Health Provisions

A major medical expense plan typically includes coverage for hospital room and board. Which of the following is normally covered under the category "room and board"?

Nursing Care

Who must sign a rider attached to a health insurance policy in order for it to be valid?

Insured and producer

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

Insured must be under a physician's care

States the scope and limits of the coverage

Insuring clause

The clause identifying which losses resulting from an accident or sickness are insured by the policy is called the

Insuring clause

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

Monthly

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

The Notice of Claims provision requires a policyowner to

Notify an insurer of a claim within a specified time

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

Exclusions

Medicare Part A does NOT provide coverage for

First 3 pints of blood

The "Use it or Lose it" rule applies to

Flexible Savings Accounts (FSA)

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?

Grace Period

HSA (Health Savings Account)

Health insurance that includes a savings account that allows you to pay for healthcare on tax-free basis. Used in association with a medical plan that carries a high deductible (HDHP)

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

Protect the Producer

Reasonable expectations doctorine

Reasonable expectation doctrine is a principle applied in insurance law which states whenever there is an ambiguity in an insurance-policy, it is resolved in favor of the insured's reasonable expectations. Usually an ambiguity arises when there are plausible, competing interpretations of a policy term. Policyholders lack sophstication to battle the insurer. Interpretation is based on what th ploicyholder thinks not wht the insurer meant

Intoxicants and Narcotics Provision

States that the insurer is not liable for any claims that result while the insured is under the influence of drugs (unless prescribed) or alcohol... The insured will have to pay their owm medical bills if injured

Individuals who participate in an HMO plan are called

Subscribers

Who may terminate coverage under a cancelable health insurance policy?

The Insurer or the insured

Coinsurance

a provision under which both the insured and the insurer share the covered losses.

Dan has a major medical expense policy with a $200 deductible and an 80/20 coinsurance provision. He incurs covered medical expenses of $100 in November and $400 in January. Under the carryover provision, what will the insurer pay?

$240

An insured files for an accident and health insurance policy claim eight days after the premium due date. The benefit payable is $500 and the overdue premium is $200. Assuming that the policy pays on a first-dollar basis and contains the unpaid premium provision, how much will the insurer pay?

$300

An individual is insured under a major medical plan with a $1,000,000 lifetime benefit. The plan has a $500 deductible and an 80% coinsurance. If the insured suffers a $50,500 medical expense during the calendar year, what is the remaining lifetime benefit?

$960,000

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

15

An insured must notify an insurer of a medical claim within how many days after an accident?

20

Health Savings Account (HSA). Distributions that are made for anything other than qualified medical expenses are considered taxable and subject to a penalty of

20%

What is the MINIMUM number of days for the Grace Period provision?

31

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?

45 Days

Subrogation Clause

A clause in the title policy that allows the insurance company who pays a claim to seek reimbursement from the party who caused the loss.

Medicare

A federal program of health insurance for persons 65 years of age and older

Free Look Provision

A policy provision required by state law that establishes a set number of days (usually 10) for the policyowner to review a newly issued policy. The policyowner may return the policy to the insurer during this time for any reason and receive a 100% refund. Also known as refund provision, unconditional refund provision, return provision, exchange provision, or right to examine.

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

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

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

At the policy's inception

Which of the following is considered a limited accident and health plan?

Cancer

Carryover Provision major medical policy

Carryover Provision - Expenses that did not satisfy the previous year's deductible and were incurred in the last 3 months of that year are used towards satisfying the current year's deductible

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

Change of occupation provision

Chris has a single major medical contract which covers all medical expenses. His plan is considered to be

Comprehensive

Which of the following health policy provisions states that the producer does NOT have the authority to change the policy or waive any of its provisions?

Entire Contract

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

Entire contract provision

Estople

Estoppel prevents an insurance company from adopting a position that is not consistent with a position it took previously if it would result in injury to the insured. This gives policyholders some assurance that their interests will not be harmed when dealing with their insurer.

What is considered a mandatory provision?

Payment of Claims

Which of these is considered a mandatory provision?

Payment of Claims

Which type of deductible must be satisfied again for each illness or accident in a major medical plan?

Per-Cause

Which of these plans allow a participant to choose either a network or non-network provider at the time when medical care is needed?

Point of Service

Which of these statements accurately describes the Waiver of Premium provision in an Accident and Health policy?

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

Guaranteed Renewable Health Insurance policy

Premiums normally increase at time of renewal

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

Prevents delayed claim payments made by the insurer

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

Proof Of Loss

Larry has a Major Medical Expense policy for his family with a $1,000 per family/per year deductible and an 80/20 coinsurance provision. If Larry's family files four claims of $400, $800, $100, and $700 in one year, how much will the insurance company pay?

They will pay $800

Which Accident and Health policy provision addresses preexisting conditions?

Time Limit on Certain Defenses

According to the Time Limit of Certain Defenses provision in an Individual Health Insurance Policy, nonfraudulent misstatements first become incontestable

Two years from the date of the policy was issued

Moral Hazzard

When the act of insuring an event increases the likelihood that the event will happen

After a health insurance application has been originated, the producer normally

is the major personal contact to the insured

cost containment

trying to control the rising cost of health care and achieving the maximum benefit for every dollar spent