Health Class
How long is a long term benefit period?
Over 2 year period with usually maximum age of 65
Define non-cancelable renewal clause
Renewal guaranteed and premiums guaranteed. Most favorable and most expensive
Defined guaranteed renewable renewal clause
Renewal guaranteed but premiums are not
Define optionally renewable renewal clause
The insurer may cease coverage for any reason but it has to be on anniversary or premium due date. Least favorable but most common. Cheapest.
What is the advantage of a PPO over a HMO?
Wider choice of providers
How long is the free look period?
10 days
If you pay premiums monthly, how long is the grace period?
10 days
What is the expectation for a Non-contributory plan?
100% participation
If you ask for a claim form or copy of an application how long does the insurance company have to do so?
15 days
When does the insured have to supply proof of loss?
180 days from loss
How long do you have to be covered under a group contract in order to qualify for continuation of benefits?
3 consecutive months
If the applicant feels the information gathered is inaccurate, they have the right to dispute the decision. Any disputed information must be responded to within ____ business days
30 business days
Exams cannot be required of any participant in employer/employee groups of 50 or more if the individual joins within _____ days of eligibility
31 days
Grace period when you pay semi annually?
31 days
How many work credits must one work in order to qualify for social security DI?
40 quarters
If the commissioner increases rates, all policyholders have to be notified when?
45 days prior to rate increase
Elimination period of social security disability?
5 months and anticipated to last at least a year or result in death
What is the typical maximum benefits for DI insurance?
50-70%
What is the expectation for contributory plans?
75% minimum participation
If a written request for the reasons behind an adverse underwriting decision is submitted within ____ days, the company has _____ days to respond
90, 21
What does partial disability pay?
A set percentage such as 50%
2 perils that health insurance cover?
Accident and sickness
When can premiums for group health insurance be adjusted?
After the first year of coverage, premiums may be adjusted every 6 months
Guaranteed purchase option
Allows you to increase your death benefit if you get a raise for example without proving evidence of insurability
Who funds Social Security?
Employees, employers, and the self employed. Not funded by the federal government
What is the most restrictive DI policy?
Any - inability to perform duties of ANY occupation
What is a conversion privilege?
At termination, the certificate holder has 31 days to convert to their own individual coverage without evidence of insurability
Residual Disability
Attempts to measure the amount of income lost instead of a set percentage
What happens to residual DI benefits as income increases?
Benefits are reduced as income increases
What does the time of payment of claims state?
Claims are to be paid immediately
What does a comprehensive major medical policy do?
Combines a basic medics expense policy and a major medical policy into one contract
List public sources
Criminal or real estate records; can be found on the internet
What does the conformity with state statutes state?
Current policies will automatically conform with changes in the law; self correcting
The out of pocket expense paid by the insured before Major Medical policies begin paying benefits?
Deductible
What isn't covered under continuation of group benefits?
Dental, vision, and prescription drugs
Define Notice of Claim
Describes the period of time the insured has to provide notice that a claim is to be filed
A major medical policy will do what in regards to the VA?
Exclude coverage for medical treated provided by a VA hospital. No double dipping
Factors that affect rate
Gender, age, health status, occupation, avocations (hobbies)
Business Overhead Expense
Generates income needed to keep the business running but doesn't pay the owner's salary
What is the Disclosure Authorization Form?
Grants permission for the insurance company to obtain and or release specified information from specified persons
Blanket Accident Insurance
Group coverage for special situations where group membership changes rapidly ie. Schools, arenas, etc
Define conditionally renewable renewal clause
Has to state in policy under what circumstances the insurer can drop you
How does presumptive DI pay?
In form of income, not lump sum
Who doesn't have to comply with the insurance protection/privacy laws?
Insurance regulators
Who doesn't have to comply with the privacy and protection laws?
Insurance regulators
List examples of presumptive disabilities
Loss of sight, hearing, speech or the loss of two or more limbs
Which renewable clause is least favorable?
Optionally Renewable
List non public sources
Medical records, MIB, credit, investigative, employer
What is malingering?
Milking a disability
When does coverage for dependent children begin?
Moment of birth
What is a MEWA?
Multiple Employer Welfare Arrangements. Groups of employers who come together in order to provide group insurance to their employees at more cost effective rates since they're a bigger group
Which renewal clause is most favorable?
Non-cancelable
Disability Buyouts
Pre-arranged contract that allows partners to buy the disabled partner's share of the business
All forms of the Accident and Heath insurance policies issued in NC must receive what?
Prior approval by the commissioner
When can the commissioner suspend an agents license?
Prior to a hearing if he believes it's needed to protect the public health, safety, or welfare
What happens if you go form a low risk job to a high risk job?
Reduction of coverage
What happens if you go from a high risk job to a low risk job?
Reduction of premiums
What is the Notice of Information Practices?
Summarizes the applicants rights under the act including the right to know what information was gathered and from whom
Corridor Deductible
The amount of money the insured must pay after the basic medical expense coverage has reached its limits and before the major medical benefits begin
What happens if age has been misstated?
The benefits will be changed according to the correct age; no time limit
What does the Notice of Claim state?
The insured must notify the company in writing within 20
The stop loss provision in major medical allows for what?
The insured to limit the amount of co-insurance out of pocket expenses for Major occurrences
Relationship between adverse underwriting decision and the insurer?
The insurer isn't allowed to use an adverse underwriting decision as the sole basis for denying insurance
Define elimination period
The policy provision that states the number of days that must pass after the insured has become disabled before the policy benefits will pay
What is the free look period?
The right to return the policy for a full premium refund within 10 days of policy delivery
When does the notice of information practice need to be provided if the information came from non-public sources?
Time of application
When does the notice of information practice need to be provided if the information came from public sources?
Time of policy delivery
What is the purpose of the "other insurance in other insurers" provision?
To determine the amount payable by multiple insurance contracts
What is the purpose of a probationary period?
To eliminate coverage for pre-existing conditions and protect against adverse selection
Least restrictive definition of total disability
Unable to perform duties of one's OWN occupation
How long does one qualify for continuation of group benefits?
Up to 18 months after losing eligibility under the group
How long is a short term benefit period
Up to 2 years
How does the commissioner get in to office?
Voters of the state elect the commissioner
What is an adverse underwriting decision?
When an application for insurance has been rejected, an existing policy has been terminated or coverage has been rated as a substandard risk
What is a hospital indemnity plan?
Where the insurer pays you a flat amount per day you're in the hospital and the benefits are paid right to you
What does the Coordination of Benefits Clause determine?
Which carrier will act as primary and which one will act as secondary
In the case of an adverse underwriting decision, when does a written request have to be submitted and when does the company has to respond?
Written request has to be submitted within 90 business days and the company has 21 business days to respond