AD Banker Health Insurance
Contract of Adhesion
1 party writes the contract with NO input from the other party. "Take it or leave it"
What is an association ?
100 members having a purpose other than buying insurance
For Group Insurance the employer with a self funded plan can hire a ?
3rd Party Administrator
Small employer , how many employees to be considered ? (Not AZ)
50 or less
What's a broker ?
A licensed person who works on behalf of applicant
Conditional Contract
Both parties must follow rules to make contract enforceable
(FCRA) Who informs the applicant about credit report ?
Consumer reporting Agency
In Medicare it has expanded to any age who have been
Diagnosed with chronic or permanent kidney failure n end stage renal disease Social Security Income for 24 months
Actuarial
Gather statistical info + determines probability of loss and set premium rates
Difference between Loss , Peril, Hazard
H - condition that increases loss P - cause of loss ex: fire windstorm L - reduction/decrease of value.
In an emergency situation get in contact with a
HMO
What's an Optional Uniform Provisions
It's to protect the insurer and included at the insurer's
Difference between Basic Expense and Major Expense
Major benefits provides for BIG illness while basic is like non emergency benefits -Medical,Hospital,Surgical
What's the difference between Private and Government Insurers ?
Majority is Private. Goverment is more like a help of aide.
What's another Title for Medicare Part C + what plans do they include
Medicare advantage HMO / PPO / Private Fee for Service Plans n Special Needs
Do you have to pay a premium for part A?
No but you have to pay a deductible
What are the Policy Renewal Provisions ?
Non cancellable - rates never increase , insurer cannot change the plan Guaranteed Renewable - no proof of insurability Conditionally Renewable - specific conditions to renew Optionally Renewable - insurer decides to renew Cancellable - lowest premium paid InsurER can cancel at anytime Period of Time - policy written only for a certain period of time
Adverse Selection example
Only those living in earthquake prone areas, seek to buy earthquake insurance OR those in the poorest of health seeking to acquire life/health insurance
What words can't you use in advertising
Only, Just, Merely, Minimum (words that describe restrictions)
What is a physician certification for LTC
Stating that the patient is ill and needs long term care
If a policy is issued based on an incomplete application it's assumed that
The insurer waives the right to challenge a claim based on incomplete application
ERISA
Think mother Teresa , provides benefits by using funds
What is the purpose of the Fair Credit Reporting Act ?
To determine the financial and moral status of applicant
For advertising you have to name the source T/F
True
Short Term Medical is for People when they need quick insurance because of loss of employment T/F
True
Subrogation
When a claim is paid by insurer but they can take legal action because of a dangerous 3rd party
Disability Income insurance is
When you are working but you might get hurt or sick outside of work, you can purchase a disability income policy
For Medicare Supplement application form T/F Does a question about replacement have to appear ?
Yes it does True
Individual disability benefits are based off
of % of income
Difference between Moral And Morale Hazard
Moral - dishonest ex insured burns down their house to collect insurance payout. Morale - attitude of confusion toward loss that increase chance of loss ex ignoring stop sign, not wearing seatbelt.
What does insurability mean ?
Applicant could meet insurERs underwriting requirements
Does the agent report come part of the contract?
No it remains confidential
For Medicare supplement, Can pre-existing conditions be excluded from coverage ?
No they can not
Do basic plans have a deductible?
No they don't
To qualify long term care
Policy has to be guaranteed renewable
Difference between Preferred / Standard / Substandard Risssssk
Preferred - lower rate Standard - rate as quoted Substandard - coverage as was but a higher premium
How do you get a conditional receipt
Premium is paid at time of application
If you lose limbs or a limb what 2 sums are those ?
Principal sum (head of school 100%) Capital sum (50% dismemberment)
Difference between Private and Government
Private is commercial companies that sell to the public Government is Social Security, Medicare, Medicaid, Tricare
Characteristics of Disability Income Policy
Probationary - Elimination - specific amount of time disabled before benefits kick in Benefit - amount of time you can receive payments
Underwriting
Process of classifying, rating a risk for the purpose of ya or nay on insurance coverage.
Who's responsibility is it to make sure the application is filled out completely
Producer
What are Mandatory Uniform Provisions ?
Provisions that must be included in every individual Accident n Health insurance policy.
With Group underwriting, what's the difference in Experience n Community rating ?
Experience is in the history of claims of group (the past) Community is examining particular geographic region
Fiduciary
A Legal trust between 2 or more parties , handles money for another person when dealing with premiums.
Policy Renewal Provisions means
A healthy policy with conditions to make sure coverage is continuous.
What is a multiple indemnity rider
A rider that provides additional benefits to an insurance policy for losses due to an accident.
There's 12 Mandatory Uniform Provisions
Entire Contract Clause Time Limit on Certain Defenses (incontestable) Grace Period Reinstatement Notice of Claim (within 20 days) Claim Form Provision (within 15 days) Proof of Loss (within 90 days) Time of Payment of Claims (immediately) Payment of Claims Physical Exam / Autopsy Legal Actions (wait 60 days) Change of Beneficiary
Difference between Occupational n Nonoccupational for qualifying benefits
Occupational covers disability due to injury n sickness on or off the job No occupational covers disability OFF the job only
Dental Care Titles Difference between Preventive / Basic / Major
P - routine check ups, X-rays, cleaning B - fillings, periodontics, root canals M - crowns, dentures, bridge work, ortho
Which parts of Medicare are Federal Government n Private Insurance providers ?
