Chapter 6 Health Insurance Policy Provisions

Periodic health claim payments MUST be made at least

Monthly

An insurer must provide an insured with claim forms within __ days after receiving notice of a loss

15

An insured must notify an insurer of a medical claim within how many days after an accident?

20 days

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

45 days

Which of the following health policy provisions states that the producer does NOT have the authority to change the policy or waive any of its provisions?

Entire Contract

Which health policy clause stipulates that an insurance company must attach a copy of the application to the policy to ensure that it is part of the contract?

Entire Contract The Entire Contract The Entire Contract provision states that the health insurance policy, together with a copy of the signed application and attached riders and amendments, constitutes the entire contract.

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

File written proof of loss

Which of the following health insurance policy provisions specifies the health care services a policy will provide?

Insuring Clause

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

Nonrenewable

Which of these is considered a mandatory provision?

Payment of Claims

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

What is considered to be a characteristic of a Conditionally Renewable Health Insurance policy?

Premiums may increase at time of renewal

Which of the following statements about a Guaranteed Renewable Health Insurance policy is CORRECT?

Premiums normally increase at time of renewal

What is the purpose of the Time of Payment of Claims provision?

Prevents delayed claim payments made by the insurer. The purpose of the Time of Payment of Claims provision is to prevent the insurance company from delaying claim payments.

What must the policyowner provide to the insurer for validation that a loss has occurred?

Proof of Loss

The Legal Actions provision of an insurance contract is designed to do all of the following, EXCEPT:

Protect the Producer

G is involved in an automobile 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

T files a claim on his Accident and Health policy after being treated for an illness. The insurance company believes that T misrepresented his actual health on the initial insurance application and is, therefore, disputing the claim's validity. The provision that limits the time period during which the company may dispute a claim's validity is called

Time Limit on Certain Defenses

An insurance company normally has 2 years to contest information provided on an accident and health application. This 2 year period begins on the date that the

insurer dates the policy

The Notice of Claims provision requires a policyowner to

notify an insurer of a claim within a specified time