Chapter 6: Health Insurance Policy Provisions

M's insurance company denied a reinstatement application for her lapsed health insurance policy. The company did not notify M of this denial. How many days from the reinstatement application date does the insurance company have to notify M of the denial before the policy will be automatically placed back in force?

45 days; health insurance will be automatically placed back in force by then

An insured pays premiums on an annual basis for an individual health insurance policy. What is the MINIMUM number of days for the Grace Period provision?

31 days

which of the following provisions specifics how long a policy owners health coverage will remain in effect if the policy owner does not pay the premium when it is due

grace period

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

guaranteed renewable

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?

guaranteed renewable

a disability income policy that only the policy owner can terminate and which the rates will never go up is considered to be

noncancellable

what type of renewability gaurentee premium rates and renewability

noncancellable

the notice of claims provision requires a policy owner

notify an insurer of a claim within an specified time

an insured must notify an insurer of medical claim within ______ days after an accident

20

which of the following statements describes what an accident and health policyowner may not do

adjust the premium payments

In health insurance policies, a waiver premium provision keeps the coverage in force without premium payments

after an insured has become totally disabled as defined in the policy

P is a major medical policy owner who is hospitalized as a result of injures sustained from participating in carjacking- how will the insurer most likely handle this claim

claim will be denied

Which health policy clause stipulates that an insurance company must attach a copy of the application to the policy to ensure that it is part of the contract?

entire contract

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 coverage amount

which health policy clause specifies the amount of benefits to be paid

insurance

what is the initial requirement for an insured to become eligible for benefits under the waiver of premium provison

insured must bender a physicians care

S filed a written Proof of Loss for a Disability Income claim on September 1. The insurance company did not respond to the claim. S can take legal action against the insurer beginning

nov 1

the provision that defines to whom the insurer will pay benefits to is called

payment of claims

which of these is considered a mandatory provision

payment of claims

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 policy owner wants to ensure the policy will continue if he/she ever becomes totally disabled

waiver of premium rider

if an individual is covered under an AD&D autopsoy can be performed in all these situations except

when states prohibits it by the law

when does a probationary period provision become effective in a health insurance contract

at the policy inception

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

a producer doesn't have the authority to change a policy or waive any of its provisions. the health provision that describes this statement is

entire contract

which of the following policy provisions prohibits an insurance company from incorporating external documents into an insurance policy

entire contract

according to the time of payments provision the insurer must pay disability income benefits no less frequently than

monthly

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

policy normally increase at time of renewable

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 characteristic of a conditionally renewable health policy

premiums may increase at time of renewal

what is the purpose of the time of payment of claims provision

prevents delayed claim payments made buy the insurer

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

what must the policy owner privide to insurer for validation that a loss has occurred

proof of loss

the legal actions provision of an insurance contract is designed to all of of the following except:

protect the producer

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

the insuring clause

states the scopes and limits of the coverage

An insurer must provide an insured with claim forms within __ days after receiving notice of a loss.

15

insurers may request a haring within ______ if their policy is rejected

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

an _______ of benefits of a health policy transfers payments to someone other than the policyowner

assignment

health insurance benefits not covered due to an act of war are

excludes by the insurer in the contract provisions

the sections of an insurance contract which will limit coverage are called

exclusions

the _______ clause identifies which losses resulting from an accident to sickness are insured bt the policy

insuring

the clause in an accident and health policy which defines the benefit amounts the insurer will pay is Called the

insuring clause

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

insuring clause

periodic health claims payments must be made at least

monthly

Under an individual health insurance policy, the time limit of a certain defense provision states that non fraudulent misstatements first become inconestatable two years

from the date the policy was issued

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

which of following is NOT included in the policy face

exclusions

after an insured gives loss of notice what must he do if the insurer doesn't furnish forms

file written proof of loss

with optionally renewable health policies, the insurer may:

review the policy annully and determine whether or not to renew it

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

the policy provision that entitles the insurer to establish conditions insured must meet while a claim is pending

time limit on certain defenses

With Accidental Death and Dismemberment policies, what is the purpose of the Grace Period?

gives policyowner additional time to pay overdue premium

T sends proof of loss to her insurer for acceptable medical expense claim under her individual health insurance policy. upon recipet, the insurer must pay the benefits

immediately

which accident and health policy provision addressed preexisting conditions

time limit on certain defenses

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

According to 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

which of the following best describes a short term medical expense policy

non renewable

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 desribes this policy is called

noncancellable

an insurance company normally has 2 years to contest information provided on an accident and health application. this 2 year period begins on the date that

the insurer dates the policy

J, an Accidental Death and Dismemberment (AD&D) policy holder, dies after injuries sustained in an accident. J's age as stated on the application five years ago was found to be understated by ten years. Which of the following actions will the insurance company take?

the insurer will adjust the benefit to what the premiums paid would have purchased at the insured actual age

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 claims validity. the provision that limits the time period during which the company may dispute a claims validity is Called

time limit on certain defenses