Long-Term Care Insurance Policy

NEW YORK LIFE INSURANCE COMPANY 51 Madison Avenue, New York, NY 10010 New York Life, Long-Term Care Insurance (800) 224-4582 www.newyorklife.com Long-Term Care Insurance Policy FEDERAL TAX-QUALIFIED COVERAGE: THIS CONTRACT FOR LONG-TERM CARE INSURANCE IS INTENDED TO BE A FEDERALLY QUALIFIED LONG-TERM CARE INSURANCE CONTRACT AND MAY QUALIFY YOU FOR FEDERAL AND STATE TAX BENEFITS. THIS POLICY IS AN APPROVED LONG-TERM CARE INSURANCE POLICY UNDER CALIFORNIA LAW AND REGULATIONS. HOWEVER, THE BENEFITS PAYABLE BY THIS POLICY WILL NOT QUALIFY FOR MEDI-CAL ASSET PROTECTION UNDER THE CALIFORNIA PARTNERSHIP FOR LONG-TERM CARE. FOR INFORMATION ABOUT POLICIES AND CERTIFICATES QUALIFYING UNDER THE CALIFORNIA PARTNERSHIP FOR LONG-TERM CARE, CALL THE [HEALTH INSURANCE COUNSELING AND ADVOCACY PROGRAM AT THE TOLL-FREE NUMBER 1 (800) 434-0222. This Policy is a legal contract between You and New York Life Insurance Company (herein called We, Us, and Our). Please read this Policy carefully and in its entirety. It is issued in exchange for Your Application, and payment of required premiums. This is a long-term care insurance policy that covers Nursing Facility Care, Residential Care Facility, and Home and Community Based Care. 30 Day Free Look Period. Please examine Your Policy promptly. Within 30 days after delivery, You can return the Policy by first class United States mail to New York Life Insurance Company. Upon our receipt of Your Policy a full premium refund will be made to You within 30 days of the Policy’s return and coverage will be void from start. PARTICIPATING. While this Policy is in effect, except while covered under the Extended Coverage Benefit, it is eligible to share in Our divisible surplus. Each year, We will determine the Policy’s share, if any. This share is payable as a dividend on the Policy Anniversary Date if all premiums due before then have been paid. For any year We determine a dividend is payable, the dividend will be used to reduce future premiums. In no event, unless the policy lapses on the Policy Anniversary Date, will the dividend be paid directly to You. Caution. If the answers on Your Application are misstated or untrue, New York Life Insurance Company may have the right to deny benefits or rescind your coverage. The issuance of this Long-Term Care Insurance Policy is based upon Your responses to the questions on Your Application. A copy of YourSPECIMEN Application is attached to this Policy. Upon receipt, please review carefully the copy of the Application attached to this Policy. Please be sure that the information shown is correct and complete and that no medical history or other information is inaccurate or has been omitted from the Application. This Application is part of the Policy and is part of the legal agreement between You and Us. The best time to clear up any questions is now before a claim arises. If, for any reason, any of Your answers are incorrect, contact Us at Our Administrative Offices: New York Life Insurance Company, Long-Term Care Insurance, P.O. Box 64670, St. Paul, MN 55164-0670, 800-224-4582. Notice to Buyer: This Policy may not cover all of the costs associated with long-term care incurred by the buyer during the period of coverage. The buyer is advised to review carefully all Policy provisions, exclusions and limitations. Guaranteed Renewable. This Policy is guaranteed renewable. You have the right, subject to the provisions of this Policy, to continue this Policy as long as You pay the premiums on time. We cannot change any of the provisions of this Policy on Our own without Your consent unless required by federal or state law, except that We have the right to change premium rates for this Policy on a Class basis as described below LTC6 (CA) 1 in the Section titled, Premium Rate Changes, and at any time due to a change in the requirements of applicable law. Premium Rate Changes. We have the right to change the premium rates for this Policy. Premium rate increases are subject to insurance department approval. Premium changes could be necessary if the actual experience of this policy differs from the originally assumed experience that was included in the premiums. Any premium change will be made on a Class basis and will take effect on Your next Policy Anniversary Date. Class means individuals in Your state who are covered under the same policy form with similar benefit design and are classified under the same risks for rating purposes. In the event We change Your premium rate, We will notify You at least 60 days prior to the change taking effect. Premium rates may also change based on any requests you make to change benefits. Insuring Agreement and Effective Date. Subject to all of the provisions, conditions and limitations of this Policy, We will pay the Benefits as described in this Policy. We make this agreement and issue this Policy in consideration of the statements made in the signed Application and payment of the initial premium. This Policy takes effect at 12:01 A.M. Central Time on the Policy Effective Date shown on the Benefit Schedule. THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY. If You are eligible for Medicare, review the “Guide to Health Insurance for People with Medicare” available from Us. SIGNED FOR NEW YORK LIFE INSURANCE COMPANY: CEO and Chairman Secretary SPECIMEN LTC6 (CA) 2 Table of Contents BENEFIT SCHEDULE ..................................................................................................... 5 I. DEFINITION OF TERMS ............................................................................................ 7 II. ELIGIBILITY AND PAYMENT OF BENEFITS PROVISIONS Payment of Benefits ..................................................................................................................................... 16 Eligibility for the Payment of Benefits .......................................................................................................... 16 Additional Benefit Eligibility Provisions ........................................................................................................ 16 Benefit Assessment ..................................................................................................................................... 17 Notification of New Benefits …………………………………………………………………………………………. .................... .17 Increases in Benefits………………………………………………………………………………………………………………………….. 18 No Preexisting Condition Exclusion ............................................................................................................ 18 III. BENEFITS INCLUDED IN THIS POLICY Facility Services Benefits .............................................................................................................................. 19 Facility Bed Reservation Benefit................................................................................................................... 19 Extended Coverage Benefit ......................................................................................................................... 19 Home and Community-Based Care Benefit ................................................................................................ 19 In-Home Support Equipment Benefit .......................................................................................................... 21 Care Plan Benefit .......................................................................................................................................... 21 Caregiver Training Benefit ........................................................................................................................... 22 Caregiver Relief Benefit ................................................................................................................................ 22 Hospice Care Benefit .................................................................................................................................... 22 World Wide Coverage Benefit ...................................................................................................................... 22 Waiver of Premium Benefit ........................................................................................................................... 23 Alternate Plan of Care ................................................................................................................................... 24 Contingent Nonforfeiture Benefit Upon Lapse ........................................................................................... 25 IV. CONDITIONS, LIMITATIONS AND EXCLUSIONS General Exclusions and Limitations ............................................................................................................. 27 Specific Exclusions and LimitationsSPECIMEN ............................................................................................................. 28 V. EFFECT OF OTHER COVERAGE Effect of Medicare......................................................................................................................................... 29 Effect of Medicaid ......................................................................................................................................... 29 Effect of No-Fault Motor Vehicle Insurance and Workers’ Compensation Benefits .................................. 29 VI. CLAIMS Notice of Claim ............................................................................................................................................. 30 Claim Forms .................................................................................................................................................

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