Washington Accident and Health (disability) Insurance laws

Standard Provisions: Grace Periods

* A policyholder is entitled to the following grace periods following the premium due date, during which the policy remains in force: - at least seven days for policies with premiums that are due weekly - at least ten days for policies with premiums that are due monthly - at least 31 days for all other policies

Standard Provisions: Entire Contract Clause

- A health insurance policy must specify that the policy, any endorsements, and any attached documents constitute the entire insurance contract. - Changes to the contract are invalid unless they are approved and endorsed by an officer of the insurance company. A producer cannot change the terms of the policy.

Open Enrollment

- A health insurer cannot deny or condition Medicare supplement insurance on an applicant's health status, claims experience, receipt of health care, or medical condition when the application is made before or during the six-month period that begins with the first day of the first month in which the applicant is at least 65 years old and is enrolled in Medicare Part B. - If the applicant submits the application within this period and has had a continuous period of creditable coverage of at least three months, the insurer cannot exclude any pre-existing conditions. If the creditable coverage is less than three months, the insurer must reduce the exclusionary period by the amount of time that the applicant had satisfied for a pre-existing condition before enrollment.

Minimum Standards for Individual Health Insurance Policies: Noncancelable or Guaranteed Renewable Policies

- A noncancelable or guaranteed renewable policy cannot terminate a spouse's coverage just because the insured's coverage was terminated, unless the insured did not pay the premium. - if the insured dies, the spouse will still be covered - The terms noncancelable or guaranteed renewable cannot be used in a policy without further explanation of their meaning. - can be used when the insured has the right to continue the policy by paying premiums until they are 65 or ready for Medicare.

Health insurance policies issued in or for delivery in Washington are forbidden

- A policy cannot impose a probationary or waiting period of more than 30 days. - A policy for certain specified diseases (involving hernia, disorder of reproductive organs, appendix, and tonsils, for instance) can impose a probationary or waiting period of up to six months, except in cases of emergency. - An accident insurance policy cannot contain a probationary or waiting period. - A policy issued after March 23, 2010 cannot exclude coverage for pre-existing conditions. - A policy or rider for additional coverage cannot be issued as a dividend unless the policyholder is offered an equivalent cash payment as an alternative, but no such dividend policy or rider can be issued for an initial term of less than six months. - An insurer cannot discriminate against policyholders, enrollees, subscribers, or certificate holders in a group health plan who are eligible for or receiving assistance from Medicaid.

Minimum Standards for Individual Health Insurance Policies: Handicapped Dependent Children

- A policy must continue coverage for any dependent child who reaches the limiting age and is incapable of self-sustaining employment due to developmental disability or physical handicap, if the child depends on the insured for support. - The policy can require that within 31 days of the child's reaching the limiting age, the insured must provide proof of the child's incapacity and dependency for coverage to continue. - Within coming of age, insured has 31 days to prove the kid still is not able to live on their own

Minimum Standards for Individual Health Insurance Policies: Other Forms of Coverage

- Accident-only coverage pays benefits for death, dismemberment, disability, or hospitalization and medical care caused - Specified accident coverage pays benefits for a specific type of accident. It covers accidental death or accidental death and dismemberment. by an accident. - Limited benefit health insurance coverage pays benefits that are less than the minimum standards required by law, but which the Commissioner approves as being in the public interest to offer for sale. Insurers who issue or deliver these policies in Washington can do so only if they provide an outline of coverage to the insured.

Minimum Standards for Individual Health Insurance Policies: Accidental Death and Dismemberment Benefits

- Accidental death and dismemberment benefits must be paid if the loss occurs within no less than 90 days of the accident, regardless of total disability - Disability income benefits cannot require the loss to begin less than 30 days after the accident. - if the insurer cancels or does not want to renew policy must pat benefits if the accident happened while the policy was still in force.

Standard Provisions: Time Limit on Certain Defenses

- After a health insurance policy has been in effect for two years, the insurer can void the policy or deny a claim only if the insured made a mistake on the application - If the insured has the right to continue a policy by paying premiums on time until at least age 50—or in the case of a policy issued after age 44, for at least five years after policy issue—the policy may demand that the insurer cannot compose a policy that has been in force for two years. - insurer cannot deny claims after 2 years from hen the policy is issued

All of the following statements about long-term care insurance policies issued in Washington are correct

- An insured's age can be a reason to refuse renewal. - Indemnification must be on the same basis for sickness and for accident. - Riders, waivers, or endorsements cannot limit coverage.

