Exam

An insured is covered by a partially contributory group disability income plan that pays benefits of $4,000 a month. If the insured pays 25% of the monthly premium, how much of the monthly benefit would be taxable?

$3,000

An insured has a major medical policy with a $500 deductible and 80/20 coinsurance. The insured is hospitalized and sustains a $2,500 bill. What is the maximum amount that the insured will have to pay?

$900

An insured buys an individual long-term care policy and is not satisfied with the provisions. Within how many days will the insured be able to return the policy for a full premium refund?

10 days

Within how many days must a carrier send an insured a written acknowledgement of the receipt of the insured's grievance?

15 days

The time limit of certain defenses provision prohibits insurers from denying a claim due to misrepresentation, as long as the policy has been in force for at least

2 years

If a pro producer is found guilty of a violation that caused claimant to suffer actual economic damages what is the punishment?

25%

What is the duration of the free-look period for Medicare supplement policies?

30 days

The Commissioner must examine each domestic and foreign company in order to determine its financial condition, ability to fulfill its obligations, compliance with insurance laws, and dealings with its policyholders at least once every

5 years

A carrier must maintain records of each grievance process for how many years?

7 years

Accidental death benefits are paid as long as death occurs within

90 days

Under the mandatory uniform provision notice of claim, the first notice of injury or sickness, covered under an accident and health policy must contain

A statement that is sufficiently clear to identify the insured and the nature of the claim.

If during the underwriting process an insurer obtains personal information about an applicant from the applicant, when must the insurer provide notice of its information practices?

At the time of policy delivery

Employees actively at work on the date coverage is transferred to another insurance carrier are

Automatically covered and exempt from any probationary period.

Which of the following is NOT required to be stated in the outline of coverage provided with a long-term care policy?

Basic information about supplementary policies

An insured is the recipient of an Accidental Death and Dismemberment (AD&D) policy purchased by his employer. The policy pays triple indemnity in case of accidental death. If the insured died as a result of an accident stipulated in the policy, how will the benefits paid be taxed?

Benefits received are considered income tax free.

Who must sign the notice regarding replacement

Both the applicant and agent

When an insurer offers services like preadmission testing, second opinions regarding surgery, and preventative care, which term would best apply?

Case management provision

Which of the following is not a characteristic or a service of an HMO plan?

Contracting with insurance companies

All of the following statements concerning accidental death and dismemberment coverage are correct, except

Death benefits are paid only if death occurs within 24 hours of an accident

All of the following could be considered rebates if offered to an insured in the sale of insurance EXCEPT

Dividends from a mutual insurer.

All of the following could be considered rebates if offered to an insured in the sale of insurance, except

Dividends from a mutual insurer.

Purpose of HMO

Early detection and regular check ups

In a group policy, the contract is between

Employer and insurance company

The HMO Act of 1973 required employers to offer an HMO plan as an alternative to regular health plans if the company had more than 25 employees. How has this plan since changed?

Employers are no longer forced to offer HMO plans.

Which types of insurance companies marketing long-term care insurance coverage must establish procedures to assure that any comparison of policies by its agents will be fair and accurate?

Every company is required to establish marketing procedures.

What type of group rating uses the actual experience of the group as a factor in developing the rates to be charged?

Experience rating

Occupation, definition of disability applies

For the first two years

As it pertains to group health insurance, cobra, stipulates, that

Group coverage must be extended for terminated employees up to a certain period of time at the former employee's expense.

the event of loss, after a notice of claim is submitted to the insurer, who is responsible for providing claims forms and to which party?

Insurer to the insured

The insurer may suspect that a moral hazard exists if the policyholder

Is not honest about his health on an application for insurance

Which of the following is true regarding the taxation of the premium in group accidental death and dismemberment policies?

It is deductible as an ordinary business expense

Which of the following is true regarding the taxation of the premium in group, accidental death and dismemberment policies

It is deductible as an ordinary business expense

Which of the following statements concerning Medicare Part B is correct?

It pays for physician services, diagnostic tests, and physical therapy.

The reason for paying a benefit amount that is less than the insurance income is because

It prevents over utilization and malingering

Which of the following statements is not correct concerning the cobra act of 1985

It requires all employers, regardless of the number or age of employees, to provide extended group health coverage.

A policyowner is reading a statement on the first page of his health insurance policy, which says "this is a limited policy." What is the name of this statement?

Limited Policy Notice

In franchise insurance premiums are usually

Lower than individual policies, but higher than group policies.

Julie must have orthodontic work performed on her incisors. Which type of service would this be called, under a nonscheduled plan?

Major service

In group insurance, what is the policy called?

Master policy

To sign up for a Medicare prescription drug plan, individuals must first be enrolled in

Medicare Part A

Under which of the following organizations are the practicing providers compensated on a fee-for-service basis?

PPO

Which of the following factors would be an underwriting consideration for a small employer carrier?

Percentage of participation

A Notice of Information Practices must be given to the applicants for an insurance policy at all of the following events EXCEPT

Policy applications

Fee for fee basis

Ppo

Under which provision can a physician submit claim information prior to providing treatment

Prospective review

A healthy insured person that is fit and eat healthy is what risk

Reduction

Which of the following would qualify as a competent party in an insurance contract?

The applicant has a prior felony conviction

In a group policy, who is issued a certificate of insurance

The individual insured

In a group policy, who is issued a certificate of insurance?

