Chapter 17- Health Insurance Provisions

7. According to Required Provision 4, when an insured applies for reinstatement of a health policy and receives a conditional receipt, how long does the insurer have to approve or deny

45 days of the date of application.

12. Bart is injured and provides notice of a health claim to the Insurer. He later receives the required claim forms. Within how many days of the loss must Bart file proof of loss with the insurance company

90.

20. The Notice of Claim provision states that the insured notify the ins. Co. within___ days of a claim

20 days

56. An insured pays premiums on an annual basis for an individual health ins. Policy. What is the MINIMUM number of days for the Grace Period provision

31

14. Required Provision 3 states that the minimum grace period for all policies (except those with monthly or weekly premium modes is

31 days.

61. Required Provision 3 states that the minimum grace period for all policies (except those with monthly or weekly premium modes) is

31 days.

21. With Accidental Death and Dissmemberment policies, what is the purpose of the Grace period

Gives the policyowner addtional time to pay past due premiums

35. Which of the following provisions specifies how long a policyowner's health coverage will remain in effect if the policyowner does not pay the premium when it is due

Grace period

31. Which of the following health ins. Policy provisions specifies the health care services a policy will provide

Insuring clause

42. Which of the following BEST describes a short-term medical expense policy

Non-renewable.

19. If an ins. Co. issues a Disability Income policy that it cannot cancel or for which it cannot increase premium, the type of renewability that best describes this policy is called

Noncancellable

49. S filed a Proof of Loss for a Disability Income claim on September 1. The ins. Co. did not respond to the claim. S can take legal action against the insurer beginning

November 1.

43. The provision that defines to whom the insurer will pay benefits to is called

Payment of Claims

55. Which of these is considered a mandatory provision

Payment of claims

38. The policy provision that entitles the Insurer to establish conditions the insured must meet while a claim is pending is

Time Limit on Certain Defenses.

60. If an individual has an Accidental Death and Dismemberment policy and dies, an autoposy can be performed in all of these EXCEPT

When the State prohibits this by law.

28. A disability policy that must be renewed, cannot be canceled until age 65, and may not have an increase in premium for any reason is called

noncancellable policy

4. The Notice of Claim Provision states that the Insured notify the insurance company within ___ days of a claim

20

62. Which of the following statements describes what an Accident and Health policyowner may NOT do

Adjust the premium payments

6. Which of the following statements is NOT correct

Agents are allowed to waive certain policy provisions.

15. The waiver of premium provision normally excludes which of the following disability acts

All of the above.

23. When does a Probationary Period provision become effective in a health ins. Contract

At the policy's inception.

48. P is a Major Medical policyowner who is hospitalized as a result of injuries sustained from participating in a carjacking. How will the insurer most likely handle this claim

Claim will be denied

30. The clause in an Accident and Health policy which defines the benefit amounts the insurer will pay is called

Insuring clause

59. A Disability Income policyowner recently submitted a claim for chronic neck problem that has now resulted in total disability. The original neck injury occurred before the application was taken 5 years prior. The neck injury was never disclosed to the insurer at the time of application. How will the insurer handle this claim

Claim will be paid and coverage will remain in force.

40. Which health policy clause stipulates that an ins. Co. must attach a copy of the application to the policy that it is part of the contract

Entire contract

44. When an ins. co. sends a policy to the insured with an attached application, the element that makes the application part of the contract between the insured and the insurer is called the

Entire contract

46. What type of renewability guarantees premium rates and renewability

Guaranteed renewable

17. T owns an Accident & Health policy and notifies her insurance company that she has chosen a less hazardous occupation. Under the Change of Occupation provision, which of the following actions may her insurance company take

Increase her policy's coverage amount

18. What is considered to be a characteristic of a Conditionally renewable Health insurance poliy

Premiums may increase at time of renewal.

33. What is the purpose of the Time of Payment of Claims provision

Prevents delayed claim payments made by the Insurer.

64. What is the purpose of the Time of Payment of Claims provision

Prevents delayed claim payments made by the insurer

54. What must the policyower provide to the insurer for validation that a loss has occurred

Proof of Loss

51. K failed to pay a renewal premium within the time granted by the insurer. K then sends in a payment which the insurer subsequently accepts. Which policy provision specifies that coverage may be restored in this situation

Reinstatement

58. Which of the following statements describes the purpose of the Insuring Clause in Health and Accident policies

States the scope and limits of coverage

34. J an Accidental and Dismemberment (AD&D) policy holder dies after injuries sustained in an accident. J's age as stated on the application five years ago was found to be understated by 10 year. Which of the following actions will the ins. Co. take

The insurer will adjust the benefit to what the premiums paid would have purchased at the time of the insured's actual age.

