Health Insurance Policy Provisions

Insurers may request a hearing within ___ if their policy is rejected

20 Days

An insured pays premiums on an annual basis for an individual health insurance policy. What is the MINIMUM number of days for the Grace Period provision?

31

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 provision specified how long a policy owner's insurance coverage will remain in effect in the policy owner does not pay the premium when it is due?

Grace Period

Which type of renewability best describes a Disability Income policy that covers an individual until the age of 65, but the insurer has the right to change the premium rate for the overall risk class?

Guaranteed Renewable

X is insured with a disability income policy that provides coverage until age 65. This policy allows the insurer to change the premium rate for the overall risk class assigned. Which of these renewability features does this policy contain?

Guaranteed Renewable

Which of the following insurance policy provisions specifies the benefits or services a policy will provide?

Insuring clause

D, the beneficiary under her husband's AD&D policy, submits an accidental death claim on May 1, 2010 following his death. However, the company denies the claim on the basis that death was due to natural causes. She decides to talk to her attorney. What is the earliest date for taking legal action against the insurer?

July 1, 2010

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

Periodic health claim payments MUST be made at least

Monthly

Which of the following statements is CORRECT about accelerated death benefits?

Must have a terminal illness to qualify

A Disability Income policy that only the policy owner can terminate and which the rates will never go up in considered to be

Noncancellable

The Notice of Claims provision requires a policy owner to ...

Notify an insurer of a claim within a specified time

P is the insured on a participating insurance policy. Which statement is true is P's premiums are waived due to a disability?

P will still receive declared dividends

M has an annual life insurance premium payment due January 1. She died January 10 without making the premium payment. What action will the insurer take?

Pay face amount minus the past due premium

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

Payment of Claims

Which of these is considered a mandatory provision?

Payment of claims

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

Premium may increase at time of renewal

Which of these statements accurately describes the Waiver of Premium provision in an Accidental and Health policy?

Premiums are waived (or paid) after the insured has been totally disabled for a specified time period

Which Accident and Health policy provision addresses preexisting conditions?

Time Limit on Certain Defenses

What type of rider would be added to an Accident and Health policy if the policyowner wants to ensure the policy will continue if he/she ever becomes totally disabled?

Waiver of Premium rider

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

20

S buys a $50,000 whole life policy with a $50,000 Accidental Death and Dismemberment rider. S dies 1 year later of natural causes. How much will the insurer pay the beneficiary?

$50,000

Monthly-premium Individual health insurance policies must provide a grace period of a least...

10 Days

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

15

P is blinded in an industrial accident. Which provision of his life insurance policy will pay a stated benefit amount?

Accidental Death and Dismemberment provision

The option that provides an additional death benefit for a limited amount of time at the lowest possible cost is called...

Accidental Death and Dismemberment rider (AD&D)

Which of the following statements describes what an Accident and Health policy owner may NOT do?

Adjust the premium payments

In health insurance policies, a waiver of premium provision keep the coverage in force without premium payments...

After an insured has become totally disabled as defined in the policy

The Consideration clause in an insurance contract contains what pertinent information?

Amount of premium payments and when they are due

Which of the following statements BEST describes what the Legal Actions provision of an Accident and Health policy requires?

An insured must wait a least 60 days after Proof of Loss has been submitted before a lawsuit can be filed

When does a Probationary Period provision become effective in a health insurance contract?

At the policy's inception

The guarantee of insurability option provides a long-term care policy owner the ability to...

Buy additional coverage at a later date

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

Change of occupation provision

N is covered by a Term Life policy and does not make the required premium payment which was due August 1. N dies September 15. What action will the insurer take?

Claim will be denied

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

An insurance company 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 insurance company anyway. A few weeks later, E suffers a heart attack and is hospitalized without completing 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

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

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

Entire Contract

Which provision prevents an insurer from changing the terms of the contract with the policyowner by referring to documents not found within the policy itself?

