Additional Provision Questions - Disability

The required provision dealing with reinstatement of a lapsed policy states that when an insured applies for reinstatement and receives a conditional receipt, the policy will be automatically reinstated (unless rejected) a-Within one year if 90 days is not reasonable. b-45 days from the date of the conditional receipt. c-30 days from the date the insurer receives the application for reinstatement. d-180 days from the date the unpaid premium was due.

b-45 days from the date of the conditional receipt.

The purpose of the Illegal Occupation provision is to a-Allow an insurer to collect extra premiums to provide coverage for an insured's illegal acts. b-Excuse an insurer from liability for a loss incurred by an insured during the commission of a felony. c-Prevent an insurance producer from rebating on large policies. d-Protect an insured from purchasing policies from an unlicensed producer.

b-Excuse an insurer from liability for a loss incurred by an insured during the commission of a felony.

All of the following are required provisions for accident and health policies (A and H), except a-Change of beneficiary clause. b-Over Insurance Provision. c-Entire contract and changes clause. d-Proof of loss requirement.

b-Over Insurance Provision. The over insurance provision is an optional provision. It is not a required provision.

Charles Adams advised his insurance company of a loss covered by his Major Medical policy. If the insurance company does not provide Mr. Adams with the proper claim forms within 15 days, he has which of the following rights? a-To file a suit against the insurance company immediately. b-To submit a description of the loss to the insurance company, in his own words, as proof of loss. c-To refuse to submit the required proof of loss. d-To receive immediate payment of his claim.

b-To submit a description of the loss to the insurance company, in his own words, as proof of loss.

Under the mandatory provision dealing with the insurance company having the right to order an autopsy if the insured should die, the insurance company may do so __________. a-under no circumstances b-if not prohibited by law c-with the beneficiary giving written permission d-at will

b-if not prohibited by law

Under the uniform policy provision, the length of the Grace Period varies according to the __________. a-all three of these b-mode of premium payment c-deductible d-length of the benefit period

b-mode of premium payment

Under Legal Actions, the policy owner could sue the insurer after __________ of filing a proof of loss. a-three years b-90 days c-60 days d-30 days

c-60 days

Under the misstatement of age provision in a health insurance policy, what can a company do if it discovers that an insured gave a wrong age at the time of application? a-Assess a penalty b-Increase the premium c-Adjust the benefits d-Cancel the policy

c-Adjust the benefits Under the misstatement of age provision in a health insurance policy, if a company discovers that an insured gave a wrong age at the time of application, it can adjust the benefits.

The policy provision that prevents an insurance company from altering its agreement with a policyowner by referring to documents or other topics not contained in the policy is called the __________. a-Benefits provision b-Legal Actions provision c-Entire Contract provision d-Incontestable provision

c-Entire Contract provision

Mr. Dillon submits a claim for medical expenses covered by his major medical policy. According to the time of payment of claims provision, how soon should the company pay the claim? a-Within 14 days b-Within 30 days c-Immediately d-Within 10 days

c-Immediately

Required Provision 7 indicates that except in the absence of the legal capacity of the insured, if it was not reasonably possible for the insured to provide proof of loss in 90 days as required in a policy, the latest time to file the proof of loss is a-Unlimited. b-Three years from the time proof is otherwise required. c-One year from the time proof is required. d-Within 90 days of a final notice from the insurer after the first 90 days.

c-One year from the time proof is required.

The Proof of Loss Provision indicates that, except in the absence of the legal capacity of the insured, if it was not reasonably possible for the insured to provide proof of loss as required in a policy, the latest time to file the proof of loss is a-Within 90 days of a final notice from the insurer. b-Three years from the time proof is otherwise required. c-One year from the time proof is required. d-Unlimited.

c-One year from the time proof is required.

At the time of a disability income application, Shawn lies about his previous heart condition. Three years after the policy issues, he is disabled due to a severe heart attack. Which of the following is true regarding this situation? a-The insurance company must pay the claim because the lie was not material. b-The insurance company has the right to cancel the policy and refuse to pay any benefits. c-The insurance company must pay benefits because the loss occurred after two years of the policy effective date. d-The insurance company may cancel the policy, but must accept a new application from the insured.

c-The insurance company must pay benefits because the loss occurred after two years of the policy effective date.

