A claim is submitted for care related to a heart condition diagnosed two years before a long-term care policy was issued. The policy's pre-existing-condition exclusion is drafted broadly. Under Pennsylvania's long-term care pre-existing-condition rules (40 P.S. § 991.1107), which principle governs the insurer's handling of the claim?
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Why A is correct
Section 40 P.S. § 991.1107 polices how pre-existing-condition limitations are used in Pennsylvania long-term care policies: the exclusion operates only within the statutory structure built by 40 P.S. § 991.1105(c) — a defined look-back to advice, diagnosis, care, or treatment, and a limited exclusion period. A broadly drafted exclusion cannot stretch beyond those bounds, and it cannot become a basis for denying claims outside the framework, such as for unrelated conditions. The Pennsylvania Insurance Department reads these provisions together as a unit: definition, limit, and application.
Why the other options are wrong
- B) The statute permits a limited pre-existing-condition exclusion; it does not make long-term care benefits immune from properly applied limitations.
- C) The reach of the exclusion is confined by the statutory look-back and the relation to the care claimed; any-condition-any-time denial exceeds the statute.
- D) The federal Medicare program plays no adjudicative role in the insurer's pre-existing-condition analysis under Pennsylvania law.
Memory hook
Broad wording, bounded use: the statute caps how far an exclusion can stretch.