Individual Health Insurance Policy General Provisions

Statute

A formal written law enacted by legislative; insurance statuses can be found in the state insurance code.

All of the following are correct about the required provision s of a health insurance policy EXCEPT?

A reinstated policy provides immediate coverage for an illness

Claim

A request filed with an insurance company asking for payment according to the terms of an insurance policy

Is covered immediately, but to protect the insurer against adverse selection, losses resulting from sickness and covered only if the sickness occurs at least 10 days after the reinstatement date.

Accidental Injury

When the insured purchased his health policy he was a window washer. He has since changed occupations and now manages a library. If the insurer is notified of the insured's change of occupation, the insurer should

Adjust the benefit in accordance with the decreased risk

If the insured under a disability income insurance policy changes to a more hazardous occupation after the policy has been issued, and a claim is filed, the insurance company should do which of the following?

Adjust the benefit in accordance with the increased risk.

An insured misstated her age on an application for an individual health insurance policy. The insurance company found the mistake after the contestable period had expired. The insurance company will take which of the following actions regarding any claim that has been issued?

Adjust the claim benefit to reflect the insured's true age

While a claim is pending, an insurance company may require

An independent examination as often as reasonably required

What is the contract provision that allows the insurer to nonrenew health coverage if certain events occur?

Conditionally renewable

Which of the following provisions requires that any policy language that is in conflict with the state statues of the state in which the insured resides is automatically amended to conform with those of the state of residence?

Conformity with State Statutes

In an optionally renewable policy, the insurer has which of the following options?

Increase premiums

What statement best describes the free look provision?

It allows the insured to return the policy within 10 days and receive a full refund of premiums.

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

Legal Action

Which renewability provision allows an insurer to terminate a policy for any reason, and to increase the premiums for any class of insureds?

Optionally renewable

Which renewable option does NOT guarantee renewal and allows the insurance company to refuse renewal of a policy at any premium due date?

Optionally renewable

When an individual is covered under two health insurance policies that have duplicate benefits which could make a claim for benefits because of an injury or illness profitable, it is called?

Overinsurance

A guaranteed renewable health insurance policy allows the:

Policyholder to renew the policy to a stated age, with the company having the right to increase premiums on the entire class

Which health insurance provision describes the insured's right to cancel coverage?

Renewal provision

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?

The insured is in an accident and incurs a large claim

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?

The insured was in compliance with the policy requirements regarding claims.

When Linda suffered a broken hip, she notified her agent, in writing, within 12 days of the loss. However, her agent did not notify the insurance company until 60 days after the loss. Which of the following statements correctly explains how this claim would be handled?

The insurer is considered to be notified since the notification to agent equals notification to the insurer.

A policy with a 31-day grace period implies

The policy will not lapse for 31 days if the premium is not paid when due

Cancellation

The termination of an in-force insurance policy by either the insured or the insurer prior to the expiration date shown in the policy.

Which provision stipulates that misstatements made in a health insurance application may not be used to deny a claim after the policy has been in force for 3 years?

Time limit on certain defenses

When an insurer issues an individual health insurance policy that is guaranteed renewable, the insurer agrees:

To renew the policy until the insured has reached age 65

How soon following the occurrence of a covered loss must an insured submit written proof of such loss to the insurance company?

Within 90 days or as soon as reasonably possible, but not to exceed 1 year

Irrevocable Beneficiary

a beneficiary who has a vested interest in the policy and therefore, the policyowner may not exercise certain rights without the consent of the beneficiary

Guaranteed Renewable

a policy that is written on a noncancellable basis with the right to renew guaranteed

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 and insured

Provision

legal clause in a insurance contract spelling out duties and rights of the insured and the insurer

An insured pays her Major Medical Insurance premium annually on March 1. Last March she forgot to mail her premium to the company. On March 19, she had an accident and broke her leg. The insurance company would?

pay claim

Expense Incurred Basis

policy pays health policy benefits as a reimbursement of actual expenses

Lapse

policy termination due to nonpayment of premium

Rose bought three policies from the same insurer. Her benefits have exceeded the maximum allowed by the insurer. Which of the following will happen?

pro rata benefit reduction

Reinstatement

returning a lapsed policy to active status