Minimum Standards for Individual Health Insurance Policies: Replacement [WAC 284-50-430]

- Application forms for health insurance policies are required to seek information from the consumer as to whether the insurance will replace another health insurance policy already in force. - If replacement is involved, an insurer or producer must give the applicant a "Notice Regarding Replacement of Accident and Sickness Insurance" before the policy is delivered. The insurer will keep a copy signed by the applicant.

, insurers must avoid the following unfair practices and methods of competition:

- Attained age rating: Using the increased age of an insured person to charge a higher premium or other additional costs in a Medicare supplement insurance policy; - Twisting: Making misrepresentations to induce a person to lapse, surrender, terminate, keep, or convert an insurance policy; - High pressure tactics: Convincing a person to buy an insurance policy by using force, fear, threats, or other undue pressure. - Cold lead advertising: Marketing insurance policies by using methods that do not conspicuously disclose the fact that insurance is being sold or that a producer or insurance company will make contact with the prospective customer.

Minimum Standards for Individual Health Insurance Policies: Disability Income Benefits

- Disability income insurance pays weekly or monthly benefits for a specified time during a disability resulting from illness or injury or both. Benefits that are payable after age 62 and reduced on the basis of age alone cannot be less than half of the benefits payable before age 62. - The benefit period must be at least six months. However, if the policy covers disability arising from pregnancy, childbirth, or miscarriage, the benefit period must be at least one month. - Furthermore, these policies cannot have an elimination period that is longer than the following: **90 days in policies providing a benefit of one year or less ** 180 days in policies providing a benefit of more than one year but less than two years ** 365 days in all other policies paying a benefit for as long as the disability continues

Insurers who market Medicare supplement policies in Washington must:

- Establish marketing procedures to ensure that their producers accurately and fairly compare policies of competitors with their own companies' policies; - Establish policies to make sure that excessive insurance is not sold; - Caution each policyholder that his or her policy may not cover all medical expenses; - Make every reasonable effort to determine whether an applicant or enrollee for Medicare supplement insurance already has disability insurance, and the types and amounts of such insurance; and - Establish procedures to verify that they are complying with these requirements.

Policy Delivery

- Health insurance policies must be delivered to the insured within a reasonable time after they are issued. If an insurer relies on its producers to deliver its policies, the insurer as well as the producer is responsible for any delay by the producer in delivering the policy. - A producer is required to physically deliver the policy to the insured. A producer cannot simply hold the policy for safekeeping or other purposes, even if the insured acknowledges that the producer is doing so.

Standard Provisions: Reinstatement

- If a policyholder fails to pay the renewal premium within the grace period and the policy lapses, the policy will nevertheless be reinstated if the insurer accepts payment at a later date - insured must apply for reinstatement and the insurer will issue a conditional receipt to the insured until the application for reinstatement is approved. - If the insurer fails to approve the application within 45 days, the policy will be automatically reinstated unless the insurer has given written notice to the insured that it will not reinstate the policy. - will cover any losses after the reinstatement is signed and any sickness related loss 10 days after reinstatement - same coverage

Guaranteed Issue

- Insurers that issued standardized Medicare supplement plans B, C, D, F, F with high deductible, G, K, L, M, or N on or after June 1, 2010 must issue coverage under a 2010 plan of any of these types without evidence of insurability to any policyholder if the new policy replaces one of these types of policies issued before June 1, 2010. - Similarly, insurers that issued standardized Medicare supplement plan A on or after June 1, 2010 must issue coverage under a 2010 plan A without evidence of insurability to a policyholder if the new policy replaces a Medicare supplement plan A issued before June 1, 2010.

All of the following statements are true about the purpose of the Health Insurance Coverage Access Act

- It is operated independent from the Washington State Health Insurance Pool (WSIP). - It is available only to Washington residents. - It allows access to health insurance coverage to Washington residents who have been denied health insurance.

