Health Policy Provisions, Clauses, and Riders

An insured pays a monthly premium of $100 for her health insurance. What would be the duration of the grace period under her policy?

10 days (The grace period is 7 days if the premium is paid weekly, 10 days if paid monthly, and 31 days for al other modes.)

L has a major medical policy with a $500 deductible and 80/20 coinsurance. L is hospitalized and sustains a $2,500 loss. What is the maximum amount that L will have to pay?

$900 (deductible + 20% of the bill after the deductible [20% of $2,000])

A dedctible is

A specified dollar amount that the insured must pay first before the insurance company will pay the policy benefits.

Which of the following is NOT an exclusion in medical expense insurance policies? A. Coverage for dependents B. Military duty C. Self-inflicted injuries D. Routine dental care

A. Coverage for dependents

Which provision concerns the insured's duty to provide the insurer with reasonable notice in the event of loss? A. Claims Initiation B. Consideration C. Notice of Claim D. Loss Notification

C. Notice of claim

The provision that provides for the sharing of expenses between the insured and the insurance company is

Coinsurance

Which provision concerns the insured's duty to provide the insurer with reasonable notice in the event of a loss? A. Loss Notification B. Claims Initiation C. Consideration D. Notice of Claim

D. Notice of Claim

Which of the following provisions would prevent an insurance company from paying a reimbursement claim to someone other than the policyowner? A. Change of beneficiary B. Entire contract clause C. Proof of loss D. Payment of claims

D. Payment of claims

In the event of loss, after a notice of claim is submitted to the insurer, who is responsible for providing claims forms and to which party?

Insurer to the insured

Which is true regarding the Uniform Individual Accident and Sickness Policy Provisions Law?

Provisions may be reworded by the insurer

An insured has endured multiple surgeries and hospitalizations for an illness during the summer months. Her insurer no longer bills her for medical expenses. What term best describes the condition she has met?

Stop-Loss Limit (A "stop-loss limit' is a specified dollar amount beyond which the insured no longer participates in the sharing of expenses)

Under a health insurance policy, benefits, other than death benefits, that have not otherwise been assigned, will be paid to

The insured

Coinsurance

The larger the percentage that is paid by the insured, the lower the required premium will be.

Which of the following will vary the length of the grace period in health insurance policies?

The mode of premium payment

An insured notifies the insurance company that he has become disabled. What provision states that claims must be paid immediately upon written proof of loss?

Time of Payment of Claims

What is the purpose of coinsurance provisions?

To help the insurance company to prevent overutilization of the policy

The insuring clause of a disability policy usually states all of the following EXCEPT: A. The identities of the insurance company and the insured B. That insurance against loss is provided C. The types of losses covered D. The method of premium payment

D. The method of premium payment

Which provision states that the insurance company must pay Medical Expense claims immediately? A. Payment of claims B. Legal actions C. Relation of earnings to insurance D. Time of payment of claims

D. Time of payment of claims

An insured is hospitalized with a back injury. Upon checking his disability income policy, he learns that he will not be eligible for benefits for at least 30 days. This indicates that his policy is written with a 30-day

Elimination period

The provision that states that both the printed contract and a copy of the application from the contract between the policyowner and the insurer is called the

Entire contract

A guaranteed renewable disability insurance policy

Is renewable at the insured's option to a specified age

The provision which prevents the insured from bringing any legal action against the company for at least 60 days after proof of loss is known as

Legal actions (This mandatory provision requires that no legal action to collect benefits may be started sooner than 60 days after the proof of loss is filed with insurer. This gives the insurer time to evaluate the claim)

Items stipulated in the contract that the insurer will not provide coverage for are found in the

Exclusions

The section of a health policy that states the causes of eligible loss under which an insured is assumed to be disabled is the: A. Insuring clause B. Incontestability clause C. Probationary period

A. Insuring Clause

What is the maximum period of time during which an insurer may contest fraudulent misstatements made in a health insurance application?

As long as the policy is in force

The premium charged for exercising the Guaranteed Insurability Rider is based upon the insured's

Attained age

Which of the following does the insuring clause NOT specify? A. The name of the insured B. A list of available doctors C. Covered perils D. The insurance company

B. A list of available doctors

The premium charged for exercising the Guaranteed Insurability Rider is based upon the insured's: A. Assume age B. Attained age C. Issue age

B. Attained age

An applicant for individual health policy failed to complete the application properly. Before being able to complete the application and pay the initial premium, she is confined to a hospital. This will not be covered by insurance because she has not met the conditions specified in the: A. Eligibility clause B. Consideration clause C. Insuring clause D. Pre-existing conditions clause

B. Consideration clause

In respect to the consideration clause, which of the following is consideration on the part of the insurer? A. Explaining policy revisions to the applicant B. Promising to pay in accordance with the contract terms C. Offering a secondary policy to the applicant

B. Promising to pay in accordance with the contract terms

Which of the following terms describes the specified dollar amount beyond which the insured no longer participates in the sharing of expenses? A. Corridor deductible B. Stop-loss limit C. Out-of-pocket limit D. First-dollar coverage

B. Stop-loss limit

Which of the following is NOT a feature of a noncancellable policy? A. The insured has the right to renew the policy for the life of the contract B. The insurer may terminate the contract only at renewal for certain conditions

B. The insurer may terminate the contract only at renewal for certain conditions

An insured purchased a noncancellable health insurance policy 1 year ago. Which of the following circumstances would NOT be a reason for the insurance company to cancel the policy: A. The insured reaches the maximum age limit specified in the policy B. Within two years of the application, the insurer discovers a misrepresentation C. The insured is in an accident and incurs a large claim D. The insured does not pay the premium

C. The insured is in an accident and incurs a large claim

Insured Z's health insurance policy year begins in Janurary. His policy contains a carry-over provision. In November, he has a small claim which is less than his deductible. Which of the following is true? A. The deductible will be waived B. The insured is now eligible for an integrated deductible until the new policy year C. The insured may carry over the amount of this year's expenses to next year, which will help satisfy next year's

C. The insured may carry over the amount of this year's expenses to next year, which will help satisfy next year's

An insured submitted a notice of claim to the insurer, but never received claims forms. He later submits proof of loss, and explains the nature and extent of loss in a hand-written letter to the insurer. Which of the following would be true? A. The claim most likely will not be paid since official claims form was not submitted B. The insurer will be fined for not providing the claims forms C. The insured must submit proof of loss to the Department of Insurance D. The insured was in compliance with policy requirement regarding claims

D. The insured was in compliance with policy requirement regarding claims

Under an individual disability policy, the MINIMUM schedule of time in which claim payments must be made to an insured is

Monthly