To qualify for benefits:

1. Your Doctor or a Licensed Health Care Practitioner must certify and provide documentation acceptable to Us which shows You have a Cognitive or Functional Impairment. We will require a copy of Your written Plan of Care; and
2. During any one Calendar Week You must receive a minimum of 3 Home Health Care Services, each for a period of at least 1 hour.

How are Benefits Paid?

Subject to the Qualifying for Benefits provision, you will receive a Weekly Benefit while You are receiving Home Health Care Services. Weekly Benefits paid while you are receiving Home Health Care Services are subject to not exceeding: (a) the allowable Maximum Benefit Period; and (b) the Lifetime Maximum Benefit.

Yes. A sickness or injury, disclosed or not disclosed on the application, for which medical care, treatment, diagnosis or advice was received or recommended within the 6 month period immediately prior to your Effective Date of coverage under the Certificate; or the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within the 6 months prior to your Effective Date of coverage under the Certificate. Treatment includes the taking of prescription drugs or medicines.

Any Loss due to a pre-existing condition is not covered unless the Loss begins more than 6 months after the Effective Date of your coverage.

We will not pay Weekly Benefits for Loss:

1. That is a result of war or any act of war, declared or undeclared or any other armed conflict;
2. Due to intentionally self-inflicted injury while sane or insane;
3. Due to injury or sickness arising out of or in the course of employment or which is compensable under any workers’ compensation or occupational disease act or law; or motor vehicle no-fault law;
4. For services provided by a member of the Immediate Family unless: (a) he or she is employed by the Home Health Care Services provider; (b) the Home Health Care Services provider receives payment for the services; and (c) he or she receives no compensation other than the normal compensation for employees of the Home Health Care Services provider.
5. For services not included in Your Plan of Care;
6. For services that would not routinely be paid in the absence of insurance;
7. For care received outside the United States or its territories; or
8. For alcoholism, drug addiction, or chemical dependency, unless as a result of a medication prescribed by a Doctor

Cognitive Impairment: A deterioration or loss in intellectual capacity that requires Substantial Supervision to protect You from threats to Your health and safety. Cognitive Impairment is evaluated and measured by clinical evidence and standardized tests that reliably measure impairment in one’s: (1) short or long-term memory; (2) orientation as to people, places, or time; and (3) deductive or abstract reasoning. Such deterioration or loss of intellectual capacity can be the result of Alzheimer’s disease or similar forms of senility or irreversible dementia.

Functional Impairment: The inability to perform at least 2 of the 6 Activities of Daily Living, listed above, without substantial assistance.

Maximum Benefit Period: The maximum number of Calendar Weeks We will pay a Weekly Benefit for Your receipt of Home Health Care Services during Your lifetime, unless any remaining Lifetime Maximum Benefit dollars are available as provided in this Certificate’s Remaining Lifetime Maximum Benefit provision. The Maximum Benefit Period is shown on the Certificate Schedule.

Remaining Lifetime Maximum Benefit: After Weekly Benefits have been paid up to the Maximum Benefit Period, You will be eligible for any remaining Lifetime Maximum Benefit dollars when:

1. You have not received Home Health Care Services for a period of at least 30 consecutive days; and
2. A Licensed Health Care Practitioner has certified that You have sufficiently recovered enough to no longer qualify as having a Functional or Cognitive Impairment and have been advised that You no longer require Home Health Care Services or other nursing or home care services, whether or not such services are covered under the terms of this Certificate. Remaining Lifetime Maximum Benefits are subject to not exceeding the allowable Maximum Benefit Period. Coverage under this Certificate ends when the Lifetime Maximum Benefit has been exhausted.