A company may change the wording of a uniform policy provision in its health insurance policy only if a-The company's board of directors approves the change. b-The modified provision is not less favorable to the company. c-The provision, as changed, is not less favorable to the insured or beneficiaries. d-The Insurance Commissioner directs that it be changed.

c-The provision, as changed, is not less favorable to the insured or beneficiaries.

It appears that Mrs. Molly may have made a material misrepresentation on her application. Which of the following provisions will allow the insurer to cancel the policy? a-Entire Contract b-Legal Action c-Time Limit on Certain Defenses d-Insuring Agreement

c-Time Limit on Certain Defenses

Mr. X walks into the Everett Clinic for a check-up. He has to pay the Clinic $25 before he can see the doctor. This money paid is called a-the co-insurance b-a stop loss c-a co-payment d-pre-certification expense

c-a co-payment

When used, the time limit on certain defenses provision in a health insurance policy determines that the policy cannot be cancelled AFTER two years, EXCEPT for a-material misrepresentation by the insured. b-concealing a material fact. c-nonpayment of premiums or fraud committed by an insured. d-incomplete policy records.

c-nonpayment of premiums or fraud committed by an insured.

Kyle had a major medical policy which lapsed a few months ago. On March 1st the insurer reinstated his policy. On March 8th he was injured at home. What benefits will be provided under the medical plan for this injury? a-Partial benefits b-No benefits c-Full benefits in 22 days d-Immediate full benefits

d-Immediate full benefits

Which of the following statements about the Time Limit on Certain Defenses provision is true? a-It usually expires after the first year of the policy. b-All of these answers are correct. c-It is applicable to group health contracts only. d-It may prohibit an insurance company from denying a claim on the basis of misstatements in an application.

d-It may prohibit an insurance company from denying a claim on the basis of misstatements in an application.

Which of the following statements about the Time Limit on Certain Defenses provision is true? a-It usually expires after the first year of the policy. b-It is applicable to group health contracts only. c-It limits the duration of an exclusion rider to a maximum of two years. d-It prohibits an insurance company from denying a claim based on misstatements after two years.

d-It prohibits an insurance company from denying a claim based on misstatements after two years.

At the time of a disability income application, Ralph lies about his previous heart condition. Six months after the policy issues, he is hit by a car and is disabled. Which of the following statements is true regarding the situation of Ralph? a-The insurance company must pay benefits because the loss occurred before two years had passed. b-The insurance company must pay the claim because the lie was not material to the car accident. c-The insurance company must pay the benefits because the loss had nothing to do with the misrepresented heart condition. d-The insurance company has the right to cancel the policy and refuse to pay any benefits.

d-The insurance company has the right to cancel the policy and refuse to pay any benefits.

In A and H contracts, the length of the Grace Period varies according to which of the following? a-The length of the elimination period. b-The generosity of the insurance company. c-The length of the benefit period. d-The mode of premium payment.

d-The mode of premium payment. The Grace Period extends coverage past the due date. Claims are covered (minus the past due premium). There must be at least a seven-day grace period for weekly payment plans, 10 days for monthly payment plans and 31 days for payment plans over 30 days.

All of the following statements pertaining to the grace period and reinstatement provision in health insurance policies are correct, except: a-Craig's premium is due June 1st. He forgot to pay his premium and on June 7th has an injury. His policy is still in effect. b-Reinstatement must be offered to an insured, but the insured must prove insurability again. c-The required grace period depends on the mode of premium payment. d-Upon reinstatement of the policy, losses from accidental injuries and sicknesses are covered immediately.

d-Upon reinstatement of the policy, losses from accidental injuries and sicknesses are covered immediately. Under the reinstatement provision, there is a new 10-day probation period established from the date of reinstatement. Probation period applies to sickness only, not to accidents.

The entire contract in health insurance policies (A and H policies) includes __________. a-the policy itself b-endorsements to the policy c-any supplements attached to the policy d-all of these answers are correct

d-all of these answers are correct

All of the following are required provisions in health insurance policies, except __________. a-notice of claim b-grace period c-entire contract d-change of occupation

d-change of occupation Change of occupation is an optional provision. The others are mandatory or standard policy provisions.

