Health Provisions
A major medical expense plan typically includes coverage for hospital room and board. Which of the following is normally covered under the category "room and board"?
Nursing Care
Who must sign a rider attached to a health insurance policy in order for it to be valid?
Insured and producer
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
States the scope and limits of the coverage
Insuring clause
The clause identifying which losses resulting from an accident or sickness are insured by the policy is called the
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
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
Which of the following is NOT included in the policy face?
Exclusions
Medicare Part A does NOT provide coverage for
First 3 pints of blood
The "Use it or Lose it" rule applies to
Flexible Savings Accounts (FSA)
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
HSA (Health Savings Account)
Health insurance that includes a savings account that allows you to pay for healthcare on tax-free basis. Used in association with a medical plan that carries a high deductible (HDHP)
The Legal Actions provision of an insurance contract is designed to do all of the following EXCEPT
Protect the Producer
Reasonable expectations doctorine
Reasonable expectation doctrine is a principle applied in insurance law which states whenever there is an ambiguity in an insurance-policy, it is resolved in favor of the insured's reasonable expectations. Usually an ambiguity arises when there are plausible, competing interpretations of a policy term. Policyholders lack sophstication to battle the insurer. Interpretation is based on what th ploicyholder thinks not wht the insurer meant
Intoxicants and Narcotics Provision
States that the insurer is not liable for any claims that result while the insured is under the influence of drugs (unless prescribed) or alcohol... The insured will have to pay their owm medical bills if injured
Individuals who participate in an HMO plan are called
Subscribers
Who may terminate coverage under a cancelable health insurance policy?
The Insurer or the insured
Coinsurance
a provision under which both the insured and the insurer share the covered losses.
Dan has a major medical expense policy with a $200 deductible and an 80/20 coinsurance provision. He incurs covered medical expenses of $100 in November and $400 in January. Under the carryover provision, what will the insurer pay?
$240
An insured files for an accident and health insurance policy claim eight days after the premium due date. The benefit payable is $500 and the overdue premium is $200. Assuming that the policy pays on a first-dollar basis and contains the unpaid premium provision, how much will the insurer pay?
$300
An individual is insured under a major medical plan with a $1,000,000 lifetime benefit. The plan has a $500 deductible and an 80% coinsurance. If the insured suffers a $50,500 medical expense during the calendar year, what is the remaining lifetime benefit?
$960,000
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
Health Savings Account (HSA). Distributions that are made for anything other than qualified medical expenses are considered taxable and subject to a penalty of
20%
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
Subrogation Clause
A clause in the title policy that allows the insurance company who pays a claim to seek reimbursement from the party who caused the loss.
Medicare
A federal program of health insurance for persons 65 years of age and older
Free Look Provision
A policy provision required by state law that establishes a set number of days (usually 10) for the policyowner to review a newly issued policy. The policyowner may return the policy to the insurer during this time for any reason and receive a 100% refund. Also known as refund provision, unconditional refund provision, return provision, exchange provision, or right to examine.
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
When does a Probationary Period provision become effective in a health insurance contract?
At the policy's inception
Which of the following is considered a limited accident and health plan?
Cancer
Carryover Provision major medical policy
Carryover Provision - Expenses that did not satisfy the previous year's deductible and were incurred in the last 3 months of that year are used towards satisfying the current year's deductible
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
Chris has a single major medical contract which covers all medical expenses. His plan is considered to be
Comprehensive
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
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
Estople
Estoppel prevents an insurance company from adopting a position that is not consistent with a position it took previously if it would result in injury to the insured. This gives policyholders some assurance that their interests will not be harmed when dealing with their insurer.
What is considered a mandatory provision?
Payment of Claims
Which of these is considered a mandatory provision?
Payment of Claims
Which type of deductible must be satisfied again for each illness or accident in a major medical plan?
Per-Cause
Which of these plans allow a participant to choose either a network or non-network provider at the time when medical care is needed?
Point of Service
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
Guaranteed Renewable Health Insurance policy
Premiums normally increase at time of renewal
What is the purpose of the Time of Payment of Claims provision?
Prevents delayed claim payments made by the insurer
What must the policyowner provide to the insurer for validation that a loss has occurred?
Proof Of Loss
Larry has a Major Medical Expense policy for his family with a $1,000 per family/per year deductible and an 80/20 coinsurance provision. If Larry's family files four claims of $400, $800, $100, and $700 in one year, how much will the insurance company pay?
They will pay $800
Which Accident and Health policy provision addresses preexisting conditions?
Time Limit on Certain Defenses
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
Moral Hazzard
When the act of insuring an event increases the likelihood that the event will happen
After a health insurance application has been originated, the producer normally
is the major personal contact to the insured
cost containment
trying to control the rising cost of health care and achieving the maximum benefit for every dollar spent