Ch. 3. Individual Sickness and Accident Insurance Policy General Provisions

which of the following does the insuring clause NOT specify? a) a list of available doctors b) covered perils c) the insurance company d) the name of the insured

a) a list of available doctors

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? a) insurer to the insured b) insured to the insurer c) insurer to the department of insurance d) insured to the department of insurance

a) insurer to the insured

which of the following is NOT a feature of a guaranteed renewable provision? a) coverage is not renewable beyond the insured's age 65 b) the insured's benefits cannot be reduced c) the insurer can increase the policy premiums on an individual basis d) the insured has a unilateral right to renew the policy for the life of the contract

c) the insurer can increase the policy premiums on an individual basis

what is the maximum period of time during which an insurer may contest fraudulent misstatement made in a health insurance application? a) 90 days after the effective policy date b) 6 months after the effective policy date c) 1 year after the effective policy date d) as long as the policy is in force

d) as long as the policy is in force

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 the 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 the policy requirements regarding claims

d) the insured was in compliance with the policy requirements regarding claims

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? a) adjust the claim benefit to reflect the insured's true age b) deny any claims and cancel the policy c) deny paying a claim based on misrepresentation d) pay the full amount of a claim because the contestable period has ended

a) adjust the claim benefit to reflect the insured's true age

In respect to the consideration clause, which of the following is consideration on the part of the insurer? a) Offering an unconditional contract b) explaining policy revisions to the applicant c) Promising to pay in accordance with the contract terms d) offering a secondary policy to the applicant

c) Promising to pay in accordance with the contract terms

which provision allows the policyholder a period of time, while coverage is in force, to examine a health insurance policy and determine whether or not to keep it? a) probationary period b) free look period c) grace period d) elimination period

b) free look period

Which renewability provision allows an insurer to terminate a policy for any reason, and to increase the premiums for any class of insureds? a) conditionally renewable b) cancellable c) guaranteed renewable d) optionally renewable

d) optionally renewable

Which of the following is true regarding a term health policy? a) it is conditionally renewable b) it is guaranteed renewable c) it is noncancellable d) it is nonrenewable

d) it is nonrenewable

an applicant for an 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) consideration clause b) insuring clause c) pre-existing conditions clause d) eligibility clause

a) consideration clause

which of the following will vary the length of the grace period in health insurance policies? a) the mode of the premium payment b) the length of any elimination period c) the length of time the insured has been insured d) the term of the policy

a) the mode of the premium payment

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? a) The insurer may deny the claim since it was not notified within the required 20-day time frame b) The insured is considered to be notified since the notification to agent equals notification to the insurer c) The insurer may delay the payment of this claim for up to 6 months d) The insurer may settle this claim for less than it otherwise would have had the notification been provided in a timely manner

b) The insured is considered to be notified since the notification to agent equals notification to the insurer

all of the following are correct about the required provisions of a health insurance policy except? a) the entire contract clause means that the signed application, policy, endorsements, and attachments constitute the entire contract b) a reinstated policy provides immediate coverage for an illness c) proof-of-loss forms must be sent to the insured within 15 days of notice of claim d) a grace period of 31 days is found in an annual pay policy

b) a reinstated policy provides immediate coverage for an illness

which provision concerns the insured's duty to provide the insurer with reasonable notice in the event of a loss? a) consideration b) notice of claim c) loss notification d) claims initiation

b) notice of claim

Which renewal option does NOT guarantee renewal and allows the insurance company to refuse renewal of a policy at any premium due date? a) noncancellable b) optionally renewable c) conditionally renewable d) guaranteed renewable

b) optionally renewable

a policy with a 31-day grace period implies? a) the policy benefits must be paid within 31 days after a claim is submitted b) the policy will not lapse for 31 days if the premium is not paid when due c) the policyholder may return the policy for a full refund within 31 days d) the policy is incontestable after 31 days of delivery

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

Insurance may change which of the following on a guaranteed renewable health insurance policy? a) individual rates b) no changes are permitted c) rates by class d) coverage

c) rates by class

Which health insurance provision describes the insured's right to cancel coverage? a) insuring clause b) cancellation provision c) renewal provision d) policy duration provision

c) renewal provision

An insured wants to name her husband as the beneficiary of her health policy. She also wishes to retain all of the rights of ownership. The insured should have her husband named as what type of beneficiary? a) contingent b) irrevocable c) revocable d) primary

c) revocable

Under the mandatory uniform provision Notice of Claim, the first notice of injury or sickness covered under an accident and health policy must contain? a) a statement from the insured's employer showing that the insured was unable to work b) an estimate of the total amount of medical and hospital expense for the loss c) a complete physician's statement d) a statement that is sufficiently clear to identify the insured and the nature of the claim

d) a statement that is sufficiently clear to identify the insured and the nature of the claim

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? a) time limit on certain defenses b) payment of claims c) proof of loss d) legal actions

d) legal actions

An insured is involved in a car accident. After the accident is determined to be her fault, the police giver her a breathalyzer test to determine whether or not she had been drinking alcohol before the accident. Her blood alcohol level is over the legal limit. What type of health benefits will her health insurance policy pay for her injuries if the policy includes the narcotics and intoxicants provision? a) only post-hospitalization benefits b) full benefits c) partial benefits d) no benefits

d) no benefits

which of the following provisions is mandatory for health insurance policies? a) recurrent disability b) unpaid premiums c) intoxicants and narcotics d) physical examination and autopsy

d) physical examination and autopsy

a guaranteed renewable health insurance policy allows the? a) policyholder to renew the policy to a stated age and guarantees the premium for the same period b) policy to be renewed at time of expiration, but the policy can be canceled for cause during the policy term c) insurer to renew the policy to a specified age d) policyholder to renew the policy to a stated age, with the company having the right to increase premiums to the entire class

d) policyholder to renew the policy to a stated age, with the company having the right to increase premiums to the entire class

An insured owes his insurer a premium payment. Since then, he incurs medical expenses. The insurer deducts the unpaid premium amount from the claim amount and pays the insured the difference. What provision allows for this? a) legal action b) proof of loss c) payment of claims d) unpaid premiums

d) unpaid premiums