Health Insurance Policy Provisions
An insured must notify an insurer of a medical claim within how many days after an accident?
20 days
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
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
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
Which of the following provisions specifies how long a policyowner's health coverage will remain in effect if the policyowner does not pay the premium when its due?
grace period
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 for the overall risk class?
guaranteed renewability
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 of the following BEST describes a short term medical expense policy?
nonrenewable
The Notice of Claims provisions requires policyowner to?
notify an insurer of a claim within a specified time
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
An insurer must provide an insured with claim forms within __ days after receiving notice of a loss.
15
What type of renewability guarantees premium rates and renewability?
noncancellable
The insuring clause
States the scope and limits of the coverage
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 of premium provision keeps the coverage in force without premium payments
after an insured has become totally disabled as defined in the policy
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 bee submitted before a lawsuit can be filed
A(n) assignment of benefits of a Health Policy transfers payments to someone other than the policyowner
assignment
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
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
Health insurance benefits NOT covered due to an act of war are?
excluded by the insurer in the contract provisions
The sections of an insurance contract which limit coverage are called?
exclusions
Under an individual Health Insurance policy, the Time Limit of Certain Defenses provisions states that nonfraudulent misstatements first become incontestable two years
from the date the policy was issued
T sends proof of loss to her insurer for an acceptable medical expense claim under her individual Health Insurance policy. Upon receipt, the insurer must pay the benefits
immediately
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's coverage amount
What is the initial requirement for an insured to become eligible for benefits under the Waiver of Premiums provision?
insured must be under a physician's care
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
According to the Time Payment of Claims provision, the insurer must pay Disability Income benefits no less frequently than which of the following options?
monthly
Periodic health claim payments MUST be made at least
monthly
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
Which of these statements accurately describes the Waiver or Premium provision in an Accident and Health policy
premiums are waived after the insured has been totally disabled for a specified period of time
What is the purpose of time of payment of claims provision?
prevents delayed claim payments paid by the insurer
What must the policyowner provide to the insurer for validation that a loss has occurred?
proof of loss
The Legal Actions provision of an insurance contract is designed to do all of the following, EXCEPT?
protect the producer
With Optionally Renewable Health policies, the insurer may
review the policy annually and determine whether or not to renew it
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's 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 claim's validity. The provision that limits the time period during which the company may dispute a claim's validity is called
time limit or certain defenses
Which Accident and Health policy provision addresses preexisting conditions?
time limit or certain defenses