NAC687B.090. Exclusions from and limitations on coverage.

     1. A long-term care insurance contract may not be delivered or issued for delivery in this State as long-term care insurance if the long-term care insurance contract limits or excludes coverage by type of illness, treatment, medical condition or accident, except for:

     (a) Preexisting conditions or diseases.

     (b) Mental or nervous disorders. This exception does not allow a limitation of benefits or exclusion of coverage on the basis of Alzheimer’s Disease.

     (c) Alcoholism and drug addiction.

     (d) Any illness, treatment or medical condition arising out of:

          (1) A war or an act of war, whether declared or undeclared.

          (2) Participation in a felony, riot or insurrection.

          (3) Service in the Armed Forces or units auxiliary thereto.

          (4) Suicide, attempted suicide or intentionally self-inflicted injury.

          (5) Aviation. This exclusion applies only to passengers who do not pay fares.

     (e) Treatment provided in a governmental facility, unless otherwise required by law, services for which benefits are available under Medicare or another governmental program, except Medicaid, and treatment received pursuant to any state or federal program for workers’ compensation, employer’s liability or occupational disease.

     (f) Treatment provided pursuant to any law governing no-fault insurance for motor vehicles.

     (g) Services provided by a member of the insured person’s immediate family.

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

     (i) Services or items available from or paid by another long-term care insurance contract.

     (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 Medicare or would be so reimbursable but for the application of a deductible or coinsurance amount.

     2. This section does not prohibit territorial limitations.

     3. Notwithstanding the provisions of subsection 2, no issuer of long-term care insurance may deny a claim because services are provided in a state other than the state in which the long-term care insurance contract or certificate was issued when the state in which services are provided:

     (a) Does not license, certify or register providers as required in the long-term care insurance contract or certificate, but the provider otherwise satisfies the requirements of the long-term care insurance contract or certificate; or

     (b) Licenses, certifies or registers providers under another name.

     4. For the purposes of this section, “preexisting condition” means a medical condition of a person for which he or she has received treatment during the 6 months preceding the effective date of the long-term care insurance contract.

     (Added to NAC by Comm’r of Insurance, eff. 11-21-88; A 1-11-90; A 1-4-91; R028-10, 12-16-2010, eff. 10-1-2011)