CHAPTER 6 HEALTH INSURANCE

optional renewability clause An optional renewability clause allows an insurer the unrestricted right to terminate coverage at any anniversary or at any premium due date.

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

modified provision is not less favorable to the insured Uniform policy provisions may have the wording changed as long as the modified version 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

guaranteed renewable policy An insurer has the right to change the premium for policyowners with a guaranteed renewable policy, but CANNOT cancel the policy.

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

conditionally renewable When an insurer has the right to terminate a health insurance policy for specific reasons other than the insured's health, the plan is described as 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

essential health benefits with no lifetime dollar limits A grandfathered plan cannot impose lifetime limits on how much health care coverage people may receive.

According to the Affordable Care Act, a grandfathered group health plan MUST cover

20 The notice of claims provision states the claimant must notify the insurance company within 20 days after the loss occurs.

According to the notice of claims provision in a health insurance policy, a claimant normally must notify the insurance company of loss within how many days after the loss occurs?

File written proof of loss The insured may file written proof of loss in any form if the insurer does NOT furnish forms after the insured gives notice of loss.

After an insured gives notice of loss, what must he/she do if the insurer does not furnish forms?

Jack-noncancellable The insurer assumes a higher risk in a noncancellable policy, therefore they charge a higher premium

Assume the following individuals are issued health insurance policies with varying renewability provisions. All other factors being equal, who would pay the highest premium?

Unpaid premium If there is an unpaid premium at the time a claim becomes payable, the amount of the premium is to be deducted from the sum payable to the insured or beneficiary.

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?

Determines what is paid by the primary and secondary insurers in the event of a claim The purpose of the coordination of benefits provision in group health care is to determine what is paid by the primary and secondary insurers in case of a claim.

In group health care, what is the purpose of the coordination of benefits provision?

Pay a premium after the due date.

In health insurance policies, the purpose of a grace period is to give a policyholder extra time to

pay for ongoing claims under the policy it replaces No loss no gain legislation requires that when health insurance is replaced, ongoing claims under the former policy must continue to be paid under the new policy.

States that have "no loss no gain" laws require a replacing policy to

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

mandatory In health insurance policies, the reinstatement provision is mandatory.

The reinstatement provision in a health insurance policy is

Legal actions The Legal actions provision of an accident and health policy dictates the time limit for filing claim disputes.

The time limit for filing claim disputes is addressed in which provision of an accident and health policy?

cancelable The renewability provision in a cancelable policy allows the insurer to cancel or terminate the policy at any time, simply by providing written notification to the insured and refunding any advance premium that has been paid.

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

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

Change of occupation provision The change of occupation provision allows an insurer to adjust policy benefits and/or rates if the insured has changed to a more hazardous occupation.

When an insured changes to a more hazardous occupation, which disability policy provision allows an insurer to adjust policy benefits and rates?

Guaranteed renewable A guaranteed renewable policy is an insurance policy that obligates the insurer to continue coverage as long as premiums are paid.

Which kind of health insurance policy assures renewability up to a specific age of the insured, although the company reserves the right to change the premium rate on a class basis?

change of occupation The change of occupation provision is considered an OPTIONAL provision.

Which of the following is NOT a required provision in an accident and health insurance policy?