Health Insurance Policy 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?

claim will be denied

A health insurance contract is valid only if the insured provides consideration in the form of the full minimum premium and the statements made in the application

consideration clause

A disability policy that must be renewed, cannot be cancelled until age 65, and may not have a increase in premium is

noncancellable policy

Policy where the insurance company cannot cancel and premiums cannot be increased

noncancellable policy

Best describes a short-term medical expense policy

nonrenewable

Provision that requires a policyowner to notify an insurer of a claim within a specified time

notice of claims

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

optionally renewable health policies

Mandatory provision

payment of claims

Provision tat defines to whom the insurer will pay benefits to is called

payment of claims

Describe waiver of premium provision in accident and health policy

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

Characteristic of a conditionally renewable health insurance policy

premiums may increase at the time of renewal

Guaranteed Renewable Health insurance policy

premiums normally increase at time of renewal

When _______ has been furnished, periodic benefit payments must be made no more less frequently than monthly

proof of loss

Accident are covered fully covered immediately and illnesses require 10 day wait with

reinstatement

Proof of loss

statement must be provided to an insurance company to show that a loss actually occurred

Purpose of the insuring clause

states the scope and limits of 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

Provision that allows the insurer to reduce the max benefits payable under the policy

change of occupation

Notice of claim provision states that the insured must notify the insurance company within ____ of a claim

20 days

Required Provision 3 states that the minimum grace period for all policies (except those with monthly or weekly premium modes) is

31 days

Health insurance will automatically be placed back in force if the insurer fails to notify an applicant within ______ that the reinstatement was denied

45 days

Bart is injured and provides notice of a health claim to his insurer He later receives the required claims forms. Within how many days of the loss must Bart file proof of loss with the insurance company

90

Accident and health policyowners may not

adjust the premium payments

Best describes what the legal action provisions of an accident and health policy requires

an insured must wait at least 60 days after proof of loss is submitted

After the insurance company receives a written request, an insured may have health insurance benefits paid to

anyone designated by the insurer

When does the probationary period become effective in a health insurance contract

at the policy inception

Health insurance benefits not covered due to an act of war

excluded by the insurer in the contract provision

With AD&D policies, what is the purpose of the grace period

gives policyowner additional time to pay past due premiums

Provision that specifies how long a policyowner's health coverage will remain in effect if the policyowner does not pay the premium when it is due

grace period

Type of renewability that guarantees premium rates and renewability

guaranteed renewable

After a policy has been in force for two years, it enters the _______, in which the insurer may not deny a claim based on information not disclosed at the time of the application

incontestable period

Provision that specifies the health care services a policy will provide

insuring clause

Time limit on certain defenses provision

limits the time an insurer can void a contract or deny a claim for material misrepresentations on the application.

Insuring clause

the clause in an accident and health policy which defines the benefit amounts the insurer will pay

Amy owns a disability income policy, with a noncancellable policy, with a noncancellable renewal provision. What is guaranteed

the coverage and the premium rate are guaranteed

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

the insured must wait 60 days after written proof of loss before legal action can be brought against the company

False statement about a noncancellable policy

the premium rate can be increased over time

Accident and health policy provision that addresses preexisting conditions

time limit and certain defenses

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

time limit on certain defenses

Prevents delayed claim payments made by the insurer

time of payments

According to Required Provision 4, when an insured applies for reinstatement of a health policy and receives a conditional receipt, how long does the insurer have to approve or deny

within 45 days of the date of application