Chapter 13

Generally, how long is a benefit period for a Major Medical Expense Plan?

One year

A prospective insured completes and signs an application for health insurance but intentionally conceals information about a pre-existing heart condition. The company issues the policy. Two months later, the insured suffers a heart attack and submits a claim. While processing the claim, the company discovers the pre-existing condition. In this situation, the company will:

Continue coverage but exclude the heart condition

A catastrophic illness would be best covered by which of the following health insurance plans?

Major medical

M has a Major Medical insurance policy with a $200 flat deductible and an 80% Coinsurance clause. If M incurs a $2,200 claim for an eligible medical expense, how much will M receive in payment for this claim?

$1,600

An individual has a Major Medical policy with a $5k deductible and an 80/20 Coinsurance clause. How much will the INSURED have to pay if a total of 15K in covered medical expenses are incurred?

$7,000

C was injured while deep sea diving and requires a hospital stay. C has a Major Medical policy with an 80/20 coinsurance clause and a $400 deductible. What is the MAXIMUM C will pay if the covered medical expenses are $2000?

$720

This type of deductible provision states that should more than one family member be involved in a common accident, or suffer the same illness, only one individual deductible amount shall be applied

Common accident deductible

M is insured under a basic Hospital/Surgical Expense policy. A physician performs surgery on M. What determines the claim M is eligible for?

Determined by the terms of the policy

A characteristic of Preferred Provider Organizations (PPOs) would be:

Discounted fees for the patient

Which of the following statements BEST describes the intent of a Coinsurance clause in a Major Medical policy?

Discourages over-utilization of the insurance coverage

Which of the following statements about Health Reimbursement Arrangements (HRA) is CORRECT?

If the employee paid for qualified medical expenses, the reimbursements may be tax-free

Which of the following statements BEST describes dental care indemnity coverage?

Services are reimbursed after insurer receives the invoice

Which of the following services is NOT included under hospitalization expense coverage?

Surgeon's fees

Which of the following statements best defines usual, customary, and reasonable (UCR) charges?

The maximum amount considered eligible for reimbursement by an insurance company under a health plan

In order to establish a Health Reimbursement Arrangement (HRA), it MUST

be established by the employer