Policies Provisions

Wavers for impairments rider

An insurance company does not cover an insureds loss due to a preexisting condition however if the insurance condition improves the company may be willing to remove the waiver

Accumulations (or Accumulation Benefits)

An insurance company may add additional percentage to policy benefits when the contract is continuously renewed for example a 10% accumulation is emulation after 5 consecutive years of renewal the purpose of accumulation is to encourage ensure to always renew policies

Double Indemnity

A clause for the payment of twice the regular benefit if an Injury is sustained under certain specified circumstances this chances this is a more limited benefit than a double indemnity benefit under life insurance policies

Time limit on certain defenses/ incontestability

A policy is incontestable after has been enforced a certain period of time usually 2 years similar to the incontestable clause unlike life insurance a fraudulent statement on a health insurance application is ground current application is grounds for contest at any time unless the policy is guaranteed renewable The policy may not be voided the nightclaims are even reduced claim solely based on preexisting conditions

Physical exam and autopsy

A provision that allows an insurer, at its own expense, to have an insured physically examined when a claim is pending or to have an autopsy performed where not prohibited by law.

Misstatement of age

Allows the insurer to go back and make changes to the benefits so that they match the correct age o Benefits will be adjusted accordingly

Payment of claims

Must be payable to the insured payment of benefits directly to a hospital or provider of medical services if a death benefit is provided under a health insurance policy this provision provides for payment of benefits to a named beneficiary if a beneficiary is not named then a benefit will go to the insurance estate if the beneficiary is a minor then the insurer must pay benefits to another blood relative is blood relative or marriage the benefit amount may not exceed a 1000

Conversion privilege for dependence

October 1st 2010 the affordable health care act mandated that all policies and plans must provide dependent coverage for children up to age 26 adopted children stepchildren and Foster children usually are eligible for coverage

Reinstatement

Under certain conditions a policy that has elapsed may be reinstated Ryan Stevens automatic if the delinquent premium is accepted by the is is accepted by the company or is authorized agent If the insurer takes no action on the application for 45 days the policy is reinstated automatically

Waiver of premium

Waves the premium payments after the insured has been told to leave the sable for a specified period of time enormous waver waiver of premium provision has a 90 days waiting period Until premiums are waived. And a period In any case and insured insured recovers from the disability then the insurer must begin to pay premiums again if the insured remains disabled waiver premium provision will remain active until the insurance reaches the age 65

Time of payment of claims

- Provides for immediate payment of the claim after the insurer receives notification and proof of loss. - 45 days

Legal actions

- The insured cannot take legal action against the company in a claim dispute until after 60 days from the time the insured submits proof of loss. - A claimant must take legal action against the company within 5 years - 60 days - 5 years

Notice of Claim

- The policyowner's obligation to the insurer to provide notification of loss within 20 days after the occurrence (or as soon as is reasonably possible). - 20 days

Filing and approval of policy forms

-Accident and health insurance policies must be issued and approved by the commissioner -If the commissioner does not reject the policy within 90 days it is considered approved as is -Insurers may request a hearing within 20 days if their policy is rejected

Types of beneficiaries

-Primary 1st in line to receive death benefit proceeds -Secondary (contingent) 2nd in line to receive death benefit proceeds -Tertiary 3rd and align to receive death benefit proceeds if no one is named death benefit will go to ensured a state

Conformity with state statues

Any policy provision that is income flightwi state statues in the state where the insurance lives athere it lives at the time the policy is issued is automatically amended to conform with the minimum statutory requirements

Availability of coverage

Authorizes insurers to issue group health insurance policies to small employers 2 - 50

Owner's rights provision

Defines the person who may name and change beneficiaries, select options available under the policy, and receive any financial benefits from the policy.

Benefit payment provision

Describes how benefits will be paid out by the policy. Some benefits are paid as a lump sum reimbursements, lump sum and diminity periods, or as a periodic income benefit

Relation of earnings to insurance

If disability income benefits from all disability income policies for the same loss exceed the insured's monthly earnings at the time of disability, the relation of earnings provision states that the insurer is liable only for that proportionate amount of benefits as the insured's earnings bear to the total benefits under all such coverage

Unpaid premiums

If there is an unpaid premium at the time a claim becomes payable, the amount of the premium is to be deducted from the sum payable to the insured or beneficiary.

Insurance with other insurer

In attempting to deal with the potential problem of overinsurance, the insurance with other insurer provision states that benefits payable for expenses incurred will be prorated in cases where the company accepted the risk without being notified of other existing coverage for the same risk.

claim forms provision

Insurer is required to send you a claim form within 15 days after notice is received

Impairment rider (exclusion rider)

Is coverage waiver or a waiver of disability when attached to a disability when attached to a disability income contract it indicates that the insurer is accepting a greater risk since it may be unable to adequately assess the total risk the insurer decides to provide coverage for the individual will limit it with regard to the impairment involved (Can be issued with or without an extra premium charge)

Insuring Clause

Part of the health insurance policy that States any definitions requiredefinitions require the kind of benefits provided and the circumstances under which they will be paid

Proof of Loss provision

Policy owner has 90 days from date of loss to submit proof of loss to Insurer; valid claim must be paid immediately upon receipt.

Other insurance with this insurer provision

Protects the insurance company

Free look (Right to examine clause)

The free look provision allows applicant to inspect the policy after receipt and make a final decision about whether it meets their needs if the individual cancels during the free look. Any premium payment is refunded if the policy is canceled during the free look, the insurance policy the insurance policy is not liable for any claims originating during that period

Illegal occupation

The illegal occupation provision specifies that the insurer is not liable for losses attributed to the insured's being connected with a felony or participation in any illegal occupation.

Consideration clause

The insurance company exchanges the promises and the policy for a 2 part consideration from the insured consideration is an exchange of something of value on which a contract is basedThe insurance company exchanges the promises and the policy for a 2 part consideration from the insured consideration is an exchange of something of value on which a contract is based

change of beneficiary

The insured, as policyowner, may change the beneficiary designation at any time unless a beneficiary has been named irrevocably.

Intoxicance and narcotics

The insurer is not liable for any loss attributed to the insured while intoxicated or under the influence of narcotics

Other insurance with this insurer

The total amount of coverage to be underwritten by a company for one person is restricted to a specified amount regardless of the number of policies issued

Change of occupation

This provision also allows the insurer to reduce the maximum benefit payable under the policy if the insured switches to a more hazardous occupation or to reduce the premium rate charged if the insured changes to a less hazardous occupation

probationary period

is used to describe the period of time from the date the policy is issued during which no claims will be paid for Sickness Only. Usually this period of time is from 15 to 30 days. Used to avoid Adverse Selection (pre-existing conditions). This helps to protect the insurer against individuals who would purchase a disability policy shortly AFTER developing a health condition that requires immediate attention.

Cancellation

o The insured must be notified 45 days in advance and must be reimbursed for any prepaid premiums.The insurer must give 10 days written notice to the insured unless the premiums are due monthly or more frequently

Assignment provision

policy owner's right to assign the policy; 2 types: absolute assignment- transfer all rights of ownership, permanent, new policy owner doesn't need insurable interest in insured; collateral assignment- transfer of partial rights, usually done to secure a loan, partial and temporary 'til debt is repaid

Life Insurance Policy Provision

the amount the insured can borrow against a policy's cash value.