Chapter 16- Health Insurance Policy Provisions

What must the policyowner provide to the insurer for validation that a loss has occured?

Proof of Loss

Time Limit on Certain Defenses

states the policy is incontestable after it has been in force a certain period of time, usually two years. This is similar to the incontestable clause. Unlike life policies, a fraudulent statement on a health insurance application is grounds for contest at any time, unless the policy is guaranteed renewable. There is a TIME LIMIT for which you must DEFEND yourself. This applies to the contestable period, preexisting conditions, and new claims. If you file a claim that you broke your leg yesterday, and the insurance company sees you moving a grand piano up 5 flights of stairs, you will probably have to DEFEND your claim. However, at some point, it is expected your leg will heal.

Entire Contract

tates the insurance policy itself, any riders and endorsements/amendments, and the application comprise the entire contract between all parties. Insurance producers cannot make changes to a policy. The entire contract provision is found at the beginning of every insurance policy issued. Only an authorized officer of the insurer is permitted to make changes to the contract. We can't send you additional paperwork later. THE ENTIRE POLICY AND APPLICATION is sent to you and that makes up your ENTIRE CONTRACT.

Which of the following provisions specifies how long a policyowner's health coverage will remain in effect if the policyowner doesn't pay the premium when it's due?

Grace Period

Which of the following is considered to be the time period after a Health policy is issued, during which no benefits are provided for illness?

Probationary period

Health insurance benefits NOT covered due to an act of war are

excluded by the insurer in the contract provisions

Which of the following is NOT included in the policy face?

exclusions

Which of the following statements about a guaranteed renewable health insurance policy is correct?

Premiums normally increase at time of renewal

According ot the Mandatory Uniform Policy Provisions, what is the maximum amount of time after the premium due date during which the policy remains in force even though the premium has not been paid?

31 days

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

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

After an insured gives notice of loss, what must he/she do if the insurer does not furnish forms?

File written proof of loss

Under an individual health insurance policy, the time limit of Certain Defenses provision states that nonfradulent misstatements first become incontestable two years

From the date the policy was issued

The ______ clause identifies which losses resulting from an accident or sickness are insured by the policy

Insuring

Which health policy clause specifies the amount of benefits to be paid?

Insuring

Which of the following health insurance policy provisions specifies the health care services a policy will provide?

Insuring clause

C is the policyowner of a Comprehensive individual Major Medical policy. C pays an annual premium which is due September 1. If C forgets to pay the premium and is hospitalized September 10, how will the insurer handle this claim?

Pay the claim in full minus the premium due

Which of these is considred a mandatory provision?

Payment of claims Optional provisions include insurance with other insurers, misstatement of Age, and change of occupation

What is considered to be a characteristic of a Conditionally Renewable Health Insurance policy?

Premiums may increase at time of renewal

What should an insured of 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

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

What type of rider would be added to an Accident and Health policy if the policyowner wants to ensure the policy will continue if he/she ever becomes totally disabled?

Waiver of premium rider

K has a health polich that must be renewed by the insurer and the premiums can only be increased if applied to the entire class of insureds. The type of policy is considered:

guaranteed renewable

An insurance company normally has 2 years to contest information provides on an accident and health application. This 2 year period begins on the date that the:

insurer dates the policy

If an insurance company issue a Dissability Income policy that is cannot cancel or for which it cannot increase premiums, the type of renewability that best describes this policy is called:

noncancellable

Which of the following BEST describes a short-term medical expense policy

nonrenewable