Section 1 health insurance

An insured has a disability income policy with a 30-day elimination period, $1000 a month benefit and a 50% partial disability benefit. The insured is totally disabled for 15 days. The total benefits paid will be ?

$0

X has a disability policy with a 30-day elimination period and a $500 a month benefit. X is disabled 3 1/2 months. How much is payable ?

$1,250

X incurs an 80/20 medical policy with a $250 annual deductible which has already been satisfied for the year x incurs $2,250 in eligible expenses, how much will the insurer pay on this claim ?

$1,800

X has an 80/20 major medical policy with a $250 deductible. Since x has not satisfied any of the deductible, if x incurs $1500 in medical expenses, how much of the bill will the insurer pay

$1000

X incurs $1400 in eligible expenses. The policy 80/20 with a $200 annual deductible. This is the first claim for the year. What is the maximum amount the insured will be required to pay on this claim ?

$440

A comprehensive medical expense policy pays 100% of the first $5,000 of expenses, has a corridor deductible of $100 and 80%/20% coinsurance. How much of a $6,100 bill will the insurance company pay ?

$5,800

X was making $2400 a month. He becomes disabled and after returning to work, is only making $1200 a month the policy benefit is $1000 a month, what will X receive in residual benefits ?

$500

HMO's may be offered as an alternative health care plan in employer groups of more than ?

25

X's policy has a 30-day elimination period. X is disabled for 3 months. X returns to work but becomes disabled again within 6 months. X is disabled for another 3 months. What is the maximum amount of time that X will receive benefits ?

5 Months

The disability benefit in a disability income policy is usually based on ?

50 to 70% of the insured's gross income at the time of the purchase

x is currently reveiving disability benefits for injuries sustained in a fire. It is a later proven that x set the fire. What will the insured take ?

Discontinue ant further benefits and make X repay the benefits that he has already received

If a disability is treated as a recurrence , the insured ?

Does not have to satisfy the elimination period again but only has whatever time was left on the benefit period

Blue cross pays the ___ whereas Blue shield pays the ______ ?

Hospital, doctor

Which of the following is the most liberal definition of total disability ?

Inability to do the duties of your own occupation

Common exclusions on health policies include all of the following except ?

Injury which occurred while being held hostage during a bank robbery.

What is used in major medical policies to limit coverage for any specific disease ?

Inside limits

A collection of health care providers, such as physicians, hospitals, or clinics, who offer their services to certain groups at prearranged prices is known as a/an ?

Preferred provider organization

The loss of any two limbs, feet, speech, hearing or eyesight is known as what type of disability ?

Presumptive

Any health policy which provides benefits to include minor children shall be effective, with respect to newborn children ?

from the moment of birth

If this is their first claim of the year, the co-insurance feature in a major medical insurance policy is 75% - 25% with a $100 deductible, how much of a $2,100 bill would the insured pay ?

$600

When does the cost-of-living rider on a disability income policy kick in ?

After the insured has been disabled for 6 months

If a health policy "covers the cost up to the semi-private room rate" this is ?

An inside/internal limit

An HMO which is characterized by a network of physicians who work out of their own facilities and participating the HMO on a part-time basis is known as ?

An open panel

X is disabled and has a disability policy that will cover him for more than 2 years. At what interval does X have to provide notice of continuing loss to the insurer ?

At least once every 6 months after having given notice of claim.

When a specialist within the insurance company reviews a file to assess whether an alternate treatment is available might be cheaper, this is known as ?

Case management

pre-admission certification is a cost control method which is one of the ways that an insurer can contain premium costs under what type of provisions ?

Case management

HMO's may be classified as which of the following ?

Closed or open panel

When the HMO is represented by a group of physicians who are salaried employees and work out if the HMO facility, this is known as/ an ?

Closed panel

Which of the following is a common feature of group Major Medical insurance ?

Coinsurance

Unfortunately, X's family was involved in an automobile accident. What is the name of the health insurance provision which explains how the deductible works in their situation ?

Common Accident

By adding the major medical to the basic, the insured now has the equivalent of comprehensive major medical coverage. The deductible which is in between the basic and the major medial coverage is known as the ?

Corridor deductible

Health maintenance organization (HMO's) are different from other health insurance providers since they ?

Emphasize preventive care

Expenses that are not covered under health insurance policies are ?

Exclusions

In a major medical policy, what limits the amount of total deductible on a per person deductible policy ?

Family deductible limit

A feature of an HMO which requires that patients get referrals from their primary care physicians before seeking care from a specialist is ?

Gate keeping

When available, dental and vision care coverages generally are issued in what type of health insurance policies ?

Group

Which type of insurer is known for stressing preventive care ?

HMO

The purpose of the probationary period is to ?

Help the insurer avoid paying benefits for losses due to illness contracted before the policy was issued.

Regardless of your expenses, this policy pays a flat amount per day in the hospital. What is it called ?

Hospital Indemnity or hospital income plan

In which type of HMO do the HMO members for the most part, represent a small percentage of the physicians patient list because the physicians are generally in private practice ?

Independent practice association (IPA)

The deductible that an insured has to pay before benefits begin to be paod by the insurer in a major medical policy is known as the ?

Initial deductible

A (an) ____ deductible must be paid at the beginning of a major medical policy. ____ A deductible is after first dollar benefits but before a major medical coinsurance feature begins.

Initial, corridor

Which of the following is true regarding the probationary period ?

It is designed to protect the company against adverse selection

If X has a disability income policy with a $2,000 monthly benefit, and X becomes partially disabled, benefit that X would be eligible for is ?

Less than the full amount

After the basic benefits are exhausted, the corridor deductible must be paid before the insurance benefits of what coverage becomes payable ?

Major medical

All of the following are characteristics of HMO's except ?

Members can go directly to a specialist and bypass their primary physician

Which of the following is usually covered as a basic hospital miscellaneous expense ?

Operating room charges

The person who provides all care for a particular member and controls all referrals for specialist care in some cases, hospital care, is known as the ?

Primary care physician

A disability income policy may contain a period of time that must elapse at the beginning of the policy before benefits are payable for a sickness. This is known as a/an

Probationary period

Preferred provider organizations (PPOs) tend to be less restrictive than health maintenance organizations (HMO's) because the PPO's ?

Provide a wider choice of physicians

In major medical comprehensive policies, a coinsurance provision ?

Provides for a percentage participation by the insured

Which disability income policy feature "makes up for a reduction in pay?"

Residual

What is the feature found in a major medical policy that replaces a certain amount of coverage each year lost as a result of a claim ?

Restoration of benefits

What does the term first dollar mean ?

The policy does not have a deductible

The words "reasonable and customary" found in a health policy mean what ?

The policy will pay what most doctors and hospitals charge for similar services in the same geographic area.

how is coinsurance in an individual health policy regulated ?

There are no regulations

Group medical expense policies must cover all of the following except ?

Work related injuries covered under workers' compensation.

A major medical insurance policy would cover expenses for all of the following except ?

charges covered under workers' compensation insurance

All of the following are features of a dental plan except ?

high policy limits

Which of the following would not affect disability benefits received under a group plan ?

individual policy

Which of the following terms in a disability policy helps determine whether a disability is considered a new disability or of it is a continuation of an old one ?

recurrent

What is the feature that limits the amount of money that an insured has to pay out of pocket once he has paid a certain amount under the coinsurance clause ?

stop loss

All of the following statements apply to deductible provisions in medical expenses policies except ?

such provisions are not used in group insurance

Total disability could be defined by all of the following except ?

the inability to perform some of the duties of your own occupation