Health Portion Chapter 6 Health Insurance Policy Provisions
The insured and insurance company will share the cost of covered losses under which health policy feature?
Answer: Payment of claims provision
Which of these statements accurately describes the Waiver of Premium in an Accident and Health policy?
Answer: Premiums are waived after the insured has been totally disabled for a specified time period
What is considered to be a characteristic of a conditionally renewable health insurance policy?
Answer: Premiums may increase at time of renewal
Which of the following statements about a Guaranteed Renewable health insurance policy is Correct?
Answer: Premiums normally increase at time of renewal
What is the purpose of the Time of Payment of claims provision?
Answer: Prevents delayed claim payments made by 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?
Answer: Probationary period
What must the policyowner provide to the insurer for validation that a loss has occurred?
Answer: Proof of Loss
The Legal Actions Provision of an insurance contract is designed to do all of the following Except?
Answer: Protect the Producer
The sections of an insurance contract which limit coverage are called
Answer Exclusions
An insurer must provide an insured with claim forms within __ days after receiving notice of a loss.
Answer: 15 days
An insured must notify an insurer of a medical claim within how many days after an accident?
Answer: 20 days
Insurers may request a hearing within ___ if their policy is rejected
Answer: 20 days
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?
Answer: 31 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?
Answer: 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?
Answer: 45 days
Which of the following statements describes what an Accident and Health Policyowner may NOT do?
Answer: Adjust the Premium payments
In health insurance policies, a waiver of premium provision keeps the coverage in force without premium payments:
Answer: 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 require?
Answer: An insured must wait at least 60 days after Proof of Loss has been submitted before a lawsuit can be filed
A(n) ____________of benefits of a health policy transfers payments to someone other than the policyowner?
Answer: Assignment
When does a Probationary Period provision become effective in a health insurance contract?
Answer: At the policy's inception
When an insured changes to a more hazardous occupation, which disability policy provision allows an insurer to adjust policy benefits and rates?
Answer: Change of occupation provision
P is a Major Medical policyowner who is hospitalized as a result of injuries sustained from participating in a carjacking. How will the insurer most likely handle this claim?
Answer: Claim will be denied
A disability income policyowner recently submitted a claim for a chronic neck problem that has now resulted in total disability. The original neck injury occurred before the application was taken 5 years prior. The neck injury was never disclosed to the insurer at the time of application. How will the insurer handle this claim?
Answer: Claim will be paid and coverage will remain in force
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?
Answer: Pay the claim in full minus the premium due
The provision that defines to whom the insurer will pay benefits to is called
Answer: Payment of claims
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?
Answer: Consideration clause
S is the policyowner of a Major Medical policy. The premiums are paid monthly and due on the 1st of each month. S fails to make September's payment and is hospitalized October 15th. When S files the claim for this hospitalization, the insurer will likely:
Answer: Deny the claim
"A producer does not have the authority to change a policy or waive any of its provisions." The health provision that best describes this statement is called the?
Answer: Entire Contract
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?
Answer: Entire Contract
Which of the following policy provisions prohibits an insurance company from incorporating external documents into an insurance policy?
Answer: Entire Contract
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
Answer: Entire contract provision
Which of the following is Not included in the policy face?
Answer: Exclusions
After an insured gives notice of loss, what must he/she do if the insurer does not furnish forms?
Answer: File Written Proof of Loss
Under an individual health insurance policy, the Time Limit of Certain Defenses provision states that nonfraudulent misstatements first become incontestable 2 years
Answer: From the date the policy was issued
With Accidental Death and Dismemberment policies, what is the purpose of the Grace Period?
Answer: Gives the policyowner additional time to pay overdue premiums
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 it is due?
Answer: 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
Answer: 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 for the overall risk class?
Answer: Guaranteed renewable
X is insured with a disability income policy that provides coverage until age 65. This policy allows the insurer to change the premium rate for the overall risk class assigned. Which of these renewability features does this policy contain?
Answer: Guaranteed renewable
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
Answer: Immediately
T applied for a Disability Income policy and has a history of back injuries. The insurer issued the policy with a statement that excludes coverage for back injuries. This statement is called a(n)
Answer: Impairment rider
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?
Answer: Increase her policy's coverage amount
What is the initial requirement for an insured to become eligible for benefits under the Waiver of Premium provision?
Answer: Insured must be under a physician's care
An insurance company normally has two years to contest information provided on an accident and health application. This 2 year period begins on the date that the?
Answer: Insurer dates the policy
The ______ clause identifies which losses resulting from an accident or sickness are insured by the policy?
Answer: Insuring clause
The clause in an Accident and Health policy which defines the benefit amounts the insurer will pay is called the
Answer: Insuring clause
Which health policy clause specifies the amount of benefits to be paid?
Answer: 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?
Answer: Monthly
Periodic health claim payments MUST be made at least
Answer: Monthly
A disability income policy that only the policyowner can terminate and which the rates will never go up is considered to be?
Answer: Noncancellable
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
Answer: Noncancellable
What type of renewability guarantees premium rates and renewability?
Answer: Noncancellable
Which of the following Best describes a short-term medical expense policy?
Answer: Nonrenewable
The notice of claims provision requires a policyowner to?
Answer: Notify an insurer of a claim within a specified time
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
Answer: November 1
Which of these is considered a mandatory provision?
Answer: Payment of claims
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?
Answer: Reinstatement
With Optionally Renewable Health policies, the insurer may
Answer: Review the policy annually and determine whether or not to renew it
The insuring clause
Answer: States the scope and limits of the coverage
Which should an insured do if the insurer does not send claims forms within the time period set forth in a health policy's claim forms provision?
Answer: Submit a 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?
Answer: The insured
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?
Answer: The insurer will adjust the benefit to what the premiums paid would have purchased at the insured's actual age
Which Accident and Health policy provision addresses preexisting conditions?
Answer: Time Limit of Certain Defenses
The policy provision that entitles the insurer to establish conditions the insured must meet while a claim is pending is
Answer: Time Limit on Certain Defenses
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
Answer: Time limit on certain defenses
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?
Answer: Waiver of premium rider
If an individual is covered under an Accidental Death policy and dies, an autopsy can be performed in all of these situations Except?
Answer: When the state prohibits this by law
Which of the following health insurance policy provisions specifies the health care services a policy will provide?
Answer: insuring clause
Under a Guaranteed Renewable health insurance policy, the insurer
Answer: may cancel the policy for nonpayment only
Health insurance benefits Not covered due to an act of war are?
Answer; Excluded by the insurer in the contract provisions
