Chapter Six: Mandatory Provisions

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?

Entire 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.

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

10 days Health insurance policies with monthly-due premiums have 10-day grace periods.

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

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

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

15 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.

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.

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

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?

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

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

90 days

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

Grace period 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.

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

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

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

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

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:

Pay the claim 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 facility of payment clause:

States benefits are payable to an individual who is related to the deceased insured by blood or marriage 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.

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

The insurer 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.

Which of the following best describes the claims forms provision?

The insurer must supply claim forms to the insured within 15 days. 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.

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

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