General

BOE elimination period

15-30 days

in regard to replacement of a policy, what is usually the probationary period for a pre-exisitng condition

15-30 days

what is the copayment for a nonscheduled dental plan?

20%

minimum number of employees for an HMO?

25 or more

**in what time must a section 1035 exchange take place?

30 days

how long must employees with kidney failure receive coverage?

30 months

what is the usual grace period for a semiannual policy?

31 days (for everything but weekly (7) and monthly (10))

*a cancellation provision gives an insurer the right to cancel a policy at any time after giving how many days notice to an insured

5 business days

when can someone take legal action after being denied a claim?

60 days to 3 years

caf plan elimination period

90 days

change of occupation provision

A Change of Occupation Provision in a health insurance policy allows an insurer to adjust the policy benefits if an insured has changed to a more hazardous occupation. If an insured has in fact changed to a more hazardous occupation when a benefit claim is submitted, the benefits will be reduced to reflect what premiums would have been purchased with the assumption of more hazardous occupation. If an insured changes to a less hazardous occupation, an insured is entitled to apply for a premium rate reduction

guaranteed renewable policy

A contract that an insured has the right to continue in force by paying premiums. During this period of time, an insurer may not change any provisions rather than a change in the premium rate (class basis only). The NAIC specifies that the policy must be renewable to at least age 50, or if issued after the age of 54, at least 5 years. Medicare Supplements and Long Term Care policies are written as Guaranteed Renewable contracts, and they cannot be cancelled by teh company at age 65

legal actions provision

Action for non-payment of a claim cannot be brought against an insurer by an insured for 60 days, but not later than three (3) years after prof of a loss

what conditions must be met for group health coverage?

All eligible members are covered regardless of physical condition, age or gender

relation to earnings provision

Allows a company to limit an insured's total Disability income, to their average income from the past 24 months (2 years). If the benefits exceed the monthly earnings of an insured, the company is only liable for a proportionate amount. The benefit may not be reduced to less than $200 per month

Renewable at the Option of Insurer/Optional Renewable

An insurer can cancel their policy for any reason. Renewability is totally at the option of an insurer, however an insurer can only cancel on an anniversary date or premium due date. If an insurer elects to renew a policy they can also increase the premium Optional Renewable policies allow an insurance company to terminate a policy on specified contract dates, for any reason and increase the premium. This clause this clause also allows an insurer to elect to discontinue a policy on its premium due date

unpaid premium provision

Any past due premiums that are due an insurer from an insured, will be deducted from the claim for benefits, and the policyholder will be paid the net amount. For example, if an insured has a claim of $600 and their premium is $100, an insured would receive $500

Noncancellable policy

Contract of health insurance that an insured has the right to continue in force by paying premiums, for a substantial period of time The company cannot cancel the policy or incrase the premium During that period of time an insurer has no right to make any changes to the contract Gnerally, the guarantee to non-cancel aplies until an insured reaches the age of 65, at which point an insured is usually elligible for Medicare However, in the case of disability income, the policy wil be renewed beyond 65 only if an insured can prove that they continue to work in a full time job

what kind of provision is other insurance in this company

Coordination of Benefits Provision provides for a pro-rated benefit reduction adn return premium in the event an insured has multiple policies with the same insurance company. This provision avoids over insurance.

insurnace with other companies provision

Expense Incurred Basis: If an insured has insurance with different that provide benefits of an expense-incurred basis, and their seperate policies cover the same expenses, each insurer (company) will pay a proportionate amount of any claim that is submitted. This also applies if the policy pays specified benefits, rather than on an expense-incurred basis Other Benefits: The same as the principle regarding policies paying specific benefits instead of paying on an expense incurred basis

proof of loss provision

Formal statement provided insured to the company Must be submitted within 90 days of their loss or as soon as possible, but not to exceed 1 year

facility of payment clause

Gives an insurer the right to expedite payments of urgently needed claims up to $5k. Benefits are paid to a relative or individual who is considered to be equitably entitled to the payment

misstatement of age provision

If an insured misstated their age at the time of their application, the benefits that were paid by an insured would be those premiums that would have been purchased at their correct age. Under the Misstatement of Age Provision, an insurance company must pay benefits according to the correct age at the time of their application

cancellation by company provision

If an insurer cancels a policy, the premium is refunded on a pro-rata (proportional) basis

taxes and HSA

Individual contributions are tax deductible. Employer contributions are included in employee's taxable income.

