make it possible for the Insured to return to the
Insured's Residence where he or she can be cared for by the Informal Caregiver.
(c) If Long Term Care or Informal Care due to the same or a related condition stops, the Caregiver Training Benefit
will again, become payable subject to the preceding conditions if LOQg Term Care or Informal Care resumes due to
a new or unrelated condition, We will consider Long Term Care or Informal Care due to the same or a related
condition to have stopped when 6 months have passed during which the Insured has received no Long Term Care
or Informal Care due to such condition.
SGT1AA
EMERGENCY ALERT SYSTEM BENEFIT
Emergency Alert System is a communication system located in the Insured's Residence which is used to summon
medical attention in case of a medical emergency.
We will pay the Emergency Alert System Benefit stated in the Schedule for the rental or lease of an Emergency Alert
System for the Insured's Residence while the Insured is living in that residence, subject to the conditions below.
(a) We will start paying the Emergency Alert System Benefit when benefits for Community Based Care start. The
Emergency Alert System Benefit will continue to be paid until 6 months pass during which the Insured receives no
Community Based Care, or, if earlier, until Nursing Home Care starts.
(b) The Insured's condition must be such that he or she could not be left alone were it not for the presence of the
Emergency Alert System.
(c) We will not pay for any charges for normal telephone service while the system is installed or for a home security
system.
(d) The Lifetime Maximum Benefit must not yet have been reached.
SGM1AA
HOSPICE CARE FACILITY BENEFIT
We will pay the Hospice Care Facility Benefit stated in the Schedule, subject to the conditions below:
(a) The conditions which must be met for the Long Term Care Benefit to become payable, stated in the Long Term
Care Benefit provision, must also be met for benefits to become payable under this provision;
(b) Care must be received in a facility that specializes in Hospice Care for patients who are expected to live less than
six months. This facility is a stand-alone facility or ward/wing of a Nursing Home and is licensed by the state in
which it is located;
(c) The benefit payable for Hospice Care in a Hospice Care Facility will equal the Long Term Care Benefit payable for
I\lursing Home Care. However, benefits will not be paid for Hospice Care in a HospiGe Care Eacility,_ Communi.ty ,
Based Care and Nursing Home Care'slmultaneously; and -. ' , ,'-., ' "-.
(d) The Lifetime Maximum Benefit must not yet have been met.
SGHC1AA
CARE ASSIST BENEFIT
The Care Assist Benefit is designed to temporarily relieve an Informal Caregiver of the duties of caring for the Insured.
We will pay the Care Assist Benefit stated in the Schedule, subject to the conditions below:
1. The Care Assist Benefit will either be paid for care furnished at the Insured's residence for up to 24 hours per day by a
Home Health Care Provider or another Informal Caregiver or care received in a Nursing Home.
2. During the 6 months prior to receipt of care, the Insured must have been Chronically III and receiving care from the
Informal Caregiver being relieved of duties. A period during which the Insured is confined in a hospital will count
towards satisfying the 6 month requirement.
3. The Waiting Period does not apply to the Care Assist Benefit.
4. The maximum amount payable per calendar year is stated in the Schedule. Unused amounts cannot be carried over
into the next calendar year.
SGCA1AA
12
REFUND OF PREMIUM AT DEATH
At the Insured's death, We will refund a portion of the premiums paid less any benefits paid or payable. The amount of the
refund is determi~ed by multiplying (a) by (c) and then subtracting (b). (a), (b) and (c) are defined as follows:
\
(a) = The Insured's total premiums paid, not including any premiums which were waived, less any unearned
premiums refunded at the Insured's death.
(b) = The Insured's total benefits paid or payable.
(c) = The applicable factor from the Schedule of Factors shown below. It is determined based on the Insured's age
on the birthday preceding the date of death.
Schedule of Factors
Age of Insured
at Death
65 or younger
66
67
68
69
70
71
72
73
74
75 or older
Factors
100%
90
80
70
60
50
40
30
20
10
No refund is made
This benefit will not be payable if the Insured has exercised the Reduced Lifetime Maximum Benefit, the Benefit Account
option or any other paid up benefit option in the Policy, as applicable.
SGF1AB
BENEFIT ACCOUNT
If the Insured has had at least 3 years of continuous coverage under the Policy, and this benefit has been in effect for at
least three years, then, at the end of the grace period of an unpaid premium, the Insured's coverage will be continued in
force with the same daily benefit but a reduced Lifetime Maximum Benefit, with no further premiums being payable.
The reduced Lifetime Maximum Benefit will equal the total premiums paid toward a plan which includes this benefit.
However, the reduced Lifetime Maximum Benefit will never be less than 30 times the Insured's daily benefit.