The individual insured

When Linda suffered a broken hip, she notified her agent, in writing, within 12 days of the loss. However, her agent did not notify the insurance company until 60 days after the loss. Which of the following statements correctly explains how this claim would be handled?

The insurer is considered to be notified since the notification to agent equals notification to the insurer.

Which of the following is true regarding optional benefits with long-term care policies?

They are available for an additional premium

An insured notifies the insurance company that he has become disabled. What provision states that claims must be paid immediately upon written proof of loss?

Time of Payment of Claims

The purpose of managed care health insurance plans is to

To control health insurance claims expenses

Which of the following is NOT a goal of risk retention?

To minimize the insured's level of liability in the event of loss

When is group disability income benefits, not taxable as income

When benefits received equal or less than employees percentage

Part C of Medicare

allows private health insurance companies to provide Medicare benefits

Occasional visits by which of the following medical professionals will NOT be covered under LTC's home health care?

attending physician

Which of the following health care plans would most likely provide the insured/subscriber with comprehensive health care coverage?

health maintenance organization plan

The provision which prevents the insured from bringing any legal action against the company for at least 60 days after proof of loss is known as

legal actions

Which of the following is the basis for a claim against an insurance policy?

loss

When compared with the administrative cost, found in individual coverage, the per capita administrative cost in group health insurance is

lower

A health insurance plan which involves financing, managing, and delivery of health care services and involves a group of providers who share in the financial risk of the plan or who have an incentive to deliver cost effective service, is called

managed care plan

The causes of loss insured against in an insurance policy are known as

perils

An applicant for health insurance has not had a medical claim in 5 years. He exercises daily and does not smoke or drink. What classification do you assume the applicant would receive from his insurer?

preferred

Which of the following is not provided by an HMO

reimbursement

An applicant is considered to be high risk, but not so much that the insurer wants to deny coverage. Which of the following is not true?

the insurer will issue a conditional coverage

An insured pays a monthly premium of $100 for her health insurance. What would be the duration of the grace period under her policy?

10 days

Insured health plans must provide mental health benefits on a nondiscriminatory basis for the diagnosis and treatment of biologically-based mental health disorders for children and adolescents under what age?

19 years okd

The time limit of certain defenses provision prohibits insurers from denying a claim due to misrepresentation, as long as the policy has been in force, for at least

2 years

Following hospitalization because of an accident, Bill was confined in a skilled nursing facility. Medicare will pay full benefits in this facility, for how many days.

20

Under the mandatory uniform provision Notice of Claim, the first notice of injury or sickness covered under an accident and health policy must contain

A statement that is sufficiently clear to identify the insured and the nature of the claim.

Which of the following options best depicts how the eligibility of members for group health insurance is determined?

By conditions of employment

To legally transact insurance in this state, an insurer must obtain which of the following?

Certificate Authority

Which of the following is NOT true of basic medical expense plans?

Coverage for catastrophic medical expenses

Which of the following is not true of basic medical expense plans

Coverage for catastrophic medical expenses

An insured is involved in an accident that renders him permanently deaf, although he does not sustain any other major injuries. The insured current job. To what extent will he receive Presumptive Disability benefits?

Full benefits

An insured is involved in an accident that renders him permanently deaf, although he does not sustain any other major injuries. The insured is still able to perform his current job. To what extent will he receive presumptive disability benefits?

Full benefits

Which of the following best describes a misrepresentation?

Issuing sales material with exaggerated statements about policy benefits

What is the benefit of experience rating?

It allows employers with low claims experience to get lower premiums.

Which of the following is not considered a misrepresentation as it pertains to unfair trade practices?

Making comparisons between different policies

Underwriting is a major consideration when an insured wishes to replace her current policy for all of the following reasons EXCEPT

Premiums always stay the same

Underwriting is a major consideration when an insured wishes to replace her current policy for all of the following reasons, except

Premiums always stay the same

After the elimination period, a totally disabled insured qualified and started receiving benefits from his disability income policy that has a waiver of premium rider. What will most likely happen to the premiums paid into the policy during the elimination period?

Premiums will be refunded

Part D of Medicare

Prescription drug coverage

A man's physician submits claim information to his insurer before she actually performs a medical procedure on him. She is doing this to see if the procedure is covered under the patient's insurance plan and for how much. This is an example of

Prospective review

All of the following are true regarding rebates EXCEPT

Rebates are allowed if it's in the best interest of the client.

Which is not true, regarding an insured who is considered to be a standard risk

The insured may have to pay slightly higher premiums.

In order for an insured under Medicare Part A to receive benefits for care in a skilled nursing facility, which of the following conditions must be met?

The insured must have first been hospitalized for 3 consecutive days

Under what condition are group, disability income benefits received by an employee not taxable as income

When the benefits received are equal or less than the employee's percentage of the contribution

All of the following are utilized by an underwriter in order to underwrite an applicant except

birth certificate

An insurance contract requires that both the insured and the insurer meet certain conditions in order for the contract to be enforceable. What contract characteristic does this describe?

conditional

Because an insurance policy is a legal contract, it must conform to the state laws, governing contracts, which require all of the following elements, except

conditions

An insurer neglects to pay a legitimate claim that is covered under the terms of the policy. Which of the following insurance principles has the insurer violated?

consideration

Which of the following terms describes making false statements about the financial condition of any insurer that are intended to injure any person engaged in the business of insurance?

defamation

All of the following may be excluded from coverage and a major medical expense policy, except

emergency surgery