Ch5 Health Insurance Policy Provisions, Riders and Exclusions

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

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

S filed a written Proof of Loss for a Disability Income claim on September 1. The insurance company did not respond to the claim. S can take legal action against the insurer beginning:

November 1

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

protect the producer

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

15

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

20

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 statements describes what an Accident and Health policyowner may NOT do?

Adjust the premium payments

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

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

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

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

File written proof of loss

With Accidental Death and Dismemberment policies, what is the purpose of the Grace Period?

Gives the policyowner additional time to pay overdue premiums

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

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

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

J purchased a Disability Income Policy that ONLY J can terminate and on which the rates will never increase above those illustrated in the policy. Which of the following types of policies did J purchase?

Noncancelable

What type of renewability guarantees premium rates and renewability?

Noncancellable

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

Prevents delayed claim payments made by the insurer

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

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

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

Health insurance benefits NOT covered due to an act of war are:

excluded by the insurer in the contract provisions

The sections of an insurance contract which limit coverage are called:

exclusions

Which of the following is NOT included in the policy face?

exclusions

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

insuring

According to the Time Limit of Certain Defenses provision in an Individual Health Insurance Policy, nonfraudulent misstatements first become incontestable:

two years from the date of the policy was issued

Periodic health claim payments MUST be made at least:

monthly

According to the Mandatory Uniform Policy Provisions, what is the maximum amount of time after the premium due date during which the policy remains in force even though the premium has not been paid?

31 days

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

At the policy's inception

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

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

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

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

Premiums may increase at time of renewal

Which of the following statements about a Guaranteed Renewable Health Insurance policy is CORRECT?

Premiums normally increase at time of renewal

What must the policyowner provide to the insurer for validation that a loss has occurred?

Proof of Loss

K has a health policy that must be renewed by the insurer and the premiums can only be increased if applied to the entire class of insureds. This type of policy is considered:

guaranteed renewable

An insurer receives proof of loss for an acceptable medical expense claim under an Individual Health Insurance Policy. Under the Time of Payment of Claims provision, the insurer MUST pay the benefits:

immediately

Which of these is considered a mandatory provision?

Payment of Claims

Which of the following provisions specifies how long a policyowner's health coverage will remain in effect if the policyowner does not pay the premium when it is due?

Grace Period

The insuring clause

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

An insurance company normally has 2 years to contest information provided on an accident and health application. This 2 year period begins on the date that the:

insurer dates the policy

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:

noncancellable

The Notice of Claims provision requires a policyowner to:

notify an insurer of a claim within a specified time

With Optionally Renewable Health policies, the insurer may:

review the policy annually and determine whether or not to renew it

An assignment of benefits of a Health Policy:

transfers payments to someone other than the policyowner

The clause identifying which losses resulting from an accident or sickness are insured by the policy is called the:

Insuring clause

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

Payment of Claims

J, an Accidental Death and Dismemberment (AD&D) policy holder, dies after injuries sustained in an accident. J's age as stated on the application five years ago was found to be understated by ten years. Which of the following actions will the insurance company take?

The insurer will adjust the benefit to what the premiums paid would have purchased at the insured's actual age

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

The clause in an Accident and Health policy which defines the benefit amounts the insurer will pay is called the:

Insuring clause

Which of the following health insurance policy provisions specifies the health care services a policy will provide?

Insuring clause

Which of the following BEST describes a short-term medical expense policy?

Nonrenewable

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

A Disability Income policyowner recently submitted a claim for a chronic neck problem that has now resulted in total disability. The original neck injury occurred before the application was taken 5 years prior. The neck injury was never disclosed to the insurer at the time of application. How will the insurer handle this claim?

Claim will be paid and coverage will remain in force

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

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

Premiums are waived after the insured has been totally disabled for a specified time period

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

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

Time Limit on Certain Defenses