(6 )- Health Insurance Policy Provisions
J purchased a Disability Income Policy that ONLY J can terminate and on which the rates will never increase above those illustrated in the policy. Which of the following types of policies did J purchase?
Noncancelable . ( A Disability Income Policy that only the policyowner can terminate and on which the rates will never increase is a Noncancelable policy.
Which of the following BEST describes a short-term medical expense policy?
Nonrenewable.
The Notice of Claims provision requires a policyowner to?
Notify an insurer of a claim within a specified time.
What must the policyowner provide to the insurer for validation that a loss has occurred?
Proof of Loss.
Which of the following statements about a Guaranteed Renewable Health Insurance policy is CORRECT?
Premiums normally increase at time of renewal.
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?
Submit the claim in any form.
An insurer must provide an insured with claim forms within __ days after receiving notice of a loss.?
"15". (Under the Claims Forms provision, an insurer must provide an insured with claim forms within a MAXIMUM of 15 days after receiving notice of a loss.)
The insuring clause?
"States the scope and limits of the coverage". ( The purpose of the insuring clause is to specify the scope and limits of the coverage provided.)
What is considered to be a characteristic of a Conditionally Renewable Health Insurance policy?
A Conditionally Renewable Health Insurance policy can increase premiums at time of renewal.
Which of the following statements describes what an Accident and Health policyowner may NOT do?
Adjust the premium payments.
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.
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 (A health insurance contract is valid only if the insured provides consideration in the form of the full minimum premium and the statements made in the application.)
Health insurance benefits NOT covered due to an act of war are?
Excluded by the insurer in the contract provisions.
After an insured gives notice of loss, what must he/she do if the insurer does not furnish forms?
File written proof of loss.
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 Renewable. (The renewal provision in a guaranteed renewable policy specifies that the policy must be renewed (as long as premiums are paid) until the insured reaches a specified age. These usually have increasing premiums.)
The clause identifying which losses resulting from an accident or sickness are insured by the policy is called the?
Insuring clause (The Insuring clause identifies which losses resulting from an accident or sickness are insured by the policy.)
Which of the following health insurance policy provisions specifies the health care services a policy will provide?
Insuring clause.
Which health policy clause specifies the amount of benefits to be paid?
Insuring.
Which health policy clause specifies the amount of benefits to be paid?
Insuring. (In an Accident & Health policy, the insuring clause states the amount of benefits to be paid.)
What is the purpose of the Time of Payment of Claims provision?
Is to prevent the insurance company from delaying claim payments.
Periodic health claim payments MUST be made at least?
Monthly.
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. (The time of payment for claims is usually specified in different policies as 60 days, 45 days, or 30 days. However, if the claim involves disability income benefits, the benefits must be paid not less frequently than monthly.)
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. (The time of payment for claims is usually specified in different policies as 60 days, 45 days, or 30 days. However, if the claim involves disability income benefits, the benefits must be paid not less frequently than 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 describes this policy is called?
Noncancellable.
Which of these is considered a mandatory provision?
Payment of Claims.
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.
What is considered to be a characteristic of a Conditionally Renewable Health Insurance policy?
Premiums may increase at time of renewal. (A Conditionally Renewable Health Insurance policy can increase premiums at time of renewal.)
K failed to pay a renewal premium within the time granted by the insurer. K then sends in a payment which the insurer subsequently accepts. Which policy provision specifies that coverage may be restored in this situation?
Reinstatement.
With Optionally Renewable Health policies, the insurer may?
Review the policy annually and determine whether or not to renew it.
The Notice of Claims provision requires a policyowner to?
Spells out the insured's duty to provide the insurer with reasonable notice in the event of a loss.
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?
The grace period ( is the additional period of time after a premium payment is due that will allow the policy to remain in force in the event of nonpayment.)
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.
With Accidental Death and Dismemberment policies, what is the purpose of the Grace Period?
The purpose of the Grace Period is to give the policyowner additional time to pay overdue premiums.
The policy provision that entitles the insurer to establish conditions the insured must meet while a claim is pending is?
Time Limit on Certain Defenses . ( This provision limits the period during which an insurer can deny a claim based on a misstatement made by the insured.)
If an individual has an Accidental Death and Dismemberment policy and dies, an autopsy can be performed in all these situations EXCEPT?
When the state prohibits this by law.
An insured must notify an insurer of a medical claim within how many days after an accident?
20.
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 (The probationary period begins when a policy goes into effect. During this period, no benefits will be paid under 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.
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. (Under the Change of Occupation provision in an Accident & Health policy, if the insured notifies the insurance company of a less hazardous occupation, the insurance company may increase the policy's coverage.)
What is considered to be a characteristic of a Conditionally Renewable Health Insurance policy?
Premiums may increase at time of renewal.
The policy provision that entitles the insurer to establish conditions the insured must meet while a claim is pending is?
Time Limit on Certain Defenses.
Which Accident and Health policy provision addresses preexisting conditions?
Time Limit on Certain Defenses.
Which Accident and Health policy provision addresses preexisting conditions?
"Time Limit on Certain Defenses". (The Time Limit on Certain Defenses provision limits the period during which an insurer can deny a claim on the basis of a preexisting condition).
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 (The waiver of premium provision keeps the coverage in force without premium payments if the insured has become totally disabled as defined in the policy.)
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 (The Entire Contract provision states that the application and policy contain all provisions and constitute the entire contract.)
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 on Certain Defenses (The Time Limit on Certain Defenses (Incontestability) provision limits the time during which the insurance company may challenge the validity of an insurance claim on the basis of a misstatement made on the insured's application.)
Which of the following statements describes the purpose of the Insuring clause in Health and Accident policies?
States the scope and limits of the coverage.
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.
What type of renewability guarantees premium rates and renewability?
Guaranteed renewable.
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. (The Entire Contract provision states that the producer does NOT have the authority to change the policy or waive any of its provisions.)
When does a Probationary Period provision become effective in a health insurance contract?
At the policy's inception.
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?
Claim will be paid and coverage will remain in force (After a policy has been in force for 2 (sometimes 3) years, it enters the incontestable period, in which the insurer may not deny a claim based on information not disclosed at the time of application.)
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.
The provision that defines to whom the insurer will pay benefits to is called?
The Payment of Claims provision in a Health Insurance policy states to whom claims will be paid.
