Health Class

How long is a long term benefit period?

Over 2 year period with usually maximum age of 65

Define non-cancelable renewal clause

Renewal guaranteed and premiums guaranteed. Most favorable and most expensive

Defined guaranteed renewable renewal clause

Renewal guaranteed but premiums are not

Define optionally renewable renewal clause

The insurer may cease coverage for any reason but it has to be on anniversary or premium due date. Least favorable but most common. Cheapest.

What is the advantage of a PPO over a HMO?

Wider choice of providers

How long is the free look period?

10 days

If you pay premiums monthly, how long is the grace period?

10 days

What is the expectation for a Non-contributory plan?

100% participation

If you ask for a claim form or copy of an application how long does the insurance company have to do so?

15 days

When does the insured have to supply proof of loss?

180 days from loss

How long do you have to be covered under a group contract in order to qualify for continuation of benefits?

3 consecutive months

If the applicant feels the information gathered is inaccurate, they have the right to dispute the decision. Any disputed information must be responded to within ____ business days

30 business days

Exams cannot be required of any participant in employer/employee groups of 50 or more if the individual joins within _____ days of eligibility

31 days

Grace period when you pay semi annually?

31 days

How many work credits must one work in order to qualify for social security DI?

40 quarters

If the commissioner increases rates, all policyholders have to be notified when?

45 days prior to rate increase

Elimination period of social security disability?

5 months and anticipated to last at least a year or result in death

What is the typical maximum benefits for DI insurance?

50-70%

What is the expectation for contributory plans?

75% minimum participation

If a written request for the reasons behind an adverse underwriting decision is submitted within ____ days, the company has _____ days to respond

90, 21

What does partial disability pay?

A set percentage such as 50%

2 perils that health insurance cover?

Accident and sickness

When can premiums for group health insurance be adjusted?

After the first year of coverage, premiums may be adjusted every 6 months

Guaranteed purchase option

Allows you to increase your death benefit if you get a raise for example without proving evidence of insurability

Who funds Social Security?

Employees, employers, and the self employed. Not funded by the federal government

What is the most restrictive DI policy?

Any - inability to perform duties of ANY occupation

What is a conversion privilege?

At termination, the certificate holder has 31 days to convert to their own individual coverage without evidence of insurability

Residual Disability

Attempts to measure the amount of income lost instead of a set percentage

What happens to residual DI benefits as income increases?

Benefits are reduced as income increases

What does the time of payment of claims state?

Claims are to be paid immediately

What does a comprehensive major medical policy do?

Combines a basic medics expense policy and a major medical policy into one contract

List public sources

Criminal or real estate records; can be found on the internet

What does the conformity with state statutes state?

Current policies will automatically conform with changes in the law; self correcting

The out of pocket expense paid by the insured before Major Medical policies begin paying benefits?

Deductible

What isn't covered under continuation of group benefits?

Dental, vision, and prescription drugs

Define Notice of Claim

Describes the period of time the insured has to provide notice that a claim is to be filed

A major medical policy will do what in regards to the VA?

Exclude coverage for medical treated provided by a VA hospital. No double dipping

Factors that affect rate

Gender, age, health status, occupation, avocations (hobbies)

Business Overhead Expense

Generates income needed to keep the business running but doesn't pay the owner's salary

What is the Disclosure Authorization Form?

Grants permission for the insurance company to obtain and or release specified information from specified persons

Blanket Accident Insurance

Group coverage for special situations where group membership changes rapidly ie. Schools, arenas, etc

Define conditionally renewable renewal clause

Has to state in policy under what circumstances the insurer can drop you

How does presumptive DI pay?

In form of income, not lump sum

Who doesn't have to comply with the insurance protection/privacy laws?

Insurance regulators

Who doesn't have to comply with the privacy and protection laws?

Insurance regulators

List examples of presumptive disabilities

Loss of sight, hearing, speech or the loss of two or more limbs

Which renewable clause is least favorable?

Optionally Renewable

List non public sources

Medical records, MIB, credit, investigative, employer

What is malingering?

Milking a disability

When does coverage for dependent children begin?

Moment of birth

What is a MEWA?

Multiple Employer Welfare Arrangements. Groups of employers who come together in order to provide group insurance to their employees at more cost effective rates since they're a bigger group

Which renewal clause is most favorable?

Non-cancelable

Disability Buyouts

Pre-arranged contract that allows partners to buy the disabled partner's share of the business

All forms of the Accident and Heath insurance policies issued in NC must receive what?

Prior approval by the commissioner

When can the commissioner suspend an agents license?

Prior to a hearing if he believes it's needed to protect the public health, safety, or welfare

What happens if you go form a low risk job to a high risk job?

Reduction of coverage

What happens if you go from a high risk job to a low risk job?

Reduction of premiums

What is the Notice of Information Practices?

Summarizes the applicants rights under the act including the right to know what information was gathered and from whom

Corridor Deductible

The amount of money the insured must pay after the basic medical expense coverage has reached its limits and before the major medical benefits begin

What happens if age has been misstated?

The benefits will be changed according to the correct age; no time limit

What does the Notice of Claim state?

The insured must notify the company in writing within 20

The stop loss provision in major medical allows for what?

The insured to limit the amount of co-insurance out of pocket expenses for Major occurrences

Relationship between adverse underwriting decision and the insurer?

The insurer isn't allowed to use an adverse underwriting decision as the sole basis for denying insurance

Define elimination period

The policy provision that states the number of days that must pass after the insured has become disabled before the policy benefits will pay

What is the free look period?

The right to return the policy for a full premium refund within 10 days of policy delivery

When does the notice of information practice need to be provided if the information came from non-public sources?

Time of application

When does the notice of information practice need to be provided if the information came from public sources?

Time of policy delivery

What is the purpose of the "other insurance in other insurers" provision?

To determine the amount payable by multiple insurance contracts

What is the purpose of a probationary period?

To eliminate coverage for pre-existing conditions and protect against adverse selection

Least restrictive definition of total disability

Unable to perform duties of one's OWN occupation

How long does one qualify for continuation of group benefits?

Up to 18 months after losing eligibility under the group

How long is a short term benefit period

Up to 2 years

How does the commissioner get in to office?

Voters of the state elect the commissioner

What is an adverse underwriting decision?

When an application for insurance has been rejected, an existing policy has been terminated or coverage has been rated as a substandard risk

What is a hospital indemnity plan?

Where the insurer pays you a flat amount per day you're in the hospital and the benefits are paid right to you

What does the Coordination of Benefits Clause determine?

Which carrier will act as primary and which one will act as secondary

In the case of an adverse underwriting decision, when does a written request have to be submitted and when does the company has to respond?

Written request has to be submitted within 90 business days and the company has 21 business days to respond