accident and health insurance test study

How soon following the occurrence of a covered loss must an insured submit written proof of such loss to the insurance company? as soon as possible Within 20 days Within 60 days Within 90 days or as soon as reasonably possible, but not to exceed one year

Within 90 days or as soon as reasonably possible, but not to exceed 1 year

on a health insurance application, a signature is required from all of the following individuals EXCEPT a. agent b. spouse of the policyowner c. proposed insured d. policyowner

b. spouse

Under a health insurance policy, benefits, other than death benefits, that have not otherwise been assigned, will be paid to The spouse of the insured The insured Creditors Beneficiary of the death benefit

insuredl

Insurers may change which of the following on a guaranteed renewable health insurance policy?

Rates by class

which of the following is true regarding coinsurance? The smaller the percentage that is paid by the insured, the lower the required premium will be The smaller this percentage that is paid by the insured the more consistent the required premium will be The larger the percentage that is paid by the insured the lower the required premium will be The larger the percentage that is paid by the insured, the higher the required premium will be

The larger the percentage that is paid by the insured, the lower the required premium will be

How many eligible employees must be included in a contributory plan? a. 90 b. 100 c. 50 d. 75 %

d. 75

which of the following would not be used in preventive care? a. chemotherapy b. pap smear c. annual physical exam d. mammogram

a. chemotherapy

an insured has a major medical policy with a $500 deductible and a coinsurance clause of 8/20. if he medical expenses of 4,000 the insurer would pay a. 3500 b. 2500 c. 2800 d. 3200

c 2800

what is the minimum grace period required in health insurance policies in this state? a. 15 b. 30 c. 7 d. 10 (days)

d. 10 days

An insured is upset that her new health insurance policy was delivered to her by certified mail and not through her agent. Which of the following is true? A There is nothing wrong with this form of policy delivery. B The insured should complain to the insurer. C The insured should ask for a new policy to be delivered. D The policy will not be legal until it is delivered by an agent.

A there is nothing wrong with this form of policy delivery

which of the following information regarding an insured is not included in an investigative consumer report, which is requested by an underwriter? a. medical history b. applicant's character c. personal habits d. general reputation

a. medical history

which of the following is NOT true of basic medical expense plans? a. low dollar limits b. coverage for catastrophic medical expenses c. no deductibles d. first-dollar coverage

b. coverage for catastrophic medical expenses

which of the following is not covered by health maintenance organizations (HMOs)? a. well-baby care b. elective services c. immunizations d. routine physicals

b. elective services

The provision in a health insurance policy that interrupts premiums being paid to the insurer while the insured is disabled is called the a. legal action against us clause b. entire contract clause c. time limit on certain defenses clause d. incontestability clause

b. entire contract clause

what type of group rating uses the actual experience of the group as a factor in developing the rates to be charged? a. individual b. experience c. district d. community (rating)

b. experience rating

An insured notifies the insurance company that he has become disabled. What provision states that claims must be paid immediately upon written proof of loss? a. legal actions b. time of payment of claims c. incontestability d. physical exam and autopsy

b. time of payment of claims

which statement best defines a mewa? a. a government health plan that provides health care for the unemployed b. a group health plan that covers medical expenses arising from work related injuries c. a joining together by employers to provide health benefits for employee d. a plan that provides hospice care for terminally ill employees

c. a joining together by employers to provide health benefits for employee

An insured is admitted to the hospital for surgery on a herniated disk. The insurance company monitors the treatment and progress in order to make sure that everything proceeds according to the insurer's schedule. This is called a. comprehensive review b. schedule monitoring c. concurrent review d. prospective review

c. concurrent review

which of the following is not a cost-saving service in a medical plan? a. second surgical opinions b. risk sharing c. denial of coverage d. preventive care

c. denial of coverage

when compared with the administrative cost found in individual coverage, the per capita administrative cost in group health insurance is a. comparable b. equal c. lower d. higher

c. lower

all of the following statements describe a MEWA except a. mewa employers retain full responsibility for any unpaid claims b. mewas can be self-insured c. mewas are groups of at least 3 employers d. mewas can be sponsored by insurance companies

c. mewas are groups of at least 3 employers the correct answer is 2 employers

under which of the following organizations are the practicing providers compensated on a fee-for-service basis? a. hmo b. blue cross/blue shield c. open panel d. ppo