The reduced Lifetime Maximum Benefit will not be ,educed due to prior benefits paid under the Policy' but, in no Case will
the total benefits paid under the Policy exceed what would have been paid had the Insured continu'ed 'to 'pay premiums.
No benefit increases will be offered after the effective date of the reduced benefit.
If the Insured has the Automatic Benefit Increase provision, no further increases under that provision will occur after the
effective date of the reduced benefit.
The reduced Lifetime Maximum Benefit will take effect on the Premium Due Date of the unpaid premium or, if later, on the
date Extension of Benefits stops.
The reduced Lifetime Maximum Benefit will be subject to the provisions of the Policy.
SGF1JB
13
LIFETIME COMPOUND AUTOMATIC BENEFIT INCREASE
On each anniversary of the Insured's Effective Date, We will increase by the Automatic Benefit Increase Percentage stated
in the Schedule' each benefit amount then in effect.
SGI1CA '
GUARANTEED BENEFIT INCREASE OPTION
On the third anniversary of the Policy Effective Date and no less than every three years thereafter, the Insured may elect to
increase each benefit amount then in effect by the amount stated in the Schedule,
If the Insured elects to increase coverage, the premium for the increase in coverage will be based on the Insured's
attained age at the time of the increase. The premium for the increase in coverage will be added to the premium being
charged for the Insured's previous amount of coverage.
The Insured has the right to accept the benefit increase offers without showing evidence of insurability as long as the
Insured increased his benefit amount at the most recent previous benefit increase offer. When an offer is declined, the
Insured must submit evidence of insurability in order to exercise the next benefit increase offer. Once We accept the
Insured's evidence of insurability, We will not require further evidence of insurability for future benefit increase offers until
another offer is declined.
SGI1GC
14
-
-
-
Continental Casualty Company
CNA Plaza A Stock Company
Chicago, Illinois 60685
ADMINISTRATIVE RIDER
It is understood and agreed that in the event the Group Long Term Care policy to which this rider is attached replaces
another Long Term Care policy, the Continental Casualty Company will waive any time periods applicable to pre-existing
conditions, waiting periods and waiver of premium qualification periods to the extent such time was spent under the policy
being replaced.
Signed for the Continental Casualty Company at its Home Office, CNA Plaza, Chicago, Illinois 60685.
~L,~
Chairman of the Board
SRAR-11
15
D"""""'"
-
---
Continental Casualty Company
CNA Plaza A Stock Company
Chicago, Illinois 60685
---
ADMINISTRATIVE RIDER
This amendment is part of the Policy. It is understood and agreed that the Guaranteed Benefit Increase Option has been
amended as follows:
Employees who are actively-at-work and their spouses may refuse any number of benefit increase offers without forfeiting
the right to accept future offers on a guarantee issue basis.
SR-15288 (G80)
~L,
SRAR-11
16
Continental Casualty Company
P.O. Box 946760
Maitland FL 32794-6760
1-(800)-528-4582
Summary of the Minnesota Life and Hea!th Insurance Guaranty Association Act and
Notice Concerning Coverage Limitations and Exclusions
If the insurer who issued your life, annuity or health insurance policy becomes impaired or insolvent you are entitled to
compensation for your policy from the assets of that insurer. The amount you recover will depend on the financial condition
of the insurer. '
In addition, residents of Minnesota who purchase life insurance, annuities or health insurance from insurance companies
authori?:ed to do business in Minnesota are protected, SUBJECT TO LIMITS AND EXCLUSIONS, in the event the insurer
becomes financially impaired or insolvent. This protection is provided by the Minnesota Life and Health Insurance
Guaranty Association.
Minnesota Life & Health Insurance Guaranty Association
1750 Hennepin Avenue
Minneapolis, Minnesota 55403
(612) 377-2101
The Maximum amount the guaranty association will pay for all policies issued on one life by the same insurer is limited to
$300,000. Subject to this $300,000 limit, the Guaranty Association will pay up to $300,000 in life insurance death benefits,
$100,000 in net cash surrender and net cash withdrawal values for life insurance, $300,000 in health insurance benefits,
including any net cash surrender and net cash withdrawal values, $100,000 in annuity net cash surrender and net cash
withdrawal values, $300,000 in present value of annuity benefits for annuities which are part of a structured settlement or
for annuities in regard to which periodic annuity benefits, for a period of not less than the annuitant's lifetime or for a period
certain of not less than ten years, have begun to be paid on or before the date of impairment or insolvency, or if no
coverage limit has been specified for a covered policy or benefit, the coverage limit shall be $300,000 in present value.