Medicare Supplement Health Insurance Act: Pre-existing Conditions

- Persons who are eligible for a Medicare supplement policy can enroll in such a policy up to 63 days after their coverage ends under an employer's group plan or a Medicare Advantage plan - A pre-existing condition cannot be defined more restrictively than a condition for which medical advice was given or treatment was recommended by a physician within three months before the effective date of coverage.

Penalty for Noncompliance

- The act prohibits anyone from filing a false claim for health insurance benefits. Each violation is a separate offense. A person cannot conceal or fail to disclose information about a claim with the intent to obtain payment on the claim. Health-care providers are also prohibited from collecting payments that violate their agreements with insurers. - Anyone who violates these prohibitions is guilty of a Class C felony and subject to imprisonment for up to five years, a fine of up to $10,000, or both.

what does the "Notice Regarding Replacement of Accident and Sickness Insurance" state

- The applicant is entitled to advice about the replacement from the existing insurer or producer, and such advice may be in the applicant's best interest. - If the applicant has considered all information available to him or her and still wants to replace the existing policy with a new one, he or she must be truthful when completing the application. - Failure to include all material medical information may give the insurer a reason to deny claims and rescind the policy.

Furthermore, whenever an applicant for a Medicare supplement policy is required to provide his or her medical history, that history must be completed by

- The applicant; - The applicant's relative; - The applicant's legal guardian; or - A physician.

An insurer can ask, but cannot require, that an individual or family member of the individual undergo a genetic test if the insurer meets the following conditions:

- The request is made for clinical research purposes. - The insurer makes it clear that compliance with the request is voluntary and that refusal will have no effect on insurability or the premium. - Genetic information acquired cannot be used for underwriting, setting premium rates, or issuing, renewing, or replacing a policy.

Medicare Supplement Health Insurance Act: Outline of Coverage; Disclosure

- When a producer or insurer initiates the sale of a Medicare supplement insurance policy, the producer or insurer is required to complete and sign an outline of coverage—a formal disclosure form—before delivering it to the applicant by the time the applicant applies for the policy. The insurer must get a receipt from the applicant after delivering the outline of coverage (unless the insurer is a direct response insurer). - When a policy offers health insurance coverage other than through a Medicare supplement policy, the outline of coverage must inform the resident that the policy is not a Medicare supplement policy. If the outline of coverage does not state this, the first page of the policy must do so. When a policy offers health insurance coverage to persons eligible for Medicare, it is required to disclose the extent to which it duplicates Medicare. However, producers cannot sell a health insurance policy that duplicates Medicare benefits unless it will pay benefits without regard to other health insurance coverage in effect and it gives the required disclosures. The law prohibits anyone from selling a Medicare supplement policy to a person who already has one, unless the policy is being sold as a replacement.

Medicare Supplement Health Insurance Act: Buyer's Guide

- When an insurer is selling or soliciting a health insurance policy offering hospital or medical expense coverage benefits to persons whose age makes them eligible for Medicare, the insurer is required to provide them with a Medicare supplement Buyer's Guide in addition to the outline of coverage. - This Buyer's Guide is called the Guide to Health Insurance for People with Medicare and was developed by the National Association of Insurance Commissioners (NAIC) and the Health Care Financing Administration (HCFA) of the U.S. Department of Health and Human Services. - The insurer must deliver the Buyer's Guide whether or not the policy it is selling is a Medicare supplement policy. - The insurer is required to deliver the Buyer's Guide to the applicant when the application is made, and the insurer is required to get a receipt for delivering it. Direct response insurers must deliver the Buyer's Guide upon request, but not later than when the policy is delivered to the insured.

insurers must follow these standards when issuing accident and health insurance policies in Washington

- basic hospital expense coverage - basic medical-surgical expense coverage - hospitalization coverage - major medical insurance - disability income insurance - accident-only policies - specified disease or specified accident coverage - Medicare supplement policies - limited benefit coverage

Standard Provisions: Discrimination Prohibited

- can't deny because of race, religion, national origin, or the presence of any sensory, mental, or physical handicap.

