211 CMR, § 55.100

Current through Register 1533, October 25, 2024

Section 55.100 - Disclosure Statement Required at the Time of Application for the Policy or Contract

REQUIRED DISCLOSURE STATEMENT FOR [ACCELERATED BENEFITS] [EARLY WITHDRAWALS ON ANNUITY PROCEEDS]

[The disclosure statement shall be substantially similar to the following form.]

[(for accelerated benefit products only)

Limitations of the Accelerated Benefit:

The accelerated benefit in this life insurance product may provide benefits to pay for long-term care services, but it is NOT part of a long-termcare or nursing home insurance policy and the amount this product pays you may not be enough to cover your medical, nursing home or other bills. You may use the money you receive from this product for any purpose, unless you qualify for benefits because of Chronic Illness only. If you qualify for benefits because of Chronic Illness only, you may use the benefits to pay for Qualified Long-Term Care Services only. Unlike conventional life insurance proceeds, accelerated benefits payable under this product rider COULD BE TAXABLE IN SOME CIRCUMSTANCES. We recommend that you contact a tax advisor when making tax-related decisions about electing to receive and use benefits from an accelerated benefit product.]

A. Consequences of This Benefit

Receipt of [accelerated benefits][early withdrawals on annuity proceeds] MAY AFFECT MEDICAID and SUPPLEMENTAL SECURITY INCOME ("SSI") ELIGIBILITY. The mere fact that you own a policy with [an accelerated benefit product][an option to make an early withdrawal on annuity proceeds without a surrender charge] may affect your eligibility for these government programs. In addition, exercising the option to [accelerate death benefits][make an early withdrawal on annuity proceeds] and receiving those benefits before you apply for these programs, or while you are receiving government benefits, may affect your initial or continued eligibility. Contact the Medicaid Unit of your local Division of Medical Assistance and the Social Security Administration for more information.

B. Medical Condition(s) enabling [accelerating of life benefit][waiver of surrender charge for early withdrawals]:

[Use whichever are included in the policy.]

(1)[__ Terminal Illness which means a condition that a physician certifies willreasonablybe expected to result in a drastically limited life span as specified in the contract.

(2)___ Chronic Illness which means a condition because of which an individual has been certified by a licensed health care practitioner as:

(a) being unable to perform (without substantial assistance from another individual) at least two Activities of Daily Living for a period of at least 90 days due to a loss of functional capacity;

(b) having a level of disability similar to the level of disability described above; or

(c) requiring substantial supervision to protect such individual from threats to health and safety due to severe cognitive impairment.

(3)___ a medical condition, including but not limited to one of the following specifically named or described conditions, which the insured's physician certifies has required or willrequire extraordinary medical intervention without which the insured would have died, or will die:

(a) Acquired Immune Deficiency Syndrome;

(b) Coronary artery disease resulting in acute infarction or requiring surgery;

(c) End-Stage Renal Disease;

(d) Major organ transplant;

(e) Medical condition requiring continuous life support;

(f) Permanent neurological deficit resulting from cerebral vascular accident; or

(4)___ [other qualifying conditions approved by the Commissioner for this policy. (list condition)____________________________________________]

C. Option(s): [list which of the following will be available at the time of a claim]:

X [insert percentage] of total [death benefit][annuity proceeds] as LUMP SUM (ALWAYS AVAILABLE except in cases that the individual qualifies for benefits because of Chronic Illness only.)

___ [insert percentage] of total [death benefit][annuity proceeds] in periodic payments

___ Up to [insert percentage] of total [death benefit][annuity proceeds] in periodic payments

[Carrier shall describe the terms of any partial distribution or periodic payment plan, including the amount, number, and frequency of payments scheduled.]

D. Premiumfor [Accelerated Benefit][Waiver of Surrender Charges for Early Withdrawals of Annuity Proceeds]: _________________________________

[Carrier shall identify the amount and date due of any separate identifiable charge for the accelerated benefit or for a waiver of the surrender charge for early withdrawals ofannuityproceeds; ifthere is no such charge, the carrier shall indicate that there is no additional charge for the provision.]

E. Administrative Expense Charge: ___________________________________

[Carrier shall include the amount and date due of any administrative expense charged to administer the accelerated benefits and an explanation of the effect on benefits.]

________________ _____________________

Signature of Applicant Signature of Carrier Representative

211 CMR, § 55.100