d ppo

a small hardware store owner is involved in a car accident that renders him totally disabled for half a year. which type of insurance would help him pay for expenses of the company during the time of his disability? a. key person insurance b. disability buy-sell agreement c. business disability policy d. business overhead expense policy

d. business overhead expense policy

income replacement contracts agree a. to cover any accident on the job, but not accidents outside of his/her job b. to replace the insured for his/her company, including hiring and training wages c. to replace the insured's income up to a stated percentage if the insured suffers a loss due to a covered accident or sickness d. to replace income if the head of the household is the primary insured, and he/she loses income due to a lay-off

c. to replace the insured's income up to a stated percentage if the insured suffers a loss due to a covered accident or sickness

when does a person qualify to receive disability-related income? a. when an injury is severe and the insured is not a dependant b. when an insured is hospitalized for more than one week c. when the insured is unable to perform his/her job duties d. when the disability reaches a designated state of severity

c. when the insured is unable to perform his/her job duties

the insurance policy, together with the policy application and any added riders form what is known as a. certificate of coverage b. contact of adhesion c. whole life policy d. entire contract

d entire contract

A brain surgeon has an accident and develops tremors in her right arm. Which disability income policy definition of total disability will cover her for all losses? a. "own occupation" - more restrictive than other definitions b. "anyoccupation" - more restrictive than other definitions c. "any occupation" - more restrictive than other definitions d. "own occupation" - less restrictive than other definitions

d. "own occupation" - less restrictive than other definitions

HIPAA applies to groups of a. at least 10 b. at least 100 c. more than 2, fewer than 50 d. 2 or more

d. 2 or more

what is the elimination period for social security disability benefits? a. 6 b. 12 c. 3 d. 5 (months)

d. 5 months

one of the differences between group underwriting and individual underwriting is that there is little or no medical information required regarding plan participants in groups of a. 100+ b. 25+ c <50 d. 50+

d. 50+

A man bought an individual health insurance policy for himself. Which of the following roles does he now legally have? a. broker b. subscriber only c. insured only d. both subscriber and insured

d. both subscriber and insured insureds are person covered by health insurance and who receive benefits. subscribers are people in whose name the contract is issued

which of the following options best depicts how the eligibility of members for group health insurance is determined? a. eligibility is not determined but simply accepted b. by the physical conditions of the applicants at the time of employement c. in such a manner as to establish individual selection as to the amounts of insurance d. by the conditions of employment

d. by the conditions of employment

if an applicant for a health insurance policy is found to be a substandard risk, the insurance company is most likely to a. require a yearly medical examination b. lower its insurability standards c. refuse to issue the policy d. charge an extra premium

d. charge an extra premium

A man is injured while robbing a convenience store. How does his major medical policy handle the payment of his claim? a. 50% of his claim will be paid b. if he's not convicted, 75% c. paid in full d. claim is denied if his policy contains illegal occupation provision

d. claim is denied if his policy contains the Illegal Occupation provision

what process will the insurance company use to monitor the insured's hospital stay to make sure that everything is proceeding according to schedule? a. prospective review b. corridor deductible c. preventive review d. concurrent review

d. concurrent review

An insured is receiving hospice care. His insurer will pay for painkillers but not for an operation to reduce the size of a tumor. What term best fits this arrangement? a. selective coverage b. limited coverage c. claims saving d. cost containment

d. cost containment

which of the following health care plans would most likely provide the insured/subscriber with comprehensive health care coverage? a. group dental insurance plan b. medical-surgical expense plan c. basic medical expense plan d. health maintenance organization plan

d. health maintenance organization plan

which of the following riders would NOT increase the premium for a policyowner? a. payor benefit rider b. waiver of premium rider c. multiple indemnity rider d. impairment rider

d. impairment rider excludes a specified condition from coverage, reducing benefits. an insurance company will not charge extra for a rider that reduces benefits

what is the benefit of experience rating? a. it helps employers with high claims experience to get group coverage b. it helps employees with low claims experience to become exempt from group premiums c. it allows employers with high claims experience to obtain insurance d. it allows employers with low claims experience to get lower premiums

d. it allows employers with low claims experience to get lower premiums

a policyowner is reading a statement on the first page of his health insurance policy, which says "this is a limited policy" what is the name of this statement? a. policy limitation notice b. statue of limitations c. limited benefit statement d. limited policy notice