An outline of coverage must accompany every individual health insurance policy delivered or issued for delivery in Washington. The outline of coverage will

- identify the types of coverage the policy provides; - describe the policy's coverage and benefits; - state the exceptions and limitations in coverage; - state the renewal provisions and any right that the insurer reserves to change premiums; and - state that the outline only summarizes the policy, which should be consulted for the policy's controlling provisions.

Washington health insurance reform legislation is intended to accomplish all of the following objectives

- increase consumers' awareness of their health coverage - improve access to information about health-care services to consumers in managed care plans - enable consumers to make better decisions about their health care

Standard Provisions: Cancelation

- insurer can cancel anytime as long as they give the person a 5 day notice - After a policy has been renewed beyond its original term, however, cancelation can take effect upon receipt of the written notice. - Upon cancelation, the insurer must return any unearned portion of the premium paid. The amount of the earned premium is computed on a pro rata basis.

Medicare Supplement Health Insurance Act: Application Responsibilities; Replacement Forms

- insurer checks if applicant has Medicare supplement policy, Medicare Advantage, Medicaid coverage, or another health insurance policy in force. - they tell the applicant that more than one Medicare supplement policy is not necessary and that the policy may not cover all of the applicant's expenses. - By March 1 every year, an insurer must report to the Commissioner with information for every individual who has more than one Medicare supplement policy issued by the insurer. - If a Medicare supplement policy replaces another Medicare supplement policy that has been in effect for at least three months, the replacing period cannot impose any new periods for pre-existing conditions, waiting periods, elimination periods, or probationary periods. -

In general, a policy cannot limit or exclude coverage by type of illness, accident, treatment, or medical condition. However, a policy can limit or exclude coverage for the following:

- mental or emotional disorders, alcoholism, and drug addiction; - routine pregnancy; - illness, treatment, or medical condition arising out of war or act of war; participation in a felony, riot, or insurrection; service in the armed forces or auxiliary units; suicide, attempted suicide, or self-inflicted injury; aviation as a crewmember; and interscholastic sports; - cosmetic surgery, unless it is for reconstructive purposes following surgery for trauma, infection, or disease, or it is to correct a functional defect caused by a congenital disease or anomaly in a covered dependent child; - foot care; - treatment in a government hospital; - benefits provided under Medicare or another government program other than Medicaid, workers' compensation, employer's liability or occupational disease law, or motor vehicle no-fault law; - services performed by a member of the covered person's immediate family; - services for which no charge is usually made in the absence of insurance; - dental care or treatment; - eye glasses and hearing aids; - rest cures, custodial care, transportation, and routine physical examinations; - territorial limitations; and - specified diseases and specified accident policies.

If the total monthly benefits paid under a disability income policy exceed one of the following—whichever is greater—then the insurer can reduce the benefits proportionally:

- the monthly earnings of the insured at the time the disability began - the average monthly earnings of the insured during the two years before the disability

Standard Provisions: Other Benefits

- this is for other insurance besides expense-incurred, but the person still has more than one insurance policies - the insurer will also prorate benefits on any basis other than expense incurred. Any premiums paid for excess coverage will be returned to the insured.

Washington enacted its Medicare Supplement Health Insurance Act to carry out the following intentions:

- to set minimum standards for benefits; - to require that an outline of coverage be used in sales of Medicare supplement insurance; - to set requirements for disclosure of information to consumers; - to prohibit certain provisions in Medicare supplement policies; - to define and prohibit certain unfair acts and practices; - to set loss ratio requirements; - to assure orderly implementation and conversion of Medicare supplement insurance benefits and premiums following changes in the federal Medicare program; - to standardize coverage, terms, and benefits of Medicare supplement policies; - to eliminate policy provisions that duplicate Medicare benefits; and - to refund premiums paid for benefits that duplicate Medicare benefits.

Health insurers cannot refuse to enroll a child in the parent's health insurance plan because the child

- was born out of wedlock; - Is not claimed as a dependent on the parent's federal income tax return; or - The child does not live with the parent or in the insurer's service area.

A long-term care insurance policy issued in Washington must trigger benefits when an insured is unable to perform how many activities of daily living?

3

Frances buys a Medicare supplement policy and a long-term care insurance policy. If she is unsatisfied with them, she can return them for a full refund of the premiums within how many days?