Entire Contract

"A producer does not have the authority to change a policy or waive any of its provisions". The health provision that best describes this statement is called the

Entire contract

Which of the following policy provisions prohibits an insurance company from incorporating external documents into an insurance policy?

Entire contract

When an insurance company 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 provision

Which of these statements about a Guaranteed insurability Option rider is NOT TRUE? A) Coverage can be added at specific events such as marriage or having a child B) Evidence of insurability is not required when the option is exercised C) Evidence of insurability is required when the option is exercised D) Coverage can be added at specific ages.

Evidence of insurability is required when the option is exercised

Insurance benefits NOT covered due to an act of war are...

Excluded by the insurer

N is a student pilot with a large life insurance policy. Which of these features would limit the insurer's obligation in the event N was killed while flying as a student pilot?

Exclusion

When an insurer issues a policy that refuses to cover certain risks, this is referred to as a(n)

Exclusion

The sections of an insurance contract which limit coverage are called

Exclusions

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

File written proof of loss

An insured is past due on his life insurance premium, but is still within the Grace Period. What will the beneficiary receive if the insured dies during this Grace Period?

Full face amount minus any past due premiums

With any insurance policy, what is the purpose of the Grace Period?

Give the policy owner additional time to pay past due premiums

B purchased a disability income policy with a rider that guarantees him the option of purchasing additional amounts of coverage at predetermined times without requiring to provide evidence of insurability. What kind of rider is this?

Guaranteed insurability rider

T applied for a Disability Income policy and has a history of back injuries. The insurer issued the policy with a statement that excludes coverage for back injuries. This statement is called a(n)

Impairment rider

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

All of these statements about the Waiver of Premium provision are correct EXCEPT....

Insured must be eligible for Social Security disability for claims to be accepted

What is the initial requirement for an insured to become eligible for benefits under the Waiver of Premium provision?

Insured must be under a physician's care

Which health policy clause specifies the amount of benefits to be paid?

Insuring

The Agreement in an insurance contract that states a specific sum of money will be paid to a designated person upon an insured's death is called...

Insuring agreement

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

Prevents delayed claim payments made by the insurer

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

Protect the producer

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

J let her life insurance policy lapse 8 months ago due to nonpayment. She can reestablish coverage under which of the following provisions?

Reinstatement provision

S buys a $10,000 Whole Life policy in 2003 and pays an annual premium of $100. S dies 5 years later in 2008 and the insurer pays the beneficiary $10,500. What kind of rider did S include on the policy?

Return of premium rider

Which of the following provisions is NOT required in HMO contracts or certificates?

Seven-Day grace period

The insuring Clause

States the scope and limits of the coverage

The insuring clause

States the scope and limits of the coverage

Which of the following statements describes the purpose of the insuring clause in an insurance policy?

States the scope and limits of the coverage

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

D was actively serving in the Marines when he was killed in an automobile accident while on leave. His $100,000 Whole life policy contains a War Exclusion clause. How much will D's beneficiary's receive?

The full face amount

The Consideration clause in an insurance policy indicates that a policy indicates that a policy owner's consideration consists of a completed application and ...

The initial premium

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

The policy provision that entitle the insurer to establish conditions the insured must meet while a claim is pending is...

Time Limit on Certain Defenses

If an individual has an Accidental Death and Dismemberment policy and dies, an autopsy can be performed in all these situations Except...

When the state prohibits this by law

B owns a Whole Life policy with a guaranteed insurability option that allows him to purchase, without evidence of insurability, stated amounts of...

Whole Life coverage at specified times

T sends proof of loss to her insurer for an acceptable medical expense claim under her individual Health Insurance policy. Upon receipt, the insurer must pay the benefits

immediately

The ___ clause identifies which losses resulting from an accident or sickness are insured by the policy.

insuring

If an insurance company issues a Disability Income policy that it cannot cancel or for which it cannot increase premiums, the type of renewability that best desribes this policy is called

non-cancellable