Unallocated annuity contracts issued to retirement plans, other than defined benefit plans, established under section 401,
403(b), or 457 of the Internal Revenue Code of 1986, as amended through December 31, 1992, are covered up to
$100,000 in net cash surrender and net cash withdrawal values, for Minnesota residents covered by the plan provided,
however, that the association shall not be responsible for more than $7,500,000 in claims from all Minnesota residents
covered by the plan. If total claims exceed $7,500,000, the $7,500,000 shall be prorated among all claimants.
These are the maximum claim amounts. Coverage by the guaranty association is also subject to the other substantial
limitations and exclusions and requires continued residency in Minnesota. If your claim exceeds the Guaranty
Association's limits you may still recover a part or 811 of that amount from the proceeds of the liquidation of the insolvent
insurer, if any exist. Funds to pay claims may not be immediately available. The Guaranty Association assesses insurers
licensed to sell life and health insurance in Minnesota after the insolvency occurs. Claims are paid from the assessment.
THE COVERAGE PROVIDED BY THE GUARANTY ASSOCIATION IS NOT A SUBSTITUTE FOR USING CARE IN
SELECTING INSURANCE COMPANIES THAT ARE WELL MANAGED AND FINANCIALLY STABLE. IN SELECTING AN
INSURANCE COMPANY OR POLICY, YOU SHOULD NOT RELY ON COVERAGE BY THE GUARANTY ASSOCIATION.
THIS NOTICE IS REQUIRED BY MINNESOTA STATE LAW TO ADVISE POLICYHOLDERS OF LIFE, ANNUITY OR
HEALTH INSURANCE POLICIES OF THEIR RIGHTS IN THE EVENT THEIR INSURANCE CARRIER BECOMES
FINANCIALLY INSOLVENT. THIS NOTICE IN NO WAY IMPLIES THAT THE COMPANY HAS ANY TYPE OF
FINANCIAL PROBLEMS. ALL LIFE, ANNUITY AND HEALTH INSURANCE POLICIES ARE REQUIRED TO PROVIDE
THIS NOTICE.
BG-15430-B22
1
CNA Plaza Chicago It, 60685-0001
CNA PRIVACY NOTICE
For Group Long- Term Care Policyholders
Protection of private information is a matter of great importance to CNA. The nature of insurance requires that we
periodically gather private information from you, the individuals we insure under your policy (Ucertificateholders"), and
applicants who are not approved for coverage. CNA recognizes that access to nonpublic personal financial and health
information must be protected. This notice explains CNA's commitment to privacy with respect to the nonpublic personal
financial or health information we maintain.
WHY WE COLLECT INFORMATION
We collect information that is necessary to review, process, or service requests for Group Long-Term Care coverage,
benefits and other services. For example, we may collect non public personal financial and health information to determine
eligibility for coverage or benefits.
TYPES OF INFORMATION WE COLLECT
We collect information directly from you as the policyholder. Generally, we request identification information from you such
as name, address and telephone number. We may also request information from you regarding your employees as
prospective certificate holders. Examples of this kind of information include employee name, address, date of birth, and
Social Security Number.
In addition to the information we collect from you, we also obtain information from applicants and certificateholders in
connection with providing Group Long-Term Care coverage or services. An example of this is information provided to us
on applications for insurance or other forms.
Information We Disclose
The information we collect as described above is used to make service, benefit and other insurance-related decisions.
This inforrndtiun is sometimes shared as perriiitted by law with -CNA affilfates and nonaffiliated third parties tc)'cc:lrry but
daily business functions; review, process or service your Group Long-Term Care products or services. Examples of
nonaffiliated third parties with whom we can and do share information are:
· Insurance regulatory authorities;
· Third party administrators engaged by you or by us for purposes of marketing, servicing, or administering Group Long-
Term Care plans; or
· Claim service and administrators engaged by us to adjust, administer, service or process claims.
1
How WE PROTECT YOUR INFORMATION
CNA restricts access to information to those employees or service providers who need to know the information in order to
provide Group Long-Term Care products or services to you, certificate holders, or applicants. We regularly review our
security measures and employee education programs to help protect this information.
When we share information with nonaffiliated third parties, we require that they have standards to keep this information
private. We do not share information with nonaffiliated third parties for purposes of marketing other products or share
personally identifiable information for industry studies.
This privacy policy is not in lieu of any other privacy notice issued by any other affiliate, business unit, department or
division of CNA. This privacy policy continues to apply even when your relationship with CNA has terminated.
WHOM To CONTACT REGARDING PRIVACY MATTERS
If you have questions regarding privacy matters, you may contact Dale Branda by telephone at 312-822-1994, bye-mail
addressed to dale.branda@cna.com, or by mail addressed to CNA Plaza, 42nd Floor South, Chicago, IL 60685, Attn: Dale
Branda.