d. limited policy notice

An insured severely burns her hand, but is not classified as disabled. Which of the following types of coverage would cover at least a portion of the insured's medical expenses? a medical expense compensation b. accidental death & dismemberment c. partial disability d. medical reimbursement

d. medical reimbursement benefit

which provision concerns the insured's duty to provide the insurer with reasonable notice in the event of a loss? a. loss notification b. claims initiation c. consideration d. notice of claim

d. notice of claim

what term is used to describe when a medical caregiver contracts with a health organization to provide services to its members or subscribers, but retains the right to treat patients who are not members or subscribers? a. closed panel b. restrictive rights c. indemnity contract d. open panel

d. open panel

what would a physician utilize if he/she wanted to know if a treatment is covered under an insured's plan and at what rate it will be paid? a. concurrent review b. comprehensive review c. supplementary chart d. prospective review

d. prospective review

in a disability policy, the elimination (or waiting) period refers to the period between a. the effective date of the policy and the date the first premium is due b. coverage under a disability policy and coverage under social security c. during which any specific illness or accident is excluded from coverage d. the first day of disability and the day the insured starts receiving benefits

d. the first day of disability and the day the insured starts receiving benefits

in a group policy, who is issued a certificate of insurance? a. the health care provider b. the insurance company c. the employer d. the individual insured

d. the individual insured

which of the following is true regarding elimination periods and the cost of coverage? a. shorter elimination, lower cost b. longer elimination, higher cost c. elimination periods have no effect on the cost d. longer elimination, lower cost

d. the longer the elimination period, the lower the cost of coverage

what does mewa stand for

multiple employer welfare arrangement

Under the Physical Exam and Autopsy provision, how many times can an insurer have the insured examined, at its own expense, while a claim is pending? unlimited None at all One examination per week of the claim processing. Two examinations per week of the claim processing period

unlimited

Under the uniform required provisions, proof of loss under a health insurance policy normally should be filed within

90 days of a loss

how is the amount of social security disability benefits calculated?

It is based upon the workers primary insurance PIE which is calculated from your average index monthly earnings over the highest 35 years

A policy with a 10-day grace period implies

The policy remains in force without penalty for 10 days even though the premium deal has not been paid

Under the mandatory uniform provision Notice of Claim, the first notice of injury or sickness covered under an accident and health policy must contain

a statement that is sufficiently clear to identify the insured and the nature of the claim

An employee insured under a group health plan has been paying $25 monthly premium for his group health coverage. The employer has been contributing $75, for the total monthly cost of $100. If the employee leaves the company, what would be his maximum monthly premium for COBRA coverage? a. 102 b 25 c. 25.5 d. 100

a. 102

To be eligible under HIPAA regulations, for how long should an individual converting to an individual health plan have been covered under the previous group plan? a. 18 mos b. 5 yrs c. 12 mos d. 63 days

a. 18 months

Income Replacement Contracts agree a. To replace the insured's income up to a stated percentage if the insured suffers a loss due to a covered accident or sickness. b. to replace income if the head of the household is the primary insured, and he/she loses income due to a lay-off c. to cover any accident on the job, but not accidents outside of his/her job d. to replace the insured for his/her company, including hiring and training wages

a. To replace the insured's income up to a stated percentage if the insured suffers a loss due to a covered accident or sickness.

If the insured under a disability income insurance policy changes to a more hazardous occupation after the policy has been issued, and a claim is filed, the insurance company should do which of the following? a. adjust the benefit in accordance with the increased risk b. cancel the policy c. increase the premium d. exclude coverage for on-the-job injury

a. adjust the benefit in accordance with the increased risk

which term describes a situation in which people who are the most likely to have claims are also the most likely to seek insurance? a. adverse selection b. insurable interest c. double indemnity d. law of large numbers

a. adverse selection

in a group prescription drug plan, the insured typically pays what amount of the drug cost? a. copayment b. none c. full amount until a deductible is met, then nothing d. full amount until deductible is met, then small copay

a. copayment

which of the following statements about occupational vs nonoccupational coverage is TRUE a. disability insurance can be written as occupational or nonoccupational b. group medical expense policies and individual medical expense policies always cover both occupational and nonoccupational injuries c. individual disability policies never cover nonoccupational injuries d. only group disability income policies can be written on an occupational basis

a. disability insurance can be written as occupational or nonoccupational

which of the following is considered a qualifying event under cobra? a. divorce b. marriage c. relocation d. promotion

