Health Insurance Exam
T calls to file a claim on his health insurance policy. Within how many days must the insurer provide T's proof of loss forms?
15 days
when an employees coverage terminated under a group health policy, the employee must be offered continuation coverage for:
18 months
An insured must notify an insurer of a medical claim within how many days after an accident?
20
renewing a producers license requires __ hours of continued education every 2 years
24
Under the affordable care act (ACA), health coverage is provided for dependents up to the age of
26
insurance policies are offered on a "take it or leave it" basis, which makes them:
contracts of adhesion
when an employee is required to pay a portion of the premium for an employer/employee group health plan, the employee is covered under which of the following plans?
contributory
a business overhead expense policy:
covers business expenses such as utilities and rent
the section of an insurance contract which limit coverage are called
exclusions
What is the reimbursement of benefits for the treatment of a beneficiary's injuries caused by a third party
subrogation
if a producer completes an insurance application, collects the initial premium, and issues the appropriate receipt ...
coverage will be contingent upon the insurer's underwriting policies
Circulation of a maliciously critical statement about any insurer's financial condition to injure the insurer is called:
defamation
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
what is an example of misrepresentation
describing a universal life policy as a security
what contact permits the remaining partners to buy-out the interest of a disabled business partner
disability buy-sell
K becomes ill after traveling overseas and is unable to work for 3 months. What kind of policy would cover her loss of income?
disability income
in the event of an illness, a _____ _____ policy would reimburse an insured for loss of earnings/income
disability income
how would you inaccurately describe the tax treatment of premiums and benefits of individual accident and health insurance
disability income policy premiums are tax-deductible
a catastrophic illness would be best covered by which health insurance plan
major medical
under a guaranteed renewable health policy the insurer:
may cancel the policy for nonpayment only
the primary difference between the CO partnership LTC policy and other LTC policies is
medicaid asset protection
a verbal or written statement which misleads a policy's features, benefits, or coverage is considered:
misrepresentation
what is considered a mandatory provision
payment of claims
P is a new employee and will be obtaining non-contributory group Major Medical insurance from her employer. Which of the following actions must she take during the open enrollment period?
sign an enrollment card
Which mode of payment is NOT used by health insurance policies?
single premium
how are group accident and health policies issued to an employer
the employer will receive the policy and employees receive a certificate
a company that has not been authorized to operate in CO is known as
a non-admitted insurer
P received Disability income benefits for 3 months then returns to work. She is able to work one month before her condition returns, leaving her disabled once again. What would the insurance company most likely regard this second period of disability as?
a recurrent disability
a "reimbursement policy" pays what amount of covered long-term care expenses
actual covered expenses up to the daily limit
what type of care isn't covered in a long-tern care policy ~acupuncture ~skilled care ~home health care ~custodial care
acupuncture
In health insurance policies, a waiver of premium provision keeps the coverage in force without premium payment:
after the insured has become totally disabled as defined in the policy
Under what circumstance will the benefits under COBRA continuation coverage end?
all group health plans are terminated by the employer
what is not required to be disclosed to an applicant for health insurance
any contingent compensation received
an applicant's medical information received from the MIB may be furnished to the
applicants physician
what is the initial source of underwriting for an insurance policy
application containing statements from the insured
When does a Probationary Period provision become effective in a health insurance contract?
at the policy's inception
B's policy provides coverage on an in-hospital basis only and contains a limited daily room and board benefit. Which of these policies does B have?
basic hospital
what type of policy would pay an employee's salary if the employer was injured in a bicycle accident and out of work for six weeks
business overhead expense
a health reimbursement arrangement must be established
by the employer
what policy feature allows an insured to defer current health charges to the following year's deductible instead of the current year's deductible
carryover provision
S wants to open a tax-exempt Health Savings Account. To qualify for this type of account, Federal law dictates that S must be enrolled in a
high-deductible health plan
paying insurance premiums on a more frequent basis will cause the policy to have
higher premiums
all accident and health policies issued in CO that provide major medical services must offer policyholders the opportunity to purchase
home health care coverage
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
The first portion of a covered Major Medical insurance expense that the insured is required to pay is called the
initial deductible
Information obtained from a phone conversation to the proposed insured can be found in which of these reports?
inspection report
what is not a required provision for an accident and health policy
insurance with other insurers
what information is not included in the CO supplement to the summary of benefits and coverage form
insurer's prior year financials
The ___ clause identifies which losses resulting from an accident or sickness are insured by the policy
insuring
Which health policy clause specifies the amount of benefits to be paid?
insuring
Stranger originated life insurance (STOLI) has been found to be in violation of which of the following contractual element?
legal purpose/ insurable interest
an insurer can deny a claim under a long-term care insurance policy for any material misrepresentation made by the insured if it has been in effect for
less than 6 months
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
J has a Disability Income policy that does NOT provide benefits for losses occurring as the result of his employment. What kind of coverage is this?
nonoccupational coverage
In an insurance contract, the insurer is the only party who makes a legally enforceable promise. What kind of contract is this?
