Ch. 16 Health Insurance Policy Provisions

Either the insured or the insurer

Coverage under a cancelable health insurance policy may be terminated by The insurer only the insured only Either the insured or the insurer An arbitration committee

Unpaid premium

Craig submits a $500 claim for medical expenses. With a past due premium of $100, the insurer pays $400. Which of the Uniform Optional Provisions covers this situation? Payment of claims Legal actions Unpaid premium Time of payment of claims

optionally renewable

Richard owns an insurance policy that is renewable only at the option of the insurance company. His policy is considered to be cancelable guaranteed renewable conditionally renewable optionally renewable

optional renewability clause

A clause that allows an insurer the right to terminate coverage at any anniversary date is called a(n) conditionally renewability clause optional renewability clause selective renewability clause cancelable clause

modified provision is not less favorable to the insured

A company may change the wording of a uniform policy provision in its health insurance policies only if the company's board of directors approves the change modified provision is not less favorable to the insurer applicant directs that it be changed modified provision is not less favorable to the insured

guaranteed renewable policy

A health insurance policy that allows an insurer to change the policyowner's premiums, but NOT cancel the policy is called a(n) guaranteed renewable policy conditionally renewable policy optionally renewable policy noncancelable policy

conditionally renewable

A health insurance policy where the insurer has the right to terminate the policy for reasons other than the insured's health is called limited renewable conditionally renewable guaranteed renewable conditionally cancelable

essential health benefits with no lifetime dollar limits

According to the Affordable Care Act, a grandfathered group health plan MUST cover pediatric oral and vision care preventative services at no cost to the insured essential health benefits with no lifetime dollar limits emergency services provided by a non-participating provider

File written proof of loss

After an insured gives notice of loss, what must he/she do if the insurer does not furnish forms? File a lawsuit Contact the insurer again requesting forms Nothing File written proof of loss

Primarily describes the free-look period

All of the following are functions of an insuring clause EXCEPT States the conditions under which the policy will pay Outlines the kind of benefits provided Primarily describes the free-look period Provides the policy's scope and limits of coverage

Contracts of adhesion

Because an insurer writes the policy language and the insured has little or no control over the content, any ambiguity in the wording is usually resolved in favor of the insured. Because the design and wording of a policy are in the hands of the insurer, insurance policies are said to be Unilateral contracts Contracts of indemnity Aleatory contracts Contracts of adhesion

For specific reasons stated in the contract only

If an individual health contract is issued on a conditionally renewable basis, the insurer has a right to refuse renewal For any reason stated or unstated For specific reasons stated in the contract only Because of changes in the covered individual's health status When losses for the policy period exceed premiums

Determines what is paid by the primary and secondary insurers in the event of a claim

In group health care, what is the purpose of the coordination of benefits provision? Determines where an insured goes to receive treatment Determines what is paid by the primary and secondary insurers in the event of a claim Ensures that a health provider receives the proper benefit amount owed Determines which parent's plan covers a dependent child

The insurer may deduct the overdue premium from the benefits

Individual health insurance policies may include a provision concerning unpaid premiums. When the provision applies, if a premium payment is overdue when a claim for benefits is made Coverage is suspended until the premium is paid. The insurer may pay the claim and then cancel the policy. A written demand for premium payment will be sent to the insured. The insurer may deduct the overdue premium from the benefits

cancelable

The type of policy where the insurer can send a notice to the insured that the policy has been cancelled in the middle of the term is called noncancelable conditionally renewable optionally renewable cancelable

pay for ongoing claims under the policy it replaces

States that have "no loss no gain" laws require a replacing policy to keep the same type of coverage as the policy it replaces not charge a different premium from the policy it replaces pay for half of any ongoing claims under the policy it replaces pay for ongoing claims under the policy it replaces

The handwritten material first, then the typewritten, and then the printed

Suppose an insurance contract contains inconsistent or contradictory provisions. Various parts of the contract are printed, typewritten, and handwritten. In seeking to determine the original intent, a court is likely to rely on The handwritten material first, then the typewritten, and then the printed The typewritten material first, then the printed, and then the handwritten The printed material first, then the typewritten, and then the handwritten All parts of the contract, giving equal importance to each

Payment of the first premium and the application

The consideration clause in health insurance usually lists the insured's consideration given for the policy as: Payment of the first premium and the application Payment of the first premium and the insurer's acceptance of the risk The application and the insurer's acceptance of the risk The application and completion of an investigative report

mandatory

The reinstatement provision in a health insurance policy is mandatory optional voluntary discretionary

Legal actions

The time limit for filing claim disputes is addressed in which provision of an accident and health policy? Legal actions Entire contract Time of payment of claims Payment of claims

Immediately

Under a provision known as time payment of claims in a health insurance policy, after receiving proof of loss, all benefits other than those that are paid in periodic installments are supposed to be paid Within 30 days Within 60 days Immediately At the end of the month

Adjust the benefits

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? Cancel the policy Increase the premium Adjust the benefits Assess a penalty

Noncancellable

What type of health insurance policy may NOT be changed in any way by the insurer, up to a specified age, so long as the premiums are paid? Guaranteed renewable Noncancellable Conditionally renewable Optionally renewable

Optionally renewable

What type of policy gives the insurer the option to terminate the policy on a date specified in the contract? Optionally renewable Conditionally renewable Cancellable Optionally cancellable

Change of occupation provision

When an insured changes to a more hazardous occupation, which disability policy provision allows an insurer to adjust policy benefits and rates? Relation of earnings to insurance provision Change of occupation provision Conformity of state statutes provision Modified occupation provision

Increase the premiums on an individual basis

Which of the following actions may an insurance company NOT do in a health policy that contains a guaranteed renewable premium benefit? Stop renewing policy when the insured reaches a specified age Cancel policy if premiums are not paid Increase the premiums on an individual basis Increase the premiums on the basis of an entire classification

Misstatement of age

Which of the following is a standard optional provision for health policies? Grace period Physical exam autopsy Change of beneficiary Misstatement of age

Assignment of medical expense payments to providers of service

Which one of the following makes health insurance claim handling more convenient for the insured? Attending physician statements Inspection reports on the insured Periodic examinations of hospitals by insurers Assignment of medical expense payments to providers of service