11/1 Quiz: MANDATORY PROVISIONS

All of the following are characteristics of the reinstatement provision for individual health insurance, EXCEPT:

Sickness has a 10-day waiting period. The correct answer is: Sicknesses are covered once a policy is reinstated.

All of the following are provisions that relate to the filing of claims and payment of benefits in health insurance, EXCEPT:

The Grace Period is the provision that allows a premium payment to be received for a certain period of time after the actual due date. The correct answer is: Grace period

Which of the following best describes the entire contract-changes provision?

The entire contract-changes provision states that modifications to an insurance contract may only be made by an executive officer of the insurer. The correct answer is: Only an executive officer of the insurer may make changes to an insurance contract.

Upon receipt of a notice of claim, the insurer must provide the potential claimant the proper claims form within how many days?

The insurer must furnish forms within 15 days. If it does not, the insured may provide proof of cause in written form in any manner they choose. The correct answer is: 15 days

Which of the following best describes the claims forms provision?

The insurer must supply claim forms to the insured for submitting proof of loss within 15 days of receiving notice of the claim, the insured may submit proof of loss on any piece of paper or in any manner the insured wishes. The insurer will be required to accept this as proof of loss. The correct answer is: The insurer must supply claim forms to the insured within 15 days.

For how many days must an insured wait after filing a claim with an insurance company before filing a legal suit against the company?

The legal action provision prohibits the insured from suing the insurer for at least 60 days after filing a written proof of loss. The company needs time to investigate and evaluate the claim. The correct answer is: 60 days

All of the following are required provisions for health and accident policies, EXCEPT:

The misstatement of age provision is an optional health and accident policy provision. The correct answer is: Misstatement of age

"Indemnities payable under this policy for any loss will be paid immediately upon receipt of due written proof of loss." This statement appears in the:

The time of payment of claims provision puts the burden on the insurance company to pay all claims in a timely manner. The correct answer is: Time of payment of claims provision

How long is the grace period for health insurance policies with monthly-due premiums?

Health insurance policies with monthly-due premiums have 10-day grace periods. The correct answer is: 10 days

What happens to Jacob's policy if he does not pay the premium by the end of the grace period?

If Jacob does not pay his premium by the end of the grace period, his policy will lapse. The correct answer is: Jacob's policy will lapse.

If an individual misstates their age on the application and the company chooses to cover an illness, it will base coverage on the:

If it chooses to retain the policy, the insurer will pay what the premium would purchase at the person's true age. The correct answer is: Amount of coverage the policy would provide at the individual's true age

An insurer may require all of the following to reinstate a health policy, EXCEPT:

Insurers cannot require the applicant to pay a reinstatement application fee. The correct answer is: Reinstatement application fee

The facility of payment clause:

The facility of payment clause states that benefits are payable to an individual who is related to the deceased insured by blood or marriage. This clause is optional. The correct answer is: States benefits are payable to an individual who is related to the deceased insured by blood or marriage

Samuel Johnson pays his health insurance premium quarterly. If he fails to make payment on April 1, when will his grace period expire?

The grace period for all premium periods over monthly is 31 days. His grace period would expire on May 1. The correct answer is: 1-May

For individual health insurance policies, how soon must the insured submit proof of loss to the insurer?

For individual health insurance policies, proof of loss must be submitted to the insurer within 90 days of the date of loss. The correct answer is: 90 days

For individual health insurance policies, how soon must the insured/claimant submit proof of loss to the insurance company?

Proof of loss must be submitted to the insurer within 90 days of the date of loss. The correct answer is: Within 90 days of the date of loss

If a company decides to reinstate a policy, when does coverage begin for losses caused by accident?

The reinstatement provision states that a reinstated policy will cover accidents that occur after reinstatement. The correct answer is: Immediately

According to the Physical Examination and Autopsy provision, who is responsible for paying the cost of examining the insured?

Where not prohibited by law, the insurer may request that a physical examination or autopsy of the insured be performed while a claim is pending. The cost of such procedure is the insurer's responsibility. The correct answer is: The insurer

How long is the grace period for individual health insurance coverage paid on a monthly basis?

Based on the NAIC required provision #3, the grace period for individual health insurance paid on a monthly basis is 10 days. The correct answer is: 10 days

Which of the following provisions designates the person to whom claim payments are to be made?

Information regarding beneficiary is contained in the payment of claims provision. The correct answer is: Payment of claims

For individual health insurance policies, an insurer may not request which of the following for a policy reinstatement?

Insurers cannot require the applicant to pay a reinstatement application fee. The correct answer is: Reinstatement fee

For individual health insurance policies, legal action may be taken against the insurer for up to ____ years from the date proof of loss is provided to the insurer.

Legal action cannot be brought after three years from the date proof of loss is provided to the insurer. The correct answer is: 3

Which of the following best describes the purpose of the incontestability provision?

The incontestability provision allows the insurer to contest any misstatement, omission or concealment made in the application. The correct answer is: Allows the insurer to contest misrepresentations in the application during the first two policy years

How much time does an insured have after filing a claim with an insurance company in which to file a legal suit against the insurer?

The insured has up to 3 years after filing a claim with an insurance company in which to file a legal suit against the insurer. The correct answer is: Three years from the date proof of loss is furnished

For individual health insurance policies, how soon must the insured/claimant provide the insurance company with notice of claim?