unilateral
R has become disabled and owns an individual disability income policy. When is R eligible to receive disability benefits
upon satisfying the elimination period requirement
which of the following phrases refers to the fees charged by a healthcare professional
usual, customary, and reasonable expenses
a business overhead expense policy covers what id a business owner becomes disabled
utilities and office rent
The commissioner may issue an emergency cease and desist order without a hearing for all of these circumstances EXCEPT ~selling insurance w/o a license ~engaging in fraudulent activity ~endangering the public ~writing controlled business
writing controlled business
All of these are characteristics of a health reimbursement arrangement (HRA) EXCEPT ~it is entirely funded by the employee ~it is entirely funded by the employer ~reimbursement for eligible medical expenses are allowed ~it can be offered with other health plans
HRA's are not entirely employee funded - they are employer funded
a life insurance arrangement which circumvents insurable interest statutes is called:
Investor-originated life insurance
what parts of a health insurance policy are guaranteed to be true
warranties
a producer who violates a cease and desist order may, after a hearing, be fined up to
$500
Under what system do a group of doctors and hospitals in a designated area contract with an insurer to provide services at a prearranged cost to the insured?
PPO (preferred provider organization)
the insuring clause:
States the scope and limits of the coverage
M applies for a health insurance policy and pays the initial premium. When the agent completes the application, a conditional receipt is left with the applicant. The insurance company's underwriting department request's M's medical record and determines that M has had asthma for many years. What will not be probable underwriting outcome
changing the policys provisions
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?
claims will be denied
the situation in which a group of physicians are salaried employees and conduct business in an HMO facility is called:
closed panel
How to best describe a hospital indemnity policy?
coverage that pays a stated amount per day of a covered hospitalization
An agent takes an individual Disability Income application, collects the appropriate premium, and issues the prospective insured a conditional receipt. The next step the insurance company will take is to
determine if the applicant is an acceptable risk by completing standard underwriting procedures
M becomes disabled and is unable to work for six months. M dies soon after from complications arising from this disability. M has a Disability Income policy that pays $2,000 a month. What BEST describes what is owed to her estate?
earned, but unpaid benefits
what health provision best describes: "a producer does not have the authority to change a policy or waive any of its provisions"
entire contact provision
what is not included in the policy face
exclusions
long term care policies will usually pay for eligible benefits using which of the following methods
expense incurred
insurer's must advise applicants in writing that an investigative consumer report may be conducted according to the
fair credit reporting act
This type of deductible provision waives the deductible for all family members after some of them have satisfied individual deductibles within the same year:
family maximum deductible
with AD&D policies what is the purpose of the grace period
gives the policyowner additional time to pay overdue premiums
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
Generally how long is a benefit period for a major medical expense plan
one year
the benefits under a disability buy-out policy are
payable to the company or another shareholder
The insured and the insurance company will share the cost of covered losses under which health policy feature
payment of claims provision
what coverage exclusions or limitations is permitted under a long-term care policy issued in CO
preexisting conditions
what is true about guaranteed renewable health policies
premiums normally increase at time of renewal
T is covered by two health insurance plans: a group plan through his employer and his spouse's plan as a dependent. When T submits a claim, his employer's plan is considered what type of carrier under the Model Group Coordination of Benefits provision?
primary carrier
what is the consideration given by an insurer in the consideration clause of a life policy
promise to pay a death benefit to a named beneficiary
with optionally renewable health policies the insurer may:
renew the policy annually and determine whether or not to renew it
D is an architect receiving Disability Income benefits who is not able to return to work full time, but can work on a part-time basis. Which of these features would allow D to continue receiving benefits?
residual benefit clause
A prepaid application for and individual disability income insurance was recently submitted to an insurer. When the insurer received the medical information bureau (MIB) report, the report showed that the applicant had suffered a stroke 18 months age, something that was not disclosed on the application. What action would the insurance company not take.
send a notice to the MIB that the applicant was declined
P is an employee who quits her job and wants to convert her group health coverage to an individual policy. After the expiration of COBRA laws, what is TRUE?
she will need to provide evidence of insurability
the percentage of an individual's primary insurance account (PIA) determines the benefits paid in which of the following programs?
social security disability income
In regards to maternity care, which of the following is not required to be covered in the State of Colorado?
standard newborn circumcision
Why must an accident & health insurance applicant answer all questions on the application?
statements and representations on the application are part of the consideration for issuing a policy
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
Under an individual health insurance policy, the time limit on certain defenses provision states that nonfraudulent misstatements first become incontestable two years from ...
the date the policy was issued
the ____ period is considered to be the time period after a health policy is issued, during which no benefits are provided for illness
the probationary period
What actions can an insurance company not take to insure a substandard applicant for disability income coverage?
they cannot lengthen the contestability period
essential benefits without annual and lifetime limits are required on any health policy purchased ...
through the federal marketplace
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
What is the elimination period of an individual disability policy?
time period a disabled person must wait before benefits are paid
what is the purpose of coordination of benefits (COB) provision
to avoid duplication of benefit payments
