Chapter six Health insurance policy provisions xcel

Under a medical expense policy the provision that addresses to whom the insurer must pay benefits is called

Payment of claims

The required health provision which obligates the insurer to initiate action is called the

Payment of claims provision

Which of these Statements accurately describes the waiver of premium provision in an accident and health policy

Premiums are waived after the insured has been totally disabled for a specified time period

What is considered to be characteristic of a conditionally renewable health insurance policy?

Premiums may increase at time of renewal

Which of the following statements about guaranteed renewable health insurance policy is correct

Premiums normally increase at time of renewal

What is the purpose of the time of payments of claims provision

Prevents delayed claim payments made by the insurer

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

Proof of Loss

If an insurance company issues a Disability Income policy that it cannot cancel or for which it cannot increase premiums, the type of renewability that best desribes this policy is called

noncancellable

What type of renewability guarantees premium rates and renewability?

noncancellable

Which of these is considered a mandatory provision?

Payment of Claims

Periodic health claim payments MUST be made at least

monthly

For individual health policies insureds who pay monthly premiums are given a grace period of

10 days

Company has how many days can you deliver claim forms to an insured after the insured gives notice of claim

15 days

When a material misstatement is discovered on an application for health insurance the insurer may contest the claim payment during what period of time following the issuance of the policy?

2 years

An insured must notify an insurer of a medical claim within how many days after an accident?

20

How many days must an insured notify the insurer of a claim under the notice of claim provisions.

20 days

And insured pays the premiums on an annual basis for an individual health insurance policy. What is the minimum number of days for the grace period provision

31

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

How many days from the date of loss messed a health insurance policy owner file proof of loss after receiving claim forms for the insurer

90 days

Mary reinstated her individual major medical policy. What will happen with mary's coverage

Accident coverage will begin May 10; Sickness coverage will begin May 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

Which of the following statements best describes what the legal actions provision of an accident and health policy requires

An insured must wait at least 60 days after Proof of Loss has been submitted before a lawsuit can be filed

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

At the policy's inception

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

Change of occupation provision

If a policyowner has a guaranteed renewable health insurance policy the contract guarantees

Continuing coverage only

If a disability income policy holder is promoted to a position In the same company that inherently Hold less risk of injury and notifies the insurance company of this change in status the disability income premium will

Decrease

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

When an insurance company sends a policy to the insured with an attached application, the element that makes the application part of the contract between the insured and the insurer is called the

Entire Contract provision

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

Which of the following provisions specifies how long a policyowners health coverage Will remain in effect if the policy owner does not pay the premium is due

Grace period

The time limit on certain defenses clause states that the

Insurer can contest the validity of statements made on a health insurance application for up to 2 years

Which health policy clause specifies the amount of benefits to be paid?

Insuring

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

Insuring clause

Which of the following health insurance policy provisions specifies the healthcare services a policy will provide

Insuring clause

Kathy Has a family health insurance policy where any dependent children she has are removed from the policy they have reached a certain age what is this age called

Limiting age

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

Lenny Who was an IT administrator recently switched professions and is now a firefighter. He owns a Disability income policy that pays a benefit of $5,000 per month, but he did not tell his insurer that he is now a firefighter. If Lenny is injured, how will the insurer handle this claim?

Pay less than $5000 a month

The provision that defines to whom the insurer will pay benefits to is called

Payment of Claims

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

Which of the following statements best describes an impairment rider for a medical expense policy?

Specific health conditions are covered by a reinsurer

Which of the following statements describes the purpose of the insuring clause in health and accident policies

States the scope and limits of the coverage

What should an insured do if the insurer does not send claims forms within the time period set forth in a health policy's Claims Forms provision?

Submit the claim in any form

The legal action provision states how much time an insured has to

Sue the insurer

A disability income policyowner recently submitted a claim for a chronic neck Problem that has now resulted in total disability. Do you original neck injury occurred before the application was taken 5 yeas prior. The neck injury was never disclosed to the insurer at the time of application. How will the insurer handle this claim

The claim will be paid and coverage will remain in force

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

T files a claim on his Accident and Health policy after being treated for an illness. The insurance company believes that T misrepresented his actual health on the initial insurance application and is, therefore, disputing the claim's validity. The provision that limits the time period during which the company may dispute a claim's validity is called

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

An underwriter determines that an applicant's risk should be recategorized due to a health issue. This policy may be issued with a(n)

exclusion for the medical condition

M completes an application for life insurance but does not pay the initial premium. All of these actions must occur before M's policy goes into effect EXCEPT

free-look period has expired

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

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

Which Accident and Health policy provision addresses preexisting conditions?

Time Limit on Certain Defenses

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

Time limit on certain defenses

If an individual has an accidental death and dismemberment policy and dies, and autopsy can be performed in all of these situations except

When the state prohibits this law

Uniform individual health policy provision Law Can an autopsy be required by an insurer

Yes unless state law forbids

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?

insured

A policy owner's rights are limited under which beneficiary designation?

irrevocable

A policyowner would like to change the beneficiary on an Accidental Death and Dismemberment (AD&D) insurance policy and make the change permanent. Which type of designation would fulfill this need?

irrevocable

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

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

nonrenewable

The notice of claims provision requires a policyowner to:

notify an insurer of a claim within a specified time

With Optionally Renewable Health policies, the insurer may

review the policy annually and determine whether or not to renew it