Ch 12

Which of the following is a Cost Containment Provision used by insurers to monitor hospital stays?

Concurrent Review Once an insured is admitted to the hospital, the insurer monitors the insured's hospital stay to make certain that everything is proceeding on schedule through the Concurrent Review Provision.

One of your clients just reinstated his health insurance plan. When is coverage effective for sickness and accident?

10 days for sickness, and immediately for accidental injuries Upon reinstatement, accidents are covered immediately and sickness after 10 days.

The Legal Actions provision preserves the insured's right to bring suit against his/her own insurer, but the insured must wait at least _____ days after filing a proof of loss before pursuing this action.

60

If an insurer cancels a contract, written notice must be provided to the insured within a certain period of time. This is a requirement under which of the following provisions?

Cancellation Cancellation (an Optional Uniform Provision) establishes that the insurer may cancel a policy with written notice to the insured of between 5 and 31 days, depending on the policy.

With a managed health care plan all _________ care must be covered as if it were provided on an in-network basis.

Emergency

Mandatory uniform provisions found in health insurance policies are designed to protect the:

Insured The mandatory uniform provisions are designed to protect the insured's interests.

Which clause in a contract would state that Jim is covered by XYZ insurer for a monthly benefit of $2,000 in the event of disability?

Insuring Clause The Insuring Clause states who is covered, by whom, for how much, for what period, and against what peril.

What is an impairment rider?

It excludes specific conditions that normally would cause the entire policy to be declined An impairment rider is a rider added to a policy that will exclude specific conditions that would normally cause a policy to be declined. The use of this rider allows an insured to qualify for a policy with the exclusion attached, where they would otherwise be declined altogether.

Which of these is a Mandatory Uniform Provision?

Legal Actions The only choice which is a Mandatory Uniform Provision is Legal Actions. All other responses are Optional Uniform Provisions. Optional: -Illegal Occupation -Misstatement of Age -Conformity with State Statutes

The Unpaid Premiums Optional Uniform Provision allows an insurer to:

Reduce the amount of a claim payment by the premium due An insurer can withhold unpaid premiums, to which it has a legal right, when paying a claim that has occurred during the grace period. Both the insurer and the insured are 'indemnified' in this manner.

Under the Entire Contract provision, all of the following may be part of the agreement between the insured and the insurer, except:

Statements made to the applicant by the producer during the application process The Entire Contract Provision (a Mandatory Uniform Provision) stipulates that the policy, a copy of the application, and any riders or endorsements constitute the entire contract between the insurer and insured. Entire Contract: -A copy of the application -The policy -Any riders or endorsements

Which statement concerning individual health policy renewal provisions is most correct?

The more favorable the renewal provision to the insured, the higher the premium The more favorable a renewal provision is to the insured, the higher the premium will be. A noncancellable policy will cost the most because its premium may not be changed in the future.

Does the insured have the right to change the beneficiary designation of a health insurance policy?

Yes, unless the beneficiary is designated as irrevocable The Change of Beneficiary Provision (a Mandatory Uniform Provision) establishes the insured's right to change the beneficiary, unless it is designated as irrevocable.

John has had his individual Health and Disability Income policies for many years. While intoxicated, he was injured as the driver in a single car accident. Who covers the medical expenses for John?

John is liable for all expenses According to the Intoxicants and Narcotics Provision (an Optional Uniform Provision), the insurer may deny coverage for John's injuries, making John liable for all expenses.

Failure to obtain ____________ in a managed care plan can result in denial of coverage, or a substantial reduction in the coverage normally provided.

Pre-authorization

The Insuring Clause under an individual A&H policy would contain all the following, except:

Premium or rate calculations Premiums or rates would be part of the Consideration Clause. All of the other answers would be part of the Insuring Clause. Contain: -The length of the policy period -What perils are covered -The name of the insured and insurer

Beth has a contract stating she must be disabled for 3 months before benefits will begin to be paid. This 3-month period is known as the:

Elimination Period The Elimination Period is a period of time that must elapse after onset of a disability before benefits begin to be paid.