Payment of benefits
The Trust pays 75% of your actual covered charges up to your daily maximum benefit. You are required to pay the remaining portion of the covered charges plus any covered charges that exceed the daily maximum benefit.
However, before paying any benefits, we must determine if any of your expenses are eligible for payment through other sources (e.g., Medicare, group health insurance, worker’s compensation). To the extent that your expenses can be covered by another source, the Trust will not pay long term care benefits.
If your expenses are only partially covered through other sources, we will calculate the amount that we would have paid if you had no other coverage. Then, following payment from the other sources, we will pay the remaining portion of your covered charges up to our calculated maximum.
In general, long term care benefits are paid until you are no longer functionally incapacitated as defined by the policy, or until you have exhausted the lifetime maximum benefit, whichever occurs first. The lifetime maximum benefit is the total amount of dollars available for your long term care services over your lifetime. The lifetime maximum benefit amount changes each September.
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