2603 POLICY PRACTICES AND PROVISIONS: LIMITATIONS AND EXCLUSIONS

2600

2601

2602

2603

2603.1 A policy shall not be delivered or issued for delivery in the District of Columbia as long-term care insurance if the policy limits or excludes coverage by type of illness, treatment, medical condition, or accident, except for the following reasons:- (a) Preexisting conditions or diseases;

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

- (c) Alcoholism and drug addiction;

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

- (1) War or act of war (whether declared or undeclared);

- (2) Participation in a felony, riot, or insurrection;

- (3) Service in the armed forces or auxiliary units of the armed forces;

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

- (5) Aviation (if insured is non-fare-paying passenger).

- (e) Treatment provided in a government facility (unless otherwise required by law);

- (f) Services for which benefits are available under Medicare or another governmental program (except Medicaid), any state or federal workers' compensation, employer's liability, or occupational disease law, or any motor vehicle no-fault law;

- (g) Services provided by a member of the covered person's immediate family;

(h) Services for which no charge is normally made in the absence of insurance;

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

(j) 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, approved July 30, 1965 (79 Stat. 290; 42 U.S.C. § 1395 et seq.), or would be so reimbursable but for the application of a deductible or coinsurance amount.

2603.2 This section is not intended to prohibit exclusions and limitations by type of provider or territorial limitations.

SOURCE: Final Rulemaking published at 52 DCR 10902 (December 16, 2005); as amended by Final Rulemaking published at 55 DCR 3759 (April 11, 2008).