The promise to pay by the insurance company represents the __________ to the insured. a-offer b-acceptance c-entire contract d-consideration

d-consideration

The Time Payment of Claims provision tells the insurance company to pay claims __________. a-within 15 days b-within 45 days c-within 90 days d-immediately

d-immediately

If a doctor or hospital wants to know if the insurance company will pay for surgery and how much will be paid for surgery for an insured, they will need to get a-pre-certification from the consumer. b-real about life. c-a certificate of insurance. d-pre-authorization from the insurer.

d-pre-authorization from the insurer.

The warranty which the insurer gives to the insured is the a-promise to issue a policy. b-promise to change a beneficiary. c-promise to check the Medical Information Bureau. d-promise to pay following a loss.

d-promise to pay following a loss.

The Legal Actions provision of an A and H (disability) policy requires that a-An insured wait at least 60 days after submission of Proof of Loss before initiating a lawsuit. b-The insurance company settle a claim within 60 days after receipt of Proof of Loss. c-Claims be settled promptly. d-An arbitrator be used to settle disputes between the insurance company and the insured.

a-An insured wait at least 60 days after submission of Proof of Loss before initiating a lawsuit. Legal Action against the insurer may be filed after 60 days of proof of loss. The statute of limitations is three years.

Mr. Callus advised his insurance company of a loss covered by his Major Medical policy. The company must provide Mr. Callus with the proper claim forms within __________ days. a-15 b-60 c-30 d-5

a-15

What makes up the entire contract? a-All three of these combined. b-The Application c-Any Endorsements or Riders d-The Policy

a-All three of these combined.

An individual health insurance policy was reinstated effective June 1st. On June 8th, the insured became ill, was hospitalized, and returned to work June 15th. The policy would provide which of the following to the insured? a-No benefits b-Partial benefits from June 8th through June 15th c-Full benefits d-Three-quarter benefits

a-No benefits No sickness benefits are paid during the probation period. A reinstated policy contains a new 10-day probation period.

The Required or Mandatory Provisions addressing the payment of claims, indicate all of the following, EXCEPT a-Payment of claims are always paid directly to the provider of the care, such as the doctor or clinic. b-Payment of claims immediately is the same as payment of claims in a reasonable period of time. c-The insurer must pay most claims immediately after receipt of proof of loss, except for disability income policies. d-Claims of periodic indemnities, such as a disability income policy, must be paid at least once a month.

a-Payment of claims are always paid directly to the provider of the care, such as the doctor or clinic. Payment of claims paid directly to the provider of the care must be ASSIGNED by the owner of the policy. It is NOT automatic.

All of the following are Standard or Mandatory Provisions found in disability (AandH) contracts, EXCEPT a-Subrogation b-Proof of Loss c-Reinstatement d-Right to Examination

a-Subrogation

The Conformity with State Statutes provision provides that a-The policy provisions in conflict with state statutes where the insured resides are automatically amended to conform to the minimum requirements of the law. b-The state statutes where the insurance company is domiciled are the regulations the insured must go by. c-Under the mandatory provision law, the insured be protected. d-The insurance regulations conform to policies written within the individual states.

a-The policy provisions in conflict with state statutes where the insured resides are automatically amended to conform to the minimum requirements of the law. Conformity with State Statutes provision states that any policy provision which is in conflict with state statutes in the state where the insured lives, is automatically amended to conform with the minimum statutory requirements.

The Time of Payment of Claims provision requires that an insurance company pay Disability Income benefits no less frequently than __________. a-monthly b-annually c-quarterly d-semiannually

a-monthly

Mr. Foust has an A and H policy which has a $100 premium due on the first of each month. Mr. Foust has missed his March 1st payment and is injured on March 15th. Under the Mandatory Grace Period provision, the insurer would a-not have to pay. b-all of these are correct. c-pay the claim and subtract out any past due premiums. d-pay the full benefits and bill the insured for the late premiums.

a-not have to pay. Monthly payment plans have a minimum 10 day grace period. After 10 days, there is no coverage.

Under Legal Actions, the policy owner must sue the insurer within __________ years after filing a proof of loss. a-three b-five c-two d-one

a-three