a. divorce

Because of the history of cancer in her family, Julie purchased a policy that specifically covers the expense of treating cancer. Her policy would be classified as what type of policy? a. dread disease policy b. family history cancer policy c. specified health policy d. term health policy

a. dread disease policy limited policy written to specifically cover cancer expense

in disability income insurance, the time between the onset of an injury or sickness and when benefits begin is known as the a. elimination period b. qualification period c. enrollment period d. probationary period

a. elimination period

as it pertains to group health insurance, cobra stipulates that a. group coverage must be extended for terminated employees up to a certain period of time at the former employee's expense b. retiring employees must be allowed to convert their group coverage to individual policies c. terminated employees must be allowed to convert their group coverage to individual policies d. group coverage must be extended for terminated employees up to a certain period of time at the employers expence

a. group coverage must be extended for terminated employees up to a certain period of time at the former employee's expense

a health insurance plan which involves financing, managing, and delivery of health care services and involves a group of providers who share in the financial risk of the plan or who have an incentive to deliver cost effective service is called a. managed care plan b. limited care plan c. preferred care plan d. self insurance

a. managed care plan

a 55-year-old employee has worked part-time for his new employer for 3 months now, but has not been offered health insurance. what factor has limited the employee's eligibility? a. number of hours worked per week b. total amount of time worked for company c. age d. income

a. number of hours worked per week

which of the following is the most common time for errors and omissions to occur on the part of an issuer? a. policy delivery b. policy renewal c. underwriting d. application process

a. policy delivery

certain conditions, such as dismemberment or total and permanent blindness, will automatically qualify the insured for full disability benefits. which disability policy does this describe? a. presumptive b. dismemberment c. partial d. residual (disability)

a. presumptive disability

under which provision can a physician submit claim information prior to providing treatment? a. prospective review b. concurrent review c. anticipatory treatment d. suspended treatment

a. prospective review

which of the following answers does not describe the principal goal of a preferred provider organization? a. provide medical services only from physicians in the network b. provide the subscriber a choice of physicians c. provide the subscriber a choice of hospitals d. provide medical services at a reduce cost

a. provide medical services only from physicians in the network

which of the following applicants could the insurer charge a higher rate of premium and not violate regulations regarding unfair discrimination? an applicant who is a. a smoker b. born in another country c. legally blind d. victim of domestic abuse

a. smoker

which of the following would be a qualifying event as it relates to COBRA? a. termination of employment due to downsizing b. termination of employment for stealing c. eligibility for coverage under another group plan d. eligibility for medicare

a. termination of employment due to downsizing

a husband and wife are insured under group health insurance plans at their own places of employment, and as dependents under their spouse's coverage. if one of them incurs hospital expenses, how will those expenses likely be paid? a. the benefits will be coordinated b. neither plan would pay c. each plan will pay in equal shares d. the insured will have to select a plan from which to collect benefits

a. the benefits will be coordinated

in a group policy, the contract is between a. the employer and the insurance company b. the individual and the insurance company c. the employer and the union d. the employee and the employer

a. the employer and the insurance company

An insurer wishes to compare the information given in an insurance application with previous insurance applications by the same applicant but for different companies. What organization can help the insurer accomplish this? a. the medical information bureau b. the state department of insurance c. social security d. the national association of insurance commissioners

a. the medical information bureau

which of the following is true regarding METs? a.they allow several small employers purchase less expensive insurance together b. they make deals with local hospitals to provide low cost coverage to the needy c. they provide insurance for larger corporations d. they provide insurance companies with medical information on applicants

a. they allow several small employers purchase less expensive insurance together

According to the rights of renewability rider for cancellable policies, all of the following are correct about the cancellation of an individual insurance policy EXCEPT a. unearned premiums are retained by the insurance policy b. the insurer must provide the insured a written notice of the cancellation c. claims incurred before cancellation must be honored d. an insurance company may cancel the policy at any time

a. unearned premiums are retained by the insurance company. any unearned premium must be returned to the policy holder, if the insurer cancels, the unearned premium will be returned on a pro rata basis.

which of the following statements is true concerning the alteration of optional policy provisions? an insurer may change the wording of optional policy provisions that would adversely affect the policyholder But must first receive state permission before the change goes into affect Once any kind of provision is written, it cannot be changed An insurer may change the wording of optional provisions, as long as the change does not adversely affect the policyholder and ensure we change the wording of optional provisions, regardless of its affect on the policyholder

an insurer may change the wording of optional provisions as long as the change does not adversely affect the policyholder

