Chapter 6 (Health Provisions)

K has a health policy that must be renewed by the insurer and the premiums can only be increased if applied to the entire class of insureds. This type of policy is considered:

Guaranteed renewable

What is the purpose of the Time of Payment of Claims provision?

Prevents delayed claim payments made by the insurer

Vhat must the policyowner provide to the insurer for validation that a loss has occurred?

Proof of Loss

A Disability Income policy that only the policyowner can terminate and which the rates will never go up is considered to be

noncancellable

Which of the following BEST describes a short-term medical expense policy?

nonrenewable

Which of the following is considered to be the time period after a Health. Policy is issued, during which no benefits are provided for illness?

probationary period

Periodic health claim payments MUST be made at least:

monthly

K failed to pay a renewal premium within the time granted by the insurer. K then sends in a payment which the insurer subsequently accepts. Which policy provision specifies that coverage may be restored in this situation?

Reinstatement

If an individual is covered under an Accidental Death Policy and dies, an autopsy can be performed in all these situations, EXCEPT:

When the state prohibits this by law

According to the Mandatory Uniform Policy Provisions, what is the maximum amount of time after the premium due date during which the policy remains in force even though the premium has not been paid?

31 days

An insured pays premiums on an annual basis for an individual health insurance policy. What is the MINIMUM number of days for the Grace Period provision?

31 days

M's insurance company denied a reinstatement application for her lapsed health insurance policy. The company did not notify M of this denial. How many days from the reinstatement application date does the insurance company have to notify M of the denial before the policy will be automatically placed back in force?

45 days

P is a Major Medical policyowner who is hospitalized as a result of injuries sustained from participating in a carjacking. How will the insurer most likely handle this claim?

Claim will be denied

G is involved in an automobile accident as a result of driving while intoxicated and suffers numerous injuries. According to the Intoxicants and Narcotics exclusion in G's policy, who is responsible for paying the medical bills?

The insured

The Legal Actions provision of an insurance contract is designed to do all of the following, EXCEPT:

protect the producer

Which of the following policy provisions prohibits an insurance company from incorporating extern. documents into an insurance policy?

Entire Contract

S filed a written Proof of Loss for a Disability Income claim on September 1. The insurance company did not respond to the claim. S can take legal action against the insurer beginning:

November 1 (60 days)

The insured and insurance company will share the cost of covered losses under which health policy feature?

Payment of Claims provision

What is considered to be a characteristic of a Conditionally Renewable Health Insurance policy?

Premiums may increase at time of renewal

An insurer must provide an insured with claim forms within ____ days after receiving notice of a loss.

15 days

An insured must notify an insurer of a medical claim within _____ days after an accident

20

Which of the following statements describes what an Accident and Health policyowner may NOT do?

Adjust the premium payments

In health insurance policies, a waiver of premium provision keeps the coverage in force without premium payments:

After an insured has become totally disabled as defined in the policy

When does a Probationary Period provision become effective in a health insurance contract?

At the policy's inception

A Disability Income policyowner recently submitted a claim for a chronic neck problem that has now resulted in total disability. The original neck injury occurred before the application was taken 5 years prior. The neck injury was never disclosed to the insurer at the time of application. How will the insurer handle this claim?

Claim will be paid and coverage will remain in force

An insurance company receives E's application for an individual health policy. E did not complete all of the medical history questions because she could not remember the exact dates. E signed the policy and submitted it to the insurance company anyway. A few weeks later, E suffers a heart attack and is hospitalized without completing the medical history questions and paying the initial premium. E is not insured. Which of the following clauses details the conditions that E did not meet?

Consideration clause

S is the policyowner of a Major Medical policy. The premiums are paid monthly and due on the 1st of each month. S fails to make September's payment and is hospitalized October 15th. When S files the claim for this hospitalization, the insurer will likely

Deny the claim

The sections of an insurance contract which limit coverage are called:

Exclusions

Which of the following is NOT included in the policy face?

Exclusions

After an insured gives notice of loss, what must he/she do if the insurer does not furish forms?

File written proof of loss

With Accidental Death and Dismemberment policies, what is the purpose of the Grace Period?

Gives the policyowner additional time to pay past due premiums

X is insured with a Disability Income policy that provides coverage until age 65. This policy allows the insurer to change the premium rate for the overall risk class assigned. Which of these renewability features does this policy contain?

Guaranteed renewable

T applied for a Disability Income policy and has a history of back injuries. The insurer issued the policy with a statement that excludes coverage for back injuries. This statement is called a(n)

Impairment rider

According to the Time Payment of Claims provision, the insurer must pay Disability Income benefits no less frequently than which of the following options?

Monthly

A Disability Income policy that only the policyowner can terminate and which the rates will never go up is considered to be

Noncancelable

Which of these is considered a mandatory provision?

Payment of Claims

J, an Accidental Death and Dismemberment (AD&D) policy holder, dies after injuries sustained in an accident. J's age, as stated on the application five years ago, was found to be understated by ten years. Which of the following actions will the insurance company take?

The insurer will adjust the benefit to what the premiums paid would have purchased at the insured's actual age

The policy provision that entitles the insurer to establish conditions the insured must meet while a claim

Time Limit on Certain Defenses

The policy provision that entitles the insurer to establish conditions the insured must meet while a claim is pending is:

Time Limit on Certain Defenses

Health insurance benefits NOT covered due to an act of war are:

excluded by the insurer in the contract provisions

T sends proof of loss to her insurer for an acceptable medical expense claim under her individual Health Insurance policy. Upon receipt, the insurer must pay the benefits

immediately

When an insured changes to a more hazardous occupation, which disability policy provisior insurer to adjust policy benefits and rates?

Change of occupation provision

A(n) ______ of benefits of a Health Policy transfers payments to someone other than the policyowner

assignment

"A producer does not have the authority to change a policy or waive any of its provisions". The health provision that best describes this statement is called the

Entire Contract

Which health policy clause stipulates that an insurance company must attach a copy of the application to the policy to ensure that it is part of the contract?

Entire Contract

Towns an Accident & Health policy and notifies her insurance company that she has chosen a less hazardous occupation. Under the Change of Occupation provision, which of the following actions may her insurance company take?

Increase her policy's coverage amount

What is the initial requirement for an insured to become eligible for benefits under the Waiver of Premium provision?

Insured must be under a physician's care

The clause in an Accident and Health policy which defines the benefit amounts the insurer will pay is called the:

Insuring clause