Health Insurance study guides

Time Limit on Certain Defenses

No statements that are found in the application will be used to deny a claim that has been in force for two years

Which of the following is mandatory for health insurance policies?

Physical Examination and Autopsy Physical Examination and Autopsy is a mandatory provision required by law

Insurance Comissioner or Director

Which of the following entities must approve all Medicare supplement advertisements Insurance Comissioner or Director An insurance company must provide a copy of any Medicare Supplement Advertisements intended to be used in this state to the Insurance Director for reviews or approval

Non contributory

100 % of eligible employees must participate employees don't pay premiums

For how long must producers maintain records of all complaints?

2 YEARS In this case, all producers must complete records of all complaints for periods of 2 years following the receipt

"Creditable Coverage" doesn't include insurance that hasnt lapsed in coverage for more than

63 Days Generally "creditable coverage" doesn't include insurance that has lapse in coverage for more than 63 days

Contributory Plan

75 % of eligible employees must participate in the plan

Indemnity

A hospital Indemnity pays a fixed amount each day the insured is hospitalized unrelated to medical expenses

Which of the following conditions would a disability income policy most likely NOT require in order to qualify for benefits

A specified income status prior to the disability Some disability Income policies require that the insured must be under the care if a physician and possibly confined to a house in order to qualify for benefits

Which of the following is NOT true regarding uniform mandatory provisions concerning claims

An insured must notify the insurer of a claim on forms prescribed by the insurer If forms aren't furnished, written proof of the occurrence, nature of the loss and extent of the loss must be submitted to the insurer

Classes of Health Insurance Policies

Classes of Health Insurance Individual vs. Group Private vs. Government Limited vs. Comprehensive Limited Health Insurance Policies only cover specific accidents/diseases while comprehensive covers all sickness or accidents that aren't specifically included

When Ken purchased his health policy he was a window washer. He has since changed occupations and now manages a library. Upon notifying of his change of occupation what should the insurer do?

Consider decreasing the premium Changing to a less hazardous occupation qualifies Ken for a lower rate

The provision which prevents the insured from bringing any legal action against the insurers for at least 60 days after proof of loss is known as

LEGAL ACTIONS This mandatory provision requires that no legal action to collect benefits may be started sooner to than 60 days after the proof of loss is filed with the insurer. Thus gives the insurer time to evaluate the claim

In franchise insurance premiums are usually

Lower than individual policies but higher then group policies Premiums charged are generally less than for an individual policy but more for group coverage

The Center for Medicare and Medicaid Services

Medicare is administered by the Center for Medicare and Medicaid Services which is funded by the United States Department of Health and Human Services

Agent Report

Only the agent is involved in completing the agents (producers) report The agents statement DOES NOT become part of the entire contract

In respect to the consideration clause, which of the following is consideration on part of the insurer

Promising to pay in accordance with the contract terms The consideration clause requires the insurer to promise to pay in accordance to the terms stated in the contract

Medical Information Bureau

Reports on previous insurance information can be obtained from the MEDICAL INFORMATION BUREAU MIB info can't be used in and of itself to decline a risk but it can give the underwriter important additional information

Noncancellable

The insurance company can't cancel a noncancellable policy nor can the premium be increased beyond what is stated in the policy. The insured has the right to renew the policy for life of the contract; the insurer can't increase the premium above the amount for which the policy was originally issued

Which of the following is true regarding METs

They allow several small employers to purchase less expensive insurance together Those small employers who can't qualify for group health insurance band together for the purpose of buying insurance

Notice of Claims Provision

The insured's duty to provide the insurer (insurance company) with reasonable notice in the event of a loss Notice is required within 20 days of the loss or as soon as reasonably possible Notice to the agent equals notice to the insurer