Chapter 10: Health Insurance Policy Provisions

Which of the following BEST describes a short-term medical expense policy? A. Conditionally renewable B. Noncancellable C. Guaranteed renewable D. Nonrenewable

Nonrenewable

The Notice of Claims provision requires a policyowner to: A. Provide proof of loss to an insurer within a specified time B. Notify an insurer of a claim within a specified time C. Wait 60 days after filing a claim to initiate a lawsuit against an insurer D. Notify their physician of a claim within a specified time

Notify an insurer of a claim within a specified time

Which of these is considered a mandatory provision A. Payment of Claims B. Insurance with other insurers C. Misstatement of Age D. Change of occupation

Payment of Claims

The insured and insurance company will share the cost of covered losses under which health policy feature? A. Subrogation Clause B. Assignment provision C. Share Clause D. Payment of Claims provision

Payment of Claims provision

Which of these statements accurately describes the Waiver of Premium provision in an Accident and Health policy? A. Past premiums on a lapsed policy are waived and coverage is restored B. The insured is paid a monthly benefit to keep insurance premiums current in the event oof total disability C. Premiums are waived after the insured has been unemployed for a specified time period D. Premiums are waived after the insured has been totally disabled for a specified time period

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

Which of the following statements about a Guaranteed Renewable Health Insurance policy is CORRECT? A. Premiums normally decrease at time of renewal B. Premiums normally increase at time of renewal C. Policy can be renewed at any time by the company D. Policy can be cancelled at any time by the company

Premiums normally increase at time of renewal

Insurers may request a hearing within ___ if their policy is rejected A. 20 days B. 30 days C. 60 days D. 90 days

20 days

Which of the following statements describes what and Accident and Health policyowner may NOT do? A. File a covered claim B. Assign ownership C. Cancel the coverage D. Adjust the premium payments

Adjust the premium payments

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? A. Claim will be paid and coverage will remain in force B. Claim will be denied and coverage will remain in force C. Claim will be denied and coverage will be cancelled D. Claim will be denied, the coverage cancelled, and all premiums paid will be refunded

Claim will be paid and coverage will remain in force

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? A. Consideration B. Entire Contract C. Free-Look D. Insuring

Entire Contract

Health insurance benefits NOT covered due to an act of war are: A. Excluded by the insurer in the contract provisions B. Assigned to a reinsurer C. Given a longer probationary period D. Charged a higher premium

Excluded by the insurer in the contract provisions

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? A. Allow her to take a tax deduction on unearned premiums B. Increase her policy's coverage amount C. Decrease her policy's coverage amount D. Nothing

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? A. Insured must be unemployed B. Insured must be hospitalized C. Insured must demonstrate financial need D. Insured must be under a physician's care

Insured must be under a physician's care

The ________ Clause identifies which losses resulting from an accident or sickness are insured by the policy. A. Identification B. Benefit C. Payment D. Insuring

Insuring

Which health policy clause specifies the amount of benefits to be paid? A. Insuring B. Consideration C. Free-Lock D. Payment Mode

Insuring

Which of the following health insurance policy provisions specifies the health care services a policy will provide? A. Insuring Clause B. Usual, Customary, and Reasonable Clause C. Consideration Clause D. Benefit Clause

Insuring Clause

What must the policyowner provide to the insurer for validation that a loss has occurred? A. Proof of coverage B. Proof of claim C. Proof of loss D. Proof of payment

Proof of Loss

With Optionally Renewable Health policies, the insurer may: A. Renew the policy only if no claim has been filed the previous year B. Renew the policy only with the insured's consent C. Review the policy whenever they please and determine whether or not to renew it D. Review the policy annually and determine whether or not to renew it

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

The Insuring Clause A. Specifies the additional time given to pay past due premiums B. States the scope and limits of the coverage C. States the amount of premium to be collected D. Prohibits the insured from suing the insurer for at least 60 days after filing a written proof of loss

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? A. File a lawsuit B. Submit the claim in any form C. Wait for the claim form to arrive D. Resubmit the request for a claim form

Submit the claim in any form

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? A. The reinsurer B. The insured C. The insurer D. The Guaranty Association

The insured

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? A. The insurer will pay the original benefit stated in the policy B. The insurer will adjust the benefit to what the premiums paid would have purchased at the insured's actual age C. The insurer will pay the original face amount minus any premiums deficiencies owed D. The insurer will deny the claim and refund premiums paid

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

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: A. Insuring B. Time Limit on Certain Defenses C. Grace Period D. Free-Look

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? A. Accidental Death and Dismemberment Rider B. Disability Income rider C. Guaranteed Insurability Rider D. Waiver of Premium Rider

Waiver of Premium Rider

If an individual is covered under an Accidental Death Policy and dies, an autopsy can be performed in all these situations EXCEPT: A. When the cause of death is unknown B. When the state prohibits this by law C. When consent for the autopsy is not obtained D. When foul play was a contributing factor

When the state prohibits this by law