30 days in both cases

For purposes of Washington health insurance reform legislation, a small employer is any person or business entity that is actively engaged in business and employed an average of no more than how may persons in the preceding calendar year?

50

A pre-existing condition in a long-term care insurance policy issued in Washington cannot be defined more restrictively than a condition for which medical advice or treatment was recommended by or received from a physician within how many months before the effective date of coverage?

6

Medicare Supplement Health Insurance Act: Medicare supplement insurer

A Medicare supplement insurer includes insurance companies, fraternal benefit societies, health-care service contractors, and health maintenance organizations. A direct response insurer is one who transacts insurance directly with a potential insured without the use of an insurance producer.

Minimum Standards for Individual Health Insurance Policies: Basic Hospital Expense Benefits

A basic hospital expense policy will pay an insured's hospital expenses for at least 31 days of continuous confinement while the insured receives necessary medical treatment after an accident or sickness. Coverage applies to daily hospital room and board, miscellaneous hospital services, and outpatient services.

Health Care False Claim Act: claim

A claim is any attempt to make a health care payer pay for health care.

when should the claimant notify insurance?

A claimant must notify the insurer of the loss within 20 days after the loss or as soon thereafter as reasonably possible.

When will the claimant send proof of claim

A claimant must submit the proof of claim to the insurer within one year, unless the claimant was legally incapacitated.

Health Care False Claim Act: deceptive claim

A deceptive claim is a claim that is based on a false statement of fact or the failure to reveal a material fact, with the purpose of misleading a health care payer. False means entirely or partially untrue or deceptive.

Medicare Supplement Health Insurance Act: guaranteed renewable

A guaranteed renewable Medicare supplement policy is renewable only at the insured's option through timely payment of premiums. The insurer can reserve the right to change premium rates by class.

Health Care False Claim Act: health care payment

A health care payment is a payment for health care services or the right to receive payment for such services.

Minimum Standards for Individual Health Insurance Policies: Recurrent Conditions

A policy cannot specify that a recurrent condition must be separated by a period of more than six months.

Minimum Standards for Individual Health Insurance Policies: Free-Look Provision

All health insurance policies (except single premium, nonrenewable policies) must provide the policyholder with an unconditional right to return the policy within ten days of receiving the policy and have the premium refunded if, after examining the policy, the policyholder is not satisfied with it for any reason. - if it is a Medicare supplement and long-term care insurance policies the insured gets 30 days - if the long term care is by mail, they get 60 days

Minimum Standards for Individual Health Insurance Policies: Renewal, Continuation, and Nonrenewal Provisions

All individual health insurance policies must include provisions for renewal, continuation, or nonrenewal.

Standard Provisions: Free Look, Return of Policy

All policies must have a notice either printed on its face or attached stating that the person to whom the policy is issued is allowed to return the policy within 10 days after delivery and request a refund for premium paid, if they are not satisfied for any reason. - 10 days to return policy after getting it

Medicare Supplement Health Insurance Act: Applicant

An applicant for a Medicare supplement policy is the person who will be the insured or the certificate holder (in the case of a group Medicare supplement policy). A certificate is the evidence of insurance issued under a group Medicare supplement policy.

when can the insured not sue?

An insured cannot sue an insurer on a claim before 60 days or more than 3 years have passed since filing proof of loss.

Standard Provisions: Legal Actions

An insured cannot sue the insurer on a claim before 60 days have passed since filing written proof of loss. However, an insured cannot bring suit after three years have passed since filing proof of loss.

Minimum Standards for Individual Health Insurance Policies: Outline of Coverage

An insurer cannot deliver or issue for delivery a health insurance policy unless the insurer delivers an outline of coverage with it. In the alternative, the insurer (or its producer) can give the outline of coverage to the applicant when taking the application.

Medicare Supplement Health Insurance Act: Prohibited Compensation for Replacement by Same Insurer

An insurer cannot pay producers any more than the renewal compensation that would have been paid on an existing Medicare supplement policy if an existing Medicare supplement policy is replaced by another such policy issued by the same insurer, and the benefits are substantially the same as those under the old Medicare supplement policy.

when will the insurer send claim forms?