47. Which of the following statements about a non-cancellable policy is FALSE

The premium CAN be increased over time

2. Which of the following statements about a noncancellable policy are FALSE

The premium rate CAN be increased over time

41. According to Required Provision 4, when an insured applies for reinstatement of a health policy and receives a conditional receipt, how long does the insurer have to approve or deny

Within 45 days of the date of the application

10. Anita is an office clerk at the time she purchases a Disability Income policy. She later changes her career toa king crab fisherman. If she ever becomes injured on the boat, the Change of Occupation provision states that the insurer can

adjust the benefits.

22. Health Ins. benefits NOT covered due to an act of War are

excluded by the insurer in the contract provisions.

13. On November 10, Ozzie Major Medical policy is reinstated. He is later injured in an automobile accident on Novemer 13 and immediately hospitalized. Ozzie is eligible for

full benefits (After health policy's reinstatement are fully covered immediately. Illnesses require a 10 day wait period).

3. Under a Guaranteed Renewable health insurance policy; the insurer

may cancel the policy for nonpayment only.

36. Periodic benefit payments must made no less frequently than

monthly

8. Periodic benefit payments must be made no less frequently than

monthly

26. With Optionally Renewable Health policies, the insurer may

review the policy annually and determine whether or not to renew it

50. Which of these statements accurately describes the Waiver of Premium provision in an Accident and Health policy

Premiums are waived after the Insured has been totally disabled for a specified time period.

25. The Notice of Claim provision requires a policyowner to

notify an insurer of a claim within a specified time

24. G is involved in an auto accident as a result of driving while intoxicated and suffers numerous injuries. According to the Intoxicants and Narcotics exclusion in G's policy, who is responsible for paying the medical bills

The Insured

37. After the ins. Co. receives a written request, an insured may have health ins. Benefits paid to

anyone designated by the Insured

29. M's ins. Co. denied a reinstatement application for her lapsed health ins. Policy. The co. did not notify M of this denial. How many days from the reinstatement application date does the ins. Co. have to notify M of the denial before the policy will be automatically placed back in force

45 days

16. What should an insured do if the insurer does not send claims forms within the time period set forth in a health policy's Claims Forms provision

Submit the claim in any form

63. Which Accident and Health policy provision addresses pre-existing conditions

Time Limit on Certain Defenses

1. After the insurance co. receives a written request, an insured may have health insurance benefits paid to

anyone designated by the insured.

11. A disability policy that must be renewed, cannot be cancelled until age 65, and may not have an increase in premium for any reason is called a

noncancellation policy

39. The waiver or premium provision normally excludes which of the following disabling acts

All of these

27. Which of the following BEST describes what the Legal Actions provision of an Accident Health policy requires

An insured must WAIT at least 60 days after proof of loss has been submitted before a lawsuit can be filed.

52. An ins. Co. receives E's application for an individual health policy. E did not complete all of the medical history questions because she could not remember the exact dates. E signed the policy and submitted it to the ins. Co. anyway. A few weeks alter, E suffers a heart attack and is hospitalized without completig the medical history questions and paying the initial premium. E is not insured. Which of the following clauses details the conditions that E did not meet

Consideration clause

32. T files a claim on his Accident and Health Policy after being treated for an illness. The ins. Co. believes T misrepresented his actual health on the initial ins. Application and is therefore disputing the claim's validity. The provision that limits the time period during which the co. may dispute a claim's validity is called

Insuring

5. The clause in an Accident Health policy which defines the benefit amounts the insurer will pay is called the

Insuring clause.

57. According to the Time Payment of Claims provision, the insurer must pay Disability income benefits no less frequently than which of the following options

Monthly

45. Which of the following statements about a Guaranteed Renewal Health insurance policy is CORRECT

Policy normally increase a the time of renewal.

53. What should an insured do if the insurer does not send claims forms within the time period set forth in a health policy's Claims Forms provision

Submit the claim in any form

9. Amy owns a disability income policy with a noncancellable renewal provision. Which of the following is guaranteed in her policy

The coverage and premium rate are guaranteed.