How is emergency care covered for a member of an HMO? a. an hmo emergency specialist will cover the patient b. a member of an hmo can receive care in or out of the hmo service area, but care is preferred in the service area c. a member of an hmo may receive care at any emergency facility at the same cost as if in his or her own service area d. hmos have salaried member physicians, but they do not cover emergency care

b. a member of an hmo can receive care in or out of the hmo service area, but care is preferred in the service area

A new employee who meets HIPAA eligibility requirements must be issued health coverage on what basis? a. indemnity b. guaranteed c. noncancellable d. nondiscriminatory

b. guaranteed

Who is the beneficiary in a credit health policy? a. the government b. lending institution c. insurer d. estate of the borrower

b. lending institution

in group insurance, what is the policy called? a. certificate of insurance b. master policy c. entire contract d. certificate of authority

b. master policy

under AD&D coverage, what type of benefit will be paid to the beneficiary in the event of the insured's accidental death? a. refund of premiums b. principal sum c. capital sum d. double the amount of the death benefit

b. principal sum

which of the following is not provided by an hmo? a. patient care b. reimbursement c. services d. financing

b. reimbursement

which of the following statements concerning group health insurance is correct? a. under group insurance, the insurer may reject certain individuals from coverage b. the employer is the policy holder c. only the employer receives a certificate of insurance d. each employee receives a policy

b. the employer is the policyholder

Why do group health providers usually require a certain amount of participation in the plan by eligible employees? a. to ensure the employer is being fair to the employees b. to guard against adverse selection and reduce cost c. to promote preventive care d. to ensure a higher profit for the insurer

b. to guard against adverse selection and reduce cost

which of the following components of dental insurance does not require the payment of a deductible? a. orthodontic care b. cosmetic dentistry c. routine and preventive maintenance d. routine and major restorative care

c routine and preventive maintenance

which of the following would best describe total disability? a persons: a. total loss of income b. a person's inability to qualify for insurance coverage c. a person's ability to work is significantly reduced or eliminated for the rest of his/her life d. a person's inability to perform one of the regular duties of his/her occupation

c. a person's ability to work is significantly reduced or eliminated for the rest of his/her life

An insured is receiving hospice care. His insurer will pay for painkillers but not for an operation to reduce the size of a tumor. What term best fits this arrangement? a. limited coverage b. claims sving c. cost-containment d. selective coverage

c. cost containment in a cost-containment setting, daily needs and pain relief are provided for hospice patients, but curative measures are not.

the provision that states that both the printed contract and a copy of the application form the contract between the policyowner and the insurer is called the a. aleatory contract b. master policy c. entire contract d. certificate of insurance

c. entire contract

which of the following factors does an insurer use the most to determine the extent of disability benefits that it will promise in a contract? the insured's: a. moral history b. hobbies c. income d. marital status

c. income

which of the following do the standard and preferred risk categories share? a. possible modifications to include expanded coverage b. permanent coverage c. premiums are not elevated d. more medical evaluations required

c. premiums are not elevated

a man's physician submits claim information to his insurer before she actually performs a medical procedure on him. she is doing this to see if the procedure is covered under the patient's insurance plan and for how much. this is an example of: a. claims-delayed treatment b. suspended treatment c. prospective review d. concurrent review

c. prospective review

which of the following statements concerning group health insurance is correct? a. each employee receives a policy b. under group insurance, the insurer may reject certain individuals from coverage c. the employer is the policy holder d. only the employer receives a certificate of insurance

c. the employer is the policy holder

If a policy is rated-up, which of the following is true? a. the number of exclusions decreases b. the number of benefits increases c. the premium increases d. the premium decreases

c. the premium increases

on a disability income policy that contains the "own occupation" definition of total disability, the insured will be entitled to benefits if they cannot perform a. any job that they are suited for by prior training b. any job that they are suited for by prior experience c. their regular job d. any job that they are suited for by prior education

c. their regular job

under a disability income policy, the insurer pays a monthly benefit that is less than the insured's income. What is the reason for that? a. to enable the insurer to provide affordable coverage b. to enable the insurer to reduce costs c. to prevent over utilization and malingering d. to prevent the insured from obtaining excess insurance

c. to prevent over utilization and malingering the insurer wants there to be a financial incentive to the insured to return to work