An insurer must send claim forms to a claimant within 15 days of receiving notice of a claim.

Medicare Supplement Health Insurance Act: Advertising

An insurer that sells Medicare supplement insurance to Washington residents is required to provide the Commissioner with copies of any advertisements intended for use in the state before actually using them. These copies must be filed at least 30 days before the insurer intends to use them. (If the advertisement is for radio or television, the insurer can provide an audio or video recording at the Commissioner's request.)

Minimum Standards for Individual Health Insurance Policies: Basic Medical-Surgical Expense Benefits

Basic medical-surgical expense insurance covers expenses incurred for surgical services, anesthesia, and in-hospital medical services for at least 21 days per confinement.

Abby is a licensed producer who sells long-term care insurance policies in Washington. Her license is due for renewal in six months. What must she do to renew the license?

Complete 4 hours of coursework on LTC insurance

Medicare Supplement Health Insurance Act: accident, accidental injury, and accidental means

Definitions for accident, accidental injury, and accidental means must be based on "results" language, so that whether an occurrence is determined to be an accident is based not on the actions that led to the result, but on the result itself.

Maureen's health insurance policy has been effect for the last four years. Therefore, the insurance company can contest it only on which basis?

Fraudulent application.

Which of the following is a corporation or association connected to a health-care provider or group of providers that accepts prepayment for health-care services from individuals or groups in exchange for giving them health-care services from the health-care provider or group of providers?

Health-care service contractor

Minimum Standards for Individual Health Insurance Policies: Hospital Confinement Indemnity Benefits

Hospital confinement indemnity insurance indemnifies the insured for hospitalization expenses for at least 31 days per confinement.

Standard Provisions: Expense-Incurred Benefits

If a person has other insurance that provides benefits on an expense-incurred (or for-service) basis, the total amount of coverage the person can have from a single insurer will be limited to a specific maximum amount, no matter how many health insurance policies have been issued to the person. - there is a max amount of coverage someone can get, this is so someone doesn't try to finess and get hella coverage

Permitted Compensation Arrangements

If an insurer pays a commission for the sale or renewal of a Medicare supplement policy, the commission must stay the same in terms of the percentage of premium for each year that the coverage remains in effect

Standard Provisions: Conformity with State Statutes

If any provision in a health insurance policy conflicts with the laws of the state in which the insured lives, the policy is automatically amended to conform to the minimum requirements of those laws.

Standard Provisions: Unpaid Premium

If the insured has failed to pay a premium that is due when a claim is made, the insurer may deduct the amount of the premium from the amount payable to the insured or beneficiary. - take it out of the take home money

Standard Provisions: Misstatement of Age or Sex Provision

If the insured misstated his or her age in the application, benefits payable will be what the premiums would have purchased at the correct age.

Minimum Standards for Individual Health Insurance Policies: Major Medical Expense Benefits

Major medical expense insurance covers hospital, medical, surgical, and room and board expenses for at least 31 days per confinement.

Marco, a 38-year-old accountant, applies for a health insurance policy that will replace an existing policy. Which of the following disclosure documents is he not likely to receive from the producer?

Medicare supplement Buyer's Guide

Medicare Supplement Health Insurance Act: Minimum Standards for Benefits; Exclusions for Pre-existing Conditions; Part A Deductibles and Coinsurance

Medicare supplement policies issued in or for delivery in Washington must include certain minimum standards for benefits.

Free-Look Period

Medicare supplement policies must provide for a free-look period of at least 30 days, during which the buyer can return the policy for any reason for a full refund of the premium paid. If the refund is not paid within 30 days after the buyer returned the policy, the insurer must pay a penalty of 10 percent of the refund in addition to the amount due.

Standard Provisions: Payment of Claims; Time Payment of Claims

Once the insurer receives proof of loss, it is supposed to immediately pay the benefits due to the insured, the beneficiary, or the insured's estate. If benefits are to be paid over a period of time, they cannot be paid any less often than monthly. - payments in monthly or more

Able Insurance Co. sends a health insurance policy to Scott, its producer, for delivery to Stacy, a client. Scott and Stacy are old friends. Stacy is often absentminded and misplaces important documents, so Scott files the policy in his office for safekeeping. Which of the following statements is true?

