Chapter 16

Health insurance policies must include twelve required uniform policy provisions. Each of the following is a required provision, EXCEPT: 1. Change of occupation 2. Reinstatement provision 3. Notice of claim 4. Change of beneficiary

1. Change of occupation

An accident and health policy that may never be cancelled and its premium may never be increased best describes: 1. Non-cancelable 2. Guaranteed renewable 3. Conditionally renewable 4. Optionally renewable

1. Non-cancelable

Questions posed on a health insurance application regarding other health insurance owned by the applicant are designed to prevent which of the following? 1. Over insurance 2. Pre-existing conditions 3. Claim exposures 4. Adverse selection

1. Over insurance

Which of the following policy provisions protects an insured against a small claim that may be present prior to coverage being provided under a new health insurance policy? 1. Pre-existing conditions provision 2. Coordination of benefits provision 3. Duplicate coverage provision 4. Common accident provision

1. Pre-existing conditions provision

An accident and health policy is comprised of many provisions. The purpose of the coordination of benefits provision in group health insurance is to: 1. Prevent profiting by owning an insurance policy 2. Make the insured whole again following a loss 3. Increase benefits for necessary surgery 4. Reduce out-patient benefit payments

1. Prevent profiting by owning an insurance policy

All of the following statements are true regarding the reinstatement provision in a health insurance policy, EXCEPT: 1. Reinstatement may occur without application 2. Illness is covered after a waiting period following reinstatement 3. Automatic reinstatement may occur if an insurer does not respond within 45 days of receipt of the reinstatement application 4. Accidents are covered immediately upon reinstatement

1. Reinstatement may occur without application

Claims must be submitted to an insurer in a timely fashion. Which of the following is correct regarding the claim process? 1. The insured has 20 days to notify the insurer of a claim and the insurer has 15 days to provide claim forms 2. The insured has 15 days to notify the insurer of a claim and the insurer has 20 days to provide claim forms 3. The insured has 10 days to notify the insurer of a claim and the insurer has 20 days to provide claim forms 4. The insured has 10 days to notify the insurer of a claim and the insurer has 10 days to provide claim forms

1. The insured has 20 days to notify the insurer of a claim and the insurer has 15 days to provide claim forms

All of the following statements are true regarding the insuring clause of a health insurance policy, EXCEPT: 1. This provision identifies the length of time that an insured's representations are contestable 2. This provision is generally found on the face page of the policy 3. It identifies the policy period 4. It states that both accidents and sickness can be covered

1. This provision identifies the length of time that an insured's representations are contestable

If an applicant age is under stated on an application for accident and health insurance, which of the following occurs when and if the insurer uncovers the error? 1. Policy is cancelled 2. Benefit is reduced 3. Benefit is increased 4. Benefit will not be affected

2. Benefit is reduced

An optional health insurance policy provision which allows the insurer to adjust benefit payments under certain situations or permits the insured to receive a reduced premium in other circumstances, best describes: 1. Payment of claims 2. Change of occupation 3. Relation of earnings to insurance provision 4. Time limit on certain defenses

2. Change of occupation

An Accident & Health insurer pays a claim and later finds that the insured's injury was the result of engaging in a felony. What will the insurer do? 1. Deny the claim and return the premium 2. Deny the claim 3. Attempt to recover the claim payment 4. Assess an extra premium

2. Deny the claim

Which of the following is not considered to be one of the Required Uniform Accident and Health policy provisions? 1. Grace period 2. Free-look provision 3. Time of payment of claims 4. Claim forms

2. Free-look provision

Waldo purchases a disability income policy covering him in his occupation as a teacher at a local high school. Six years later, Waldo accepts a new position as a demolition expert. What action will his insurer take after he notifies them of his occupational change? 1. Cancel the policy 2. Reduce the monthly benefit amount 3. Reduce the annual premium amount 4. Non-renew the policy on its next anniversary date

2. Reduce the monthly benefit amount

Group health insurance policies are also comprised of several provisions or clauses. A group insurance provision which limits the insured's liability for covered claims is the: 1. Corridor deductible 2. Stop loss provision 3. Restoration of benefits provision 4. Coverage limitation provision

2. Stop loss provision

Which provision states that no action can be brought against an insurer (by the insured) until 60 days after written proof of loss has been furnished to the insurer? 1. Proof of loss 2. Claim forms 3. Legal action 4. Notice of claim

3. Legal action

Major medical insurance includes a policy feature which states that the insurer will pay 100% of covered medical expenses once an insured's out-of-pocket expenses equal a predetermined amount. This feature is known as a: 1. Coinsurance amount 2. Deductible 3. Stop loss limit 4. Absolute limit

3. Stop loss limit

When an insured files a claim with an insurer, he or she cannot take any legal action against the insurance company until what period of time passes? 1. 3 years 2. 30 days 3. 2 years 4. 60 days

4. 60 days

Each of the following is true regarding optional provisions available in a health insurance policy, EXCEPT: 1. Conformity with state statutes' guarantees that the policy complies with state law 2. Misstatement of age permits the insurer to adjust benefits relative to the correct premium 3. Relation of earnings to insurance protects against over-insurance for disability income benefits 4. Illegal occupation provides coverage if an insured is injured while committing a felony

4. Illegal occupation provides coverage if an insured is injured while committing a felony

Which health insurance policy provision states that in consideration of the payment of a premium, the insurer agrees to pay policy benefits to an insured upon receipt of a written proof of loss? 1. The waiver of premium provision 2. The time limit on certain defenses clause 3. The consideration clause 4. The insuring clause

4. The insuring clause

The assignment or transfer of one's interest in a policy to another is allowed. Which of the following best describes the concept of assignment? 1. The legal transfer of the proposed insured's rights and interest under a policy 2. The legal transfer of the insured's rights and interest under a policy 3. The legal transfer of the insurer's rights and interest under a policy 4. The legal transfer of the policyowner's rights and interest under a policy

4. The legal transfer of the policyowner's rights and interest under a policy