physical exams/autopsy provision

Insurers require an insured to submit to physical examinations while alive and receiving benefits All physical conditions must be reported when applying for a Health Insurance policy Health Insurance Policy Provision allows an insurer (company) at its own expense, to examine an insured (client) when a claim is pending, and this may be done as often as necessary. In the event of a death, the company has the right to conduct an autopsy

limited policy definition

Limited perils and amounts refer to a policy that covers only one contingency.

conditionally renewable policy

May only be terminated for certain conditions, at renewal, with a possible premium increase, an example of a condition that could cause termination would be when an insured is not employed and received Disability income payments. This allows an insurer to not renew for conditions that are not health related

claim forms provision

Must supply an insured with claim forms within 15 days after the notice of a claim to an insurer or the producer If the forms are not provided by an insurer, written proof of the claim, nature of the loss, and extent of the loss must be submitted to the company The claim cannot be denied if the forms wre not provided, or the notice of the claim wasn't provided on the claim forms

Non-renewable (cancellable, term)

Non-renewable (cancellable, term) is a special health insurance policy that makes no provision for renewal or termination other than the expiration of the policy Example: travel accident policy that will cover a period of time

*what law authorized the NAIC to develop a model for medicare supplement policies?

Omnibus budget reconciliation Act of 1990

what services does medicare part B cover

Physician and surgeon services Home health care Outpatient medical services and supplies Diagnostic and physical therapy

Reinstatement provision

Putting a lapsed policy back in force, requirint payment of back premiums and provoding evidence of insurability Reinstatement is generally automatic if an insurer or an authorized representative accepts the health policy premium and does not require reinstatement application Coverage automatically reinstated if not refused within 45 days of hte date the conditional recept was issued. Accidental injuries covered immediately by an insurer following the reinstatement, however; sicknesses are only covered 10 days after the reinstatement

notice of claim prov

Required within 20 days of the loss, or as soon as reasonably possible. Notice provided to the producer constitutes notice to an insurer

millitary suspesne provision

Some policies may contain millitary service exclusions or a clause that suspends coverage while serving in the military Additionally there may be a clause that provides for a reduction in premiums, or a refund of premiums during this period

consideration clause

Specifies the premium de, the frequencey of a payment to be made by an insured. An insurer's consideration is the promise to pay in accordance with the terms of the contract

payment of claims provision

Specifies to whom an insurer can make claim payments While an insured is living, all benefits are payable to an insured. If an insured is deceased, penidng claims are paid to the beneficiary IF there is no beneficiary, the benefits will be paid to the deceased insured's estate, unless provisions have been made to pay the benefits directly to the hospital or physician who had rendered them services

conformity of state statutes provision

States that any provision in all individual Health Policies, on their effective date, must be amended to conform to the minimum requirements of the state in which an insured resides. A Conformity with State Statutes Provision must be included in the policy, and used instead of having a policy form for each state

insuring clause provision

States the perils insured, the persons involved, and the terms of the contract Generalized statement that identifies the basic agreement between the company and an insured

right to examine provision

The Free Look Provision permits an insured (client) to review their policy for 10 days after the policy was delivered. If dissatisfied, the policy can be returned to an insurer for a full refund

time payment of claims provision

Time Payment of Claims Provision requires claims to be paid immediately If the claim is a disability income benefit Claim, benefits must not be paid less than on a monthly basis

alchohol and narcoticx prov

Void an insurer's liability if the claims result of an insured being intoxicated, or under the influence of an narcotic; unless administered by the advice of a physician

illegal occupation provision

Voids an insurer's liability if an insured commits or attempts to commit a felony, or is engaged in an illegal occupation and an injury occurs

how are PPO physicians pay?

a fee for each service they provide

an insurance company that is owned by its policyholders and can pay annual dividends to them is considered

a mutual company

which has broader coverage: accidental injury or accidental bodily injury?

accidental bodily injury

the tendency of poorer risks seeking out insurance coverage is related to

adverse selection

*what medicare supplement plans would have the core benefits?

all of them

When is the best time to provide a medical supplement buyer's guide to an applicant?

at the time of their application

a group policy used to provide accident and health coverage on a group of persons being transported by a common carrier, without naming the insured persons individually is called

blanket policy

what term relates to giving up an insurance policy voluntarily?

cancellation

what are some of the characteristics of advertising?