Scott's actions constitute an unfair practice.

Abby purchased a long-term care policy on June 15. Two weeks later, she lost her job and decided that she could no longer afford the policy. What are her options?

She can return the policy for a full refund of premium.

Medicare Supplement Health Insurance Act: Sickness

Sickness cannot be defined more restrictively than an illness or disease of the insured that first appears after the effective date of coverage and while the policy is in force. The definition can exclude sickness or illness for which benefits are provided under worker's compensation, occupational disease, employer's liability, or similar law.

Which of the following is a valid basis for an insurer to refuse to insure a child under a parent's health insurance plan?

The child's parents are divorced.

Standard Provisions: Illegal Occupation

The insurer can exclude any loss that arises from the insured's participation in a felony or engagement in an illegal occupation. - it's not their problem

Standard Provisions: Physical Examination and Autopsy

The insurer has the right to conduct a physical examination of the insured whenever and as often as reasonably necessary to investigate a claim. The insurer may also conduct an autopsy of the deceased insured unless the law forbids it.

Health Care False Claim Act:

The purpose of the Health Care False Claim Act is to control the cost of health care by reducing fraudulent insurance claims. The act imposes specific penalties for violations.

Henry, an insurance prospect, meets with Lisa, a producer. Lisa determines that Henry would be well served by buying a long-term care insurance policy. While submitting the application, she learns that Henry receives Medicaid benefits. She submits the application, and the policy is issued. Which of the following statements about Lisa's actions is true?

The sale was prohibited.

Minimum Standards for Individual Health Insurance Policies

These standards are required in individual health insurance policies issued or delivered in Washington. However, they do not apply to long-term care, Medicare supplement, or disability income insurance policies.

Which of the following statements about preexisting conditions with respect to LTC insurance policies is true?

They cannot be excluded if they arose more than six months before the effective date of coverage.

Standard Provisions: Change of Beneficiary

Unless the insured makes an irrevocable beneficiary designation, the insured retains the right to change the beneficiary. Consent of any beneficiary is not required for the insured to surrender or assign the policy or to change any beneficiary or for other changes in the policy.

Completion of Application

When an application form asks an applicant to provide answers to questions about his or her health to determine whether the applicant is eligible for coverage or to determine the existence of a pre-existing condition, the questions must be clear and precise. They should not lead the applicant to reply in unavoidably vague or general answers.

Suitability of Recommended Purchase; Excessive Insurance

When recommending the purchase or replacement of a Medicare supplement policy, a producer must reasonably try to determine whether the policy is appropriate for the customer. The sale of a Medicare supplement policy that will result in the customer having more than one such policy is prohibited. Also, an insurer cannot issue a Medicare supplement policy to anyone who is enrolled in Medicare Part C unless the effective date of coverage is after the termination date of the person's Part C coverage.

How does the Health Care False Claim Act help control the cost of health care in Washington?

by penalizing fraudulent claims

Which of the following is a benefit trigger under a long-term care policy?

cognitive impairment

Which of the following would not be considered an activitiy of daily living (ADL) for the purpose of triggering benefits under a long-term care insurance policy?

communicating

An insurance company issues a health insurance policy to Doug's client, and the policy is sent to Doug to deliver to his client. The client travels often and is unavailable when Doug calls to deliver the policy. What should Doug do?

deliver the policy to the client at the first reasonable opportunity

A long-term care insurance policy issued in Washington can limit or exclude benefits for which of the following?

mental or nervous disorders

When soliciting a prospective customer for the sale of a life insurance policy offering long-term care insurance benefits, Marla must provide certain disclosure documents. What is the proper order in which she must present these documents?

outline of coverage, Shopper's Guide, policy summary

Which of the following standard provisions of a health insurance policy is not intended to prevent overinsurance?

payment of claims

Which of the following is not considered an activity of daily living that, if the insured is unable to perform it, could trigger the payment of benefits from a long-term care insurance policy?

speaking

A pre-existing condition in a Medicare supplement policy issued in Washington cannot be defined more restrictively than a condition for which medical advice or treatment was recommended by or received from a physician within how many months before the effective date of coverage?

three