§431:10H-203 - Limitations and exclusions.

§431:10H-203 Limitations and
exclusions. (a) A policy may not be
delivered or issued for delivery in this State as long-term care insurance if
the policy limits or excludes coverage by type of illness, treatment, medical
condition, or accident, except as follows:

(1) Preexisting conditions or diseases;

(2) Mental or nervous disorders; however, this shall
not permit exclusion or limitation of benefits on the basis of Alzheimer's
disease;

(3) Alcoholism and drug addiction;

(4) Illness, treatment, or medical condition arising
out of:

(A) War or act of war, whether declared or
undeclared;

(B) Participation in a felony, riot, or
insurrection;

(D) Suicide (sane or insane), attempted suicide,
or intentionally self-inflicted injury; or

(E) Aviation (this exclusion applies only to
non-fare-paying passengers);

(5) Treatment provided in a government facility
(unless required by law), services for which benefits are available under
medicare or other governmental program (except medicaid), any state or federal
workers' compensation, employer's liability, or occupational disease law, or
any motor vehicle insurance law, services provided by a member of the covered
person's immediate family, and services for which no charge is normally made in
the absence of insurance;

(6) Expenses for services or items available or paid
under another long-term care insurance or health insurance policy; or

(7) In the case of a qualified long-term care
insurance contract, expenses for services or items to the extent that the
expenses are reimbursable under Title XVIII of the Social Security Act or would
be so reimbursable but for the application of a deductible or coinsurance
amount.

(b) This section is not intended to prohibit
exclusions and limitations by type of provider. However, no long-term care
issuer may deny a claim because services are provided in a state other than the
state of policy issue under the following conditions:

(1) When the state other than the state of policy
issue does not have the provider licensing, certification, or registration
required in the policy, but where the provider satisfies the policy
requirements outlined for providers in lieu of licensure, certification,
registration; or

(2) When the state other than the state of policy
issue licenses, certifies, or registers the provider under another name.

For purposes of this subsection, "state of
policy issue" means the state in which the individual policy or
certificate was originally issued.