Health Insurance Policy Provisions

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

20 days

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 days

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

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

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 renewability

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

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

nonrenewable

The Notice of Claims provisions requires policyowner to?

notify an insurer of a claim within a specified time

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

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

15

What type of renewability guarantees premium rates and renewability?

noncancellable

The insuring clause

States the scope and limits of the coverage

Which of the following statements describes what an Accident and Health policyowner may NOT do?

adjust the premium payments

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

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

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

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

Under an individual Health Insurance policy, the Time Limit of Certain Defenses provisions states that nonfraudulent misstatements first become incontestable two years

from the date the policy was issued

T sends proof of loss to her insurer for an acceptable medical expense claim under her individual Health Insurance policy. Upon receipt, the insurer must pay the benefits

immediately

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 Premiums provision?

insured must be under a physician's care

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

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

Periodic health claim payments MUST be made at least

monthly

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

payment of claims

Which of these is considered a mandatory provision?

payment of claims

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

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

What is the purpose of time of payment of claims provision?

prevents delayed claim payments paid by the insurer

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

proof of loss

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

protect the producer

With Optionally Renewable Health policies, the insurer may

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

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

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 or certain defenses

Which Accident and Health policy provision addresses preexisting conditions?

time limit or certain defenses

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 bee submitted before a lawsuit can be filed

A(n) assignment of benefits of a Health Policy transfers payments to someone other than the policyowner

assignment

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

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 its due?

grace period