Part A Hospital (government) Part B Medical Insurance n Outpatient expenses (government) Part C combo A n B (private insurance providers) Part D Prescription drug coverage (private insurance providers)
What does principal of indemnity mean
Prenup you get the money that you had before marriage.
Blue Cross n Blue Shield are
Prepaid plans and have an agreement with physicians
What treatments have to do with Ambulatory Care ?
Preventative care Health education Family Planing Dental/vision
HMO is similar to Blue Cross because of prepaid but they focus on what?
Prevention care and members pay a copayment
What reduces medical expenses in a HMO
Preventive medicine through physical exams n diagnostic procedures Reducing # of unnecessary hospital admissions
Legal interpretations Affecting Contracts are (9)
Principal of Indemnity- prenup Utmost of Good faith Representations Misrepresentations Warranties - guaranteed true Concealment - holding back of material fact Fraud - intentional deception Waiver Estoppel -judicial denial
Medicare Part B exclusions for example
Prescription Drugs / Long Term Care
Long term care exclusions can be..
Acute care Rest cures Intentionally self inflicted injuries Mental disorders Injury arising out of committing a felony
Other Standard Provisions and Clauses for Individual n Group Insurance Contracts
Right to Examine (Free Look) Insuring Clause - insured /insurer / amount of coverage Consideration Clause - promise to pay premium Owner's Right Pre-existing Condition Provision Probationary Period Elimination Period Wavier of Premium 1st DollarCoverage Coordination of Benefits Eligible Expense Military Suspension Provision
With Basic Health Insurance Policy the hospital expense pays for what kind of room and board ?
Semi-private
Part A includes the following coverage like rooms blood? What kind
Semi-private room n board Operating room cost Prescription drug + anesthesia Hospital supplies Blood AFTER 1st 3 pints
Difference between individual n Group
Single person purchase insurance for family, not dependent on employer. Most expensive, require proof of insurability. Group has Employer sponsored, underwriting the whole group then that makes the average premium. Proof of insurability not required.
What are Long Term Facilities n Levels of care ?
Skilled Nursing Care - 24 hr supervised nurse Intermediate care - daily care provided by licensed medical professional Custodial care - non medical care with assistance
T/F Producers must report any material facts that may affect underwriting ?
True
For Cobra , how many employees for cobra to work ?
20 or more
How many people for a group health plan to be primary ?
20 people
Who is required to report any activity of laundering money ?
Agents/Brokers
Prepaid is like an
All you can eat buffet
What are the 10 Optional Uniform Provisions
Change of Occupation Misstatement of Age Other Insurance with this Insurer -more than 1 policy with same insurance Insurance with Other Insurers - has a same policy with different insurance companies Relationship of Earnings to Insurance Unpaid Premiums Conformity with Statue Statues Illegal Occupation/Act Intoxicants and Narcotics Cancellation - with written notice
There's 3 different Authorities, What are they ? + meaning
EIA) Express Implied Apparent
Aleatory Contract
Exchange of value is unequal
Who oversees the operation of management
Executives
What is coverage based on
Financial loss due to an accident , sickness or death.
Misstatement of material fact by a person who knows or believe that statement to be false
Fraud/ Fraudulent Act
2 Types of Policies for Disability Income Insurance
Indemnity Policy - pays an income benefit 60% Income Replacement Policy - receive benefits because of loss of income due to an accident
What does guaranteed renewable mean
Insurer has to keep giving coverage as long as premium is still getting paid
Part A provides coverage for inpatient charges +
Skilled nursing, home health care and hospice
Worker compensation benefits are mandated by
The state
An insurable interest must exist at the time of
Application
Limited Policies like Accidental Death n Dismemberment How many days within the date of accident that they will get a prin or cap SUM?
90days
For employer group insurance, after waiting period , how many days does Employee have to enroll ?
30 days
If the employee gets 100% for group disability then what does spouse and kids get ?
50%
Part A coverage up to how many days ?
90 days 1-60 fully covered 60-90 copayment
For Dental scheduled means _______ and non schedule means _______
Basic and Comprehensive plans
What are 6 of activities of daily living ?
Bathing/Continence/Dressing/Eating/Toileting/Transferring
Dental care types Endodontics - Orthodontics - Periodontics - Prosthodontics -
E - root canals O- teeth alignment P - gum problem n disease P - bridgework dentures
A long-term care policy may only be canceled how?
By the insurer for nonpayment of premium
A legal contract has 4 elements between the parties
Competent Parties Legal Purpose Agreement (offer-acceptance) Consideration (exchange of money for a promise)
What's the difference between contributory and noncontributory?
Contributory plans is when 75% participation to pay premium from employees n employer Non plans means 100% participation from employer
Gramm-Leach-Bliley Act has to do with?
In insurance it's about a privacy notice
Domestic is same state Foreign is another state Alien is outside of US so what's non/admitted insurer ?
Is an insurer approved or authorized to write business in the specific state.
What does Ambulatory have to do with anything ?
It's facilities that care about cost effectiveness of outpatient services
Medical Info Bureau
It's not for profit , service for underwriting Help lower cost of insurance
Difference between Supplemental Major Medical and Comprehensive Major Medical Policy ?
Supplemental covers when the basic plan is exhausted into a Major plan with a mandatory Corridor deductible. Comprehensive is when the coverage has both Basic n Major in 1 single policy.