The notice of claim provision requires that the insurer be notified of a claim within 20 days of the date of loss. The correct answer is: Within 20 days of the date of loss

Before paying a claim, an insurance company asks an insured to have a medical examination, at its expense. The insured:

The physical examination and autopsy clause gives the insurer the right to require a medical examination. The correct answer is: Must comply with the request because the physical examination and autopsy clause requires it

If a company decides to reinstate a policy, when does coverage begin for losses caused by sickness?

The reinstatement provision states that a reinstated policy will cover only sickness losses that begin more than 10 days after reinstatement. The correct answer is: 10 days

The NAIC Uniform Provisions Law applies to:

The Uniform Individual Accident and Sickness Policy Provisions Law only applies to individual accident and sickness policies. The correct answer is: Individual health insurance policies

The entire contract includes:

The entire contract provision in an insurance contract states that the complete agreement between the insured and the insurer is contained in the contract. This includes the policy and any attached papers, including declarations, exclusions, conditions, and endorsements. The correct answer is: All of the above

According to the claims form provision in a health insurance policy, what is the insured entitled to do if the insurance company does not send out the claim forms within the specified time period?

If the insurer does not provide claim forms to the insured within the specified period, the insured may submit proof of loss on any form. The correct answer is: Submit the claim on any form, which the insurance company must accept as proof of loss

Under the claim forms provision, what is the insured allowed to do, if the insurer does not provide claim forms within 15 days?

If the insurer does not supply claim forms to the insured for submitting proof of loss within 15 days of receiving notice of the claim, the insured may submit proof of loss on any piece of paper or in any manner the insured wishes. The insurer will be required to accept this as proof of loss. The correct answer is: The insured may submit the proof of loss on any form or manner to the insurer.

How soon after a loss must an insured under a health insurance policy provide notice of claim to the insurer?

The insured must provide written notice of loss to the insurer within 20 days of the loss. The correct answer is: 20 days

All of the following are required provisions under the NAIC Uniform Provisions Law, EXCEPT:

The misstatement of age provision is optional. The correct answer is: Misstatement of age

An insured requests a claim form from their insurer for a covered loss. The health insurer fails to send out claims forms to the insured within the time period required by the claims form provision. Under the claims form provision, the insured should:

According to the claims form provision, the insurer must accept any claims form as sufficient proof of loss if the insurer has not provided forms for claims. The insured is obligated only to provide proof of loss in writing. The correct answer is: Submit the claim using any form, which the insurer is obliged to accept as proof of loss

How are grace periods established for health insurance policies?

The length of the grace period depends on the premium payment mode (how frequently premiums are paid). The correct answer is: Grace periods are based on the premium payment mode.

For individual health insurance policies, who is responsible for paying the cost of autopsy or examination of an insured, according to the physical examination and autopsy provision?

Where not prohibited by law, the insurer may request that a physical examination or autopsy of the insured be performed while a claim is pending. The cost of such procedure is the insurer's responsibility. The correct answer is: The insurance company

To which type of health insurance policies does the NAIC Uniform Provisions Law apply?

The Uniform Individual Accident and Sickness Policy Provisions Law only applies to individual accident and sickness policies. The correct answer is: Individual health insurance policies

While investigating a current claim, an insurance company learns the insured claimant had not included their full medical history on the application and that the current claim results from a condition that was probably pre-existing 4 years ago, when the application was approved. The company will:

The company may not refuse to pay the claim because of the time limit that is placed on pre-existing conditions and misstatements. In most states, after the policy has been in force for 3 years, the insurer may not refuse to pay claims using the misrepresentation or pre-existing conditions defense. The correct answer is: Pay the claim

All of the following are false regarding the reinstatement provision for individual health policies, EXCEPT:

Once a health insurance policy is reinstated, accidents are covered immediately, but sicknesses are not covered until 10 days have passed from the date of reinstatement. The correct answer is: Accidents are covered immediately upon reinstatement, and sicknesses are covered after a 10-day waiting period.

The entire contract provision in a health and accident policy includes two basic parts. These are:

The entire contract provision in an insurance contract states that the complete agreement between the insured and the insurer is contained in the contract. This includes the policy and any attached papers, including declarations, exclusions, conditions, and endorsements. The other 3 choices are incorrect because they are too limited. The contract includes all attached papers. The correct answer is: Policy and any attached papers

Notice of claim must be provided to the insurer within:

The notice of claim provision requires that the insurer be notified of a claim within 20 days of the date of loss. The correct answer is: 20 days of the date of loss

Of the following health insurance provisions, which states that an insurance agent may not waive any provision or make any change in an insurance contract?

The entire contract provision states that any change to the policy must be made by an executive officer of the insurance company, with consent of all parties to the contract. An agent is not granted authority, under any circumstances, to make a change to a policy, or waive any provision. The correct answer is: Entire contract

Marilyn Woodson has always paid her health insurance premium quarterly. She recently changed the payment period to weekly. What will the grace period be on the new cycle?

The grace period for weekly premium periods is 7 days. The correct answer is: 7 days

Adam fails to pay his premium for his health insurance policy before the end of the grace period. A couple months later, Adam decides he wants to reinstate his policy. He submits a policy application to the insurance company. Adam does not receive a reply from the insurer. If his application is accepted, when will the policy be reinstated?

Unless denied, reinstatement is considered to be effective on the 45th day after the reinstatement application is submitted to the insurer. The correct answer is: 45 days after the reinstatement application is submitted to the insurer