Individual Health Insurance Policy General Provision
Uniform Optional Provision - Change of Occupation
Because the occupartion of the insured is an important underwriting consideration, particularly for disability income insurance, health insurance policies usually include a provision that allows the isurer to adjust benefits if the insured changes occupations. If the insured makes a change to a more hazardous occupation, upon claim, benefits will be reduced to that which premiums paid would have purchased assuming the more hazardous occupation. If the change is to a less hazardous occupation, the insured is entitled to apply to the insurer for a rate reduction
Uniform Optional Provision - Insurance with other Insurers
If the insured has 2 or more policies from different companies that provide benefits on an expense-incurred basis, and the policies cover the same expenses, and if the insurance companies were not notified that the other coverage existed, then each insurer will pay a proportionate share of any claim
Uniform Optional Provision - Intoxicants and Narcotics
The insurer is not liable for any claims that result while the insured is intoxicated or under the influence of drugs (unless administered by a physician)
Uniform Optional Provision - Conformity with State Statutes
This provision states that any provison of the policy which, on its effect date, is in conflict with the statues of the state in which the insured resides on that date is, atuomatically amended to conform with the minimum requirement of the statues
Uniform Optional Provision - Unpaid Premium
Upon payment of a claim, any past due premiums will be deducted from the claim and the policyholder will be paid the net amount
Proof of Loss
after a loss occurs, the claimant must submit proof of loss within 90 days of the loss or as soon as reasonably possible, but not to exceed one year
General Provisions - Military Suspense Provision
if a policy contains a military service exclusion or a provision suspending coverage during military service, or if the premiums are either redued or refunded for the period of military service, that fact must be clearly stated in the policy.
General Provisions - Interest on Claims Proceeds
if an action to recover the claim proceeds due under an individual or group accident and sickness policy results in a judgement against an insurer, interest on the judgment at the legal rate shall be paid from the date presentation to the insurer of proof of loss to the date the judgement is entered
Uniform Optional Provision - Misstatement of Age
if the insured misstated his or her age at the time of the application, the benefits paid under the policy would be adjusted to what the premium paid would have been purchased at the correct age
Reinstatement
if the premium has not been paid by the end of the policy's grace period, the policy will lapse (terminate). This provision stipulates under what conditions the insured may reinstate converage
General Provisions - Renewability Clause - Nonrenewable
in some cases, an individual may need health insurance for a specified period of time. Coverage is then considered a "term" health policy, which is not renewable. When it expires, the insured must purchase another policy
General Provisions - Consideration Clause
makes it clear that both parties to the contract must give some valuable consideration
General Provisions - Renewability Clause - Renewable at Option of Insurer
optional renewability is similar to conditional renewability, except that the insurer may cancel the policy for any reason, on certain homogenous classes (not individials within a class)
Physical Examinations and Autopsy
provision gives the insurer the right to examine th insured, at its own expense, as often as may be reasonably necessary while a claim is pending. The insurer also usually has the right to conduct an autopsy, if not forbidden by state law
General Provisions - Renewability Clause - Guaranteed Renewable
provision is similar to the noncancelable with the exception that the insurer can increase the policy premium on the policy anniversary date
Time Limite on Certain Defenses
provision similar to the incontestability provision found in life insurance policies. No statement of misstatement (except fradulent misstatements) made in the application at the time of issue will be used to deny a claim after the policy has been in force for 2 years
Uniform Optional Provision - Relation of Earning to Insurance
provision that allows the insurance company to limit the insured's benefits to his/her average income over the last 24 months
Time of Payment of Claims
provision that specified that claims are to be paid immediately upon written proof of loss
Payment of Claims
provision that specifies to whom claims payments are to be made
Notice of Claim
provision that spells out the insurd's duty to proide the insurere with reasonable notice in the event of a loss. Notice is required within 20 days of the loss, or as soon as reasonably possible. Notice to the agent equals notice to the insurer
Cancellation by insurer or insured
since premiums are paid in advance, cancellation by either party triggers a refund of unearned premium
Entire Contract; Changes
the entire contract provision states that the health insurance policy, together with a copy of the signed application and attached riders and amendments, constituted the entire contract. Only an executive officer of the company, not an agent, has authority to make any changes to the policy
General Provisions - right to examine
the free look provison allows the insured a period of days to look over the policy, and if dissatisfied for any reason, return it for a full refund (commonly 10 days)
General Provisions - Renewability Clause - Noncanelable
the insurance company cannot cancle a noncancelable policy, nor can the premium be increased beyond what is stated in the policy (note that the policy may call for an increase in a certain year such as "age 65" but that must be stated in the original contract)
Grace period
the period of time after the premium due date in which premiums may still be paid before the policy lapses for nonpayment of the premium
Uniform required provisions
the uniform individual accident and sickness policy provisions law, which was developed by the national association of insurance commissioners (NAIC), has been adopted in all states. This law established standard provisions that are to be included in all individual health insurance policies. Although wording may differ from one insurer to another, the basic provisions are the same. Some of these provisions are similar to life insurance policy provisions
Legal Actions
this provision limits the time in which a claimant may seek recovery from an insurer under a policy. The insured must wait 60 days, but not later than 3 years after proof of loss, before legal action can be brought against the company
Uniform Optional Provision - Illegal Occupation
this provision states that liability will be denied if the insured is injured while committing an illegal act or is engaged in an illegal occupation
Change of beneficiary
this provision stipulates that the policyowner may change the beneficiary at any time by providing a written request to the insurer, unless the beneficiary is disignated as ireevocable. The conses of the beneficiary is not required. If the beneficiary designation is irrevocable, the policyholder must first obtain the permission of the beneficiary before any change can be made
Claim Forms
upon receipt of a notice of claim, the company must supply claims forms to the insured within a specified number of days
General Provisions - Insuring Clause
usually located on the first page of the policy, it identifies the insured and the insurance company and states what kind of loss (peril) is covered
Uniform Optional Provision - Other Insurance in this Insurer
when an insured purchases several polices with the same insurance company and over-insurers, this provision will apply. This provision provides for a pro rata benefit reducation and return of premium in the event of multiple policies with the same company when the benefits exceed a stated maximum
General Provisions - Renewability Clause - Conditionally Renewable
with a conditionally renewable policy, the insurer may terminate thecontract only at renewal for certain conditions that are stipulated in the contract
