Health Insurance Policy Provisions
In group health care, what is the purpose of the coordination of benefits provision?
Determines what is paid by the primary and secondary insurers in the event of a claim
The time limit for filing claim disputes is addressed in which provision of an accident and health policy?
Legal actions
All of the following are functions of an insuring clause EXCEPT
Primarily describes the free-look period
A mandatory second surgical opinion provision typically requires the insured to do which one of the following?
Seek a second opinion for surgeries that are on a list of elective surgeries
It is the company's responsibility to supply a claim form to an insured within how many days after receiving notice of claim?
15
Under the Uniform Policy Provisions Law, a required provision concerning notice of claim obligates a policyholder to give the insurer or its agent notice of a claim within
20 days of a loss, or as soon as reasonably possible
The minimum grace period on a health insurance policy paid on a quarterly basis is
31 days
Which of the following is the usual grace period for a semi-annual premium policy?
31 days
The legal action provision in a health contract is limited to no more than ___ years.
5
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
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
After an insured gives notice of loss, what must he/she do if the insurer does not furnish forms?
File written proof of loss
Under a provision known as time payment of claims in a health insurance policy, after receiving proof of loss, all benefits other than those that are paid in periodic installments are supposed to be paid
Immediately
Which of the following actions may an insurance company NOT do in a health policy that contains a guaranteed renewable premium benefit?
Increase the premiums on an individual basis
The part of a health insurance policy that states the kind of benefits provided and the circumstances under which they will be paid is the
Insuring clause
Assume the following individuals are issued health insurance policies with varying renewability provisions. All other factors being equal, who would pay the highest premium?
Jack-noncancellable
Diana, the beneficiary under her husband's AD&D policy, submits an accidental death claim on May 1, 2010 following his death. However, the company denies the claim on the basis that death was due to natural causes. She decides to talk to her attorney. What is the earliest date for taking legal action against the insurer?
July 1, 2010
What type of health insurance policy may NOT be changed in any way by the insurer, up to a specified age, so long as the premiums are paid?
Noncancellable
Which of the following types of health insurance policies prevents the company from changing the premium rate or modifying the coverage in any way?
Noncancellable
What type of policy gives the insurer the option to terminate the policy on a date specified in the contract?
Optionally renewable
In health insurance policies, the purpose of a grace period is to give a policyholder extra time to
Pay a premium after the due date.
Medical expense Plan A pays up to $4,000. Plan B pays up to $3,000. If a person covered under both plans incurs $6,000 in expenses and Plan A is primary, which is true under the coordination of benefits provision?
Plan A pays up to $4,000 and Plan B pays up to $2,000
Suppose an insurance contract contains inconsistent or contradictory provisions. Various parts of the contract are printed, typewritten, and handwritten. In seeking to determine the original intent, a court is likely to rely on
The handwritten material first, then the typewritten, and then the printed
Craig submits a $500 claim for medical expenses. With a past due premium of $100, the insurer pays $400. Which of the Uniform Optional Provisions covers this situation?
Unpaid premium
The type of policy where the insurer can send a notice to the insured that the policy has been cancelled in the middle of the term is called
cancelable
Which of the following is NOT a required provision in an accident and health insurance policy?
change of occupation
A health insurance policy where the insurer has the right to terminate the policy for reasons other than the insured's health is called
conditionally renewable
According to the Affordable Care Act, a grandfathered group health plan MUST cover
essential health benefits with no lifetime dollar limits
A health insurance policy that allows an insurer to change the policyowner's premiums, but NOT cancel the policy is called a(n)
guaranteed renewable policy
The reinstatement provision in a health insurance policy is
mandatory
A company may change the wording of a uniform policy provision in its health insurance policies only if the
modified provision is not less favorable to the insured
A policy that the insurer may not cancel or increase the premium for is referred to as
noncancellable
A clause that allows an insurer the right to terminate coverage at any anniversary date is called a(n)
optional renewability clause
States that have "no loss no gain" laws require a replacing policy to
pay for ongoing claims under the policy it replaces