Health Provisions

An insured must wait at least 60 days after Proof of Loss has been submitted before a lawsuit can be filed.

Which of the following statements BEST describes what the Legal Actions provision of an Accident and Health policy requires?

Premiums normally increase at the time of renewal

Which of the following statements about a Guaranteed Renewable Health Insurance policy is correct?

Adjust the premium payments

Which of the following statements describes what an Accident and Health policyowner may NOT do?

Guaranteed Renewable

Which type of renewability best describes a Disability Income policy that covers an individual until the age of 65, but the insurer has the right to change the premium rate for the overall risk class?

Policyowner additional time to pay overdue premiums

With Accidental Death and Dismemberment policies, what is the purpose of the Grace Period?

Entire contract

"A producer does not have the authority to change a policy or waive any of its provisions." The health provision that best describes this statement is called the

Claim will be paid and coverage will remain in force

A Disability Income policyowner recently submitted a claim for a chronic neck problem that has now resulted in total disability. The original neck injury occurred before the application was taken 5 years prior. The neck injury was never disclosed to the insurer at the time of application. How will the insurer handle this claim?

File written proof of loss

After an insured gives notice of loss, what must he/she do if the insurer does not furnish forms?

insurer dates the policy

An insurance company normally has 2 years to contest information provided on an accident and health application. This 2 year period begins on the date that the:

Consideration clause

An insurance company receives E's application for an individual health policy. E did not complete all of the medical history questions because she could not remember the exact dates. E signed the policy and submitted it to the insurance company anyway. A few weeks later, E suffers a heart attack and is hospitalized without completing the medical history questions and paying the initial premium. E is not insured. Which of the following clauses details he conditions that E did not meet?

20

An insured must notify an insurer of a medical claim within ___ days after an accident

31

An insured pays premiums on an annual basis for an individual health insurance policy. What is the MINIMUM number of days for the Grace Period provision?

15

An insurer must provide an insured with claim forms within __ 10 days after receiving notice of a loss.

Insured must be under a physician's care

What is the initial requirement for an insured to become eligible for benefits under the Waiver of Premium provision?

Prevents delayed claim payments made by the insurer

What is the purpose of the Time Payment of Claims provision?

Proof of loss

What must the policyowner provide to the insurer for validation that a loss has occurred?

Insuring

Which health policy clause specifies the amount of benefits to be paid?

noncancellable

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 describes this policy is called:

After an insured has become totally disabled as defined in the policy

In health insurance policies, a waiver of premium provisions keeps the coverage in force without premium payments:

Pay the claim in full minus the premium due

C is the policyowner of a Comprehensive individual Major Medical policy. C pays an annual premium which is due September 1. If C forgets to pay the premium and is hospitalized September 10, how will the insurer handle this claim?

excluded by the insurer in the contract provisions

Health insurance benefits NOT covered due to an act of war are:

When the state prohibits this by law

If an individual is covered under an Accidental Death Policy and dies, an autopsy can be performed in all these situations, EXCEPT:

45 days

M's insurance company denied a reinstatement application for her lapsed health insurance policy. The company did not notify M of this denial. How many days from the reinstatement application date does the insurance company have to notify M of the denial before the policy will be automatically placed back in force?

States the scope and limits of the coverage

The insuring clause

31

According to the Mandatory Uniform Policy Provisions, what is the maximum amount of time after the premium due date during which the policy remains in force even though the premium has not been paid?

Monthly

According to the Time Payment of Claims provision, the insurer must pay Disability Income benefits no less frequently than which of the following options?

the Insured

G is involved in an automobile accident as a result of driving while intoxicated and suffers numerous injuries. According to the Intoxicants and Narcotics exclusion in G's policy, who is responsible for paying the medical bills?

The insurer will adjust the benefit to what the premiums paid would have purchased at the insured's actual age

J, an Accidental Death and Dismemberment (AD&D) policy holder, dies after injuries sustained in an accident. J's age, as stated on the application five years ago, was found to be understated by ten years. Which of the following actions will the insurance company take?

Reinstatement

K failed to pay a renewal premium within the time granted by the insurer. K then sends in a payment which the insurer subsequently accepts. Which policy provision specifies that coverage may be restored in this situation?

guaranteed renewable

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:

monthly

Periodic health claim payments MUST be made at least:

November 1

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:

deny the claim

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

impairment rider

T applied for a Disability Income policy and has a history of back injuries. The insurer issued the policy with a statement that excludes coverage for back injuries. This statement is called a(n):

Time limit on certain defenses

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:

Increase her policy's coverage amount

T owns an Accident & Health policy and notifies her insurance company that she has hosen a less hazardous occupation. Under the Change of Occupation provision, which of the following actions may her insurance company take?

immediately

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

Protect the producer

The Legal Actions provision of an insurance contract is designed to do all of the following, EXCEPT:

notify an insurer of a claim within a specified time

The Notice of Claims provision requires a policyowner to:

notify an insurer of a claim within a specified time

The Notice of Claims provisions requires a policyowner to:

Insuring

The ___________ clause identifies which losses resulting from an accident or sickness are insured by the policy.

Payment of claims provision

The insured and insurance company will share the cost of covered losses under which health policy feature?

Time Limit on Certain Defenses

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

Payment of claims

The provision that defines to whom the insurer will pay benefits to is called:

exclusions

The section of an insurance contract which limit coverage are called:

exclusions

The sections of an insurance contract which limit coverage are called:

may cancel the policy for nonpayment only

Under a Guaranteed Renewable health insurance policy, the insurer

from the date that the policy was issued

Under an individual Health Insurance policy, the Time Limit of Certain Defenses provision states that nonfraudulent misstatements first become incontestable two years

Submit the claim in any form

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?

Entire contract provision

When an insurance company sends a policy to the insured with an attached application, the element that makes the application part of the contract between the insured and the insurer is called the:

Change of occupation provision

When an insured changes to a more hazardous occupation, which disability policy provision allows an insurer to adjust policy benefits and rates?

At the policy's inception

When does a Probationary Period provision become effective in a health insurance contract?

Entire contract

Which health policy clause stipulates that an insurance company must attach a copy of the application to the policy to ensure that it is part of the contract

Nonrenewable

Which of the following BEST describes a short-term medical expense policy?

Insuring clause

Which of the following health insurance policy provisions specifies the health care services a policy will provide?

Exclusions

Which of the following is NOT included in the policy face?

Entire contract

Which of the following policy provisions prohibits an insurance company from incorporating external documents into an insurance policy?

Grace Period

Which of the following provisions specifies how long a policyowner's health coverage will remain in effect if the policyowner does not pay the premium when it is due?