clear, precise, understandable

an insurer monitors care an insured is receiving in the hospital to be sure that everything is preceding according to schedule. This best describes

concurrent review

in order for a contract to become valid, each party must give the other party something known as value. This fulfills the essential part of the contract known as

consideration

in regard to an insurance contract, which part generally defines or indicates the value that each party gives to each other?

consideration

becky is insured under her employer's plan and she pays part of their premium amount. what does this describe?

contributory plan

when an insurance comp pays for painkillers, but not to remove a tumor is called

cost-containment

renewabilty clause

defines the right of an insurer and an insured to cancel or renew coverage

*advertisements for insurance, in magazines or by parcel post, are examples under what type of marketing system?

direct response method

Subsidies/Tax Credits:: small businesses, 25 or less employees, with an average annual income of less than $50k

eligible for a tax credit if the employer pays at least 50% of the premiums. the maximum credit will be 50% of the employer's contribution and 35% for non-profit employers.

what is a caf plan?

employee chooses the health care options that are suited for their needs. Employee's contributions are made with pre tax dollars and are not taxable.

*the NAIC activities include drafting model legislation and

exchanging info and developing uniformity in regulatory practices

a master policy is the name of the policy for?

group i

what kind of policy assures renewability up to a specific age with a premium rate increase?

guaranteed renewable

Ed wants a health savings account with his employer. what kind of insurnace plan will be most likely associated with the HSA?

high deductible

Frank just suffered a stroke. what ltc benefit would help him at home with speech therapy?

home health care

under reinstatement provision, when is coverage automatically reinstated?

if not refuesd within 45 days of conditional receipt accidental injury within immediately after reinstatement sickness 10 days after reinstatement

at the time of an application for disability benefits, what factor determines the amount of an insured's coverage?

income

who pays the larger share of a coinsurance amount?

insurer

what kind of care is daily but not 24 hour care?

intermediate

estoppel

legal right to stop someone from asserting a right that was previously waived

in a disability income policy, what is the relationship between waiting, benefit period and premium?

longer benefit period, shorter waiting period=> higher premium

when would an accident death and dismemberment policy pay the principal amount, other than for an accidental death?

loss of 2 or more limbs, blindness in both eyes

what term relates to a larger group of people that spread risk for a small specific cost called

loss sharing

tri-care refers to a health care system exclusively designed for?

millitary presonnel

if a producer makes untrue statements on the application, it is conidered a

misrepresesntation

*when are lenders allowed to suggest a source for credit insurance?

never

what medicare plan gives benefits through a managed health care plan?

part C

capital sum

percentage of principal sum, lesser amount is paid if insured loses single limb or body part

a medical insurance plan in which the health care provider is paid a regular fixed amount for providing care to an insured and doe s not receive additional amounts of compensation dependent upon the procedure preformed (is called?)

prepaid plan

*all medical plans since 2014 must cover...

preventative health services

insurance companies base their insurance on

retention

when you want your wife to be a beneficiary but want to retain rights of onwership, what type of beneficary do you designate your wife?

revocable

what kind of medicare policy requires the use of specific providers, except in emergency situations?

select

what metal level under the PPACA , will cover 70& of the costs

silver

what are home services covered in long term care?

skilled care, intermediate care, custodial care, home health care, adult day care, respite care

old age survivors disability insurance is the official name of what program?

social security

*what HMO entity is responsible for making premium payments?

subscriber

taxes: individual contributions to health savings accounts are

tax deductible

if an employee has a fully contibutory disability income plan, what's up with the employee's income benefits and taxes?

tax free

entire contract provusion

the printed contract and application between the client and the insurance company. Also contains insuring agreements, exclusions, endorsements and conditions No changes may be made to the policy w/o hte express written agreement of both parties. ALL changes become part of the contract Only an executive officer of the company is authorized to make any changes to the policy. The executive officer's signature binds the contract

why is a disability benefit payment less than an insured's income?

to prevent over insurance and malingering

what is the main purpose of a total disability plan?

to protect individuals against the economic loss of a prime wage earner

what is the name of the military health care plan

tri-care

what are blue cross and blue sheild? (service orgs)

voluntary non-profit organizations that have contractual agreements with hospitals and doctors. They are not insurance companies. They are prepaid by subscribers generally monthly for their service.

*which of the following is not a social security benefit?

welfare

what is retention?

when an insured has decided to assume the financial responsibility for certain events by the use of deductalbes, co-payments, self insurance.

when will secondary insurance cover the claims' not covered by employer for kidney failure under medicare?

when an insured has suffered kidney failure in last 18 months