THIS NOTICE IS PROVIDED ON BEHALF OF CONTINENTAL CASUAL TV COMPANY, A CNA AFFILIATE.
June 2001
2
CNA
333 S.Wabash Ave. Chicago IL 60604 Dale R. Branda
Assistant Vice President
' Marketing&National Account Management
Group Long Term Care
Telephone 312-822-1994
April 17, 2009 Facsimile 312-894-3731
Internet dale.branda@cna.com
Linda Magee
City of Columbia Heights
590 40th Ave NE
Columbia Heights, MN 55421
Amendment to Group Long-Term Care Policy #10212
Underwritten by Continental Casualty Company
Dear Linda:
At the end of 2008 we contacted you with good news about our approval for the Minnesota Partnership
Program. By now, everyone in your plan who qualifies has been notified. We also mentioned that,
while reviewing our policy forms for Partnership approval, the Minnesota Department of Commerce
asked us to change the Continuation of Coverage provision in all our Minnesota policies to reflect
current regulations. The enclosed rider amends your group policy as requested by the Department.
The change affected by this rider applies to everyone insured under a Minnesota contract, whether or
not they qualify for the Minnesota Long Term Care Partnership. The new language has no effect on the
ability of individuals to continue their coverage. All our plans remain fully portable, and individuals may
keep them as long as they continue to pay premiums. There is no change to rates or any other
provision of your CNA Group Long-Term Care policy.
Please attach this rider to your master application and policy for future reference. If you have any
questions, please do not hesitate to contact your account manager, Michael Clark, at (312) 822-2817 or
by e-mail at Michael.Clark @cna.com. We appreciate your business and the opportunity to serve your
employees. If there is anything we can do for you, please do not hesitate to contact us.
Sincerely,
Q:: aLg
10212-1
Continental Casualty Company CNA
333 S. Wabash Ave. A Stock Company
Chicago, Illinois 60604
POLICY AMENDMENT
Holder: City of Columbia Heights
Policy Number: 10212
Effective Date: May 28, 2008
IT IS HEREBY AGREED that, effective on and after the Effective Date indicated above, the Policy to which this
Amendment is attached is amended as follows:
The provision entitled "Continuation of Coverage Due To Termination" is amended to read as follows:
CONTINUATION OF COVERAGE DUE TO TERMINATION
The Insured becomes eligible for continuation of coverage on the date his or her coverage under the Policy
terminates as provided in Paragraphs (a) and (b) of the Individual Terminations provision. Coverage will be
continued by Our issuing a "Conversion Rider" which will, in effect, convert the Insured's group certificate to an
individual long term care policy with no stoppage in coverage. Coverage levels, benefit levels, and premiums will
remain unchanged from that of the group Certificate. The following conditions apply, however, before the
conversion is complete:
(a) The Insured must remit the first quarterly premium to Us for the continued coverage and We must receive it
within 60 days from the date coverage terminates under the Policy or, if a claim started before termination,
when waiver of premium stops. The Insured must remit the first quarterly premium to Us regardless whether
a bill has been sent by Us or received by the Insured. The Insured not receiving a bill for continuation of
coverage is not to be considered a clerical error made by Us or the Holder.
The first quarterly premium for the continued coverage is three times the Insured's monthly premium and is
due on the date coverage terminates under the Policy. The first quarterly premium should be paid by check,
made out to 'Continental Casualty Company' and identify the Insured's Certificate Number and Social
Security Number. The remittance should be sent to CNA-GLTC, P.O. Box 946760, Maitland, FL 32794-
6760.
(b) Upon receipt of the Insured's remittance of the first quarterly premium for continuation coverage, We will
verify that the Insured is eligible for continuation and provide ongoing billings. All future premiums under the
individual policy are due quarterly. The Insured must remit them directly to Us. We will consider requests for
payment modes other than quarterly.
(c) Coverage will be continued with the same benefits and provisions as the group Policy, such that the Insured
is left in the same position as if coverage had not terminated.
(d) The Insured's coverage under the individual policy is effective as of the date coverage terminates under the
group Policy. The Insured will not be covered or receive benefits simultaneously under the group Policy and
the individual policy.
(e) There is no continuation of coverage if Extension of Benefits stops due to the Lifetime Maximum Benefit
having been reached.
S R-M N PTR-01 2 10212-2
This Amendment takes effect at 12:01 a.m., standard time on the Effective Date, at the address of the Holder; it expires
concurrently with the Policy to which it is attached and is subject to all the definitions, conditions and provisions of the
Policy not inconsistent herewith.
Continental Casualty Company
Chairman of the Board
S R-M N PTR-01 3 10212-3