Accident and Health Insurance Provisions

If the insured pays a monthly premium for health insurance, how long would the grace period be on the policy?

10 days

Which of the following does the Insuring Clause NOT specify? A. A list of available doctors B. Covered perils C. The insurance company D. The name of the insured

A

Which of the following entities has the authority to make changes to an insurance policy? A. Insurers executive officer B. Department of insurance C. Broker D. Producer

A

Under the mandatory uniform provision Notice of Claim, the first notice of injury or sickness covered under an accident and health policy must contain

A statement that is sufficiently clear to identify the insured and the nature of the claim.

Will claims be paid for injury or sickness resulting from an insured's intoxication?

An insurer is not liable for any injury or sickness claim resulting from intoxication. However treatment for substance abuse may be covered.

According to the Time Limit on Certain Defenses provision in health insurance policies, when can an insurer contest fraudulent misstatements on a health insurance application?

Any time while the policy is in force

What is the maximum period of time during which an insurer may contest fraudulent misstatements made in a health insurance application?

As long as the policy is in force

The insuring clause of a disability polish usually states all of the following EXCEPT A. The types of losses covered B. The method of premium payment C. The identities of the insurance company and the insured D. That insurance against loss is provided

B

Which of the following provisions requires that any policy language that is in conflict with the state statutes of the state in which the insured resides is automatically amended to conform with those of the state of residence? A. Legal actions B. Conformity with state statutes C. Incontestability D. Insurance with other insurers

B

What is the name of the act by the insured to voluntarily give up insurance?

Cancellation

How will changing one's occupation to be more hazardous affect the health insurance policy in force?

Claim benefits will be reduced to what the premium would have bought for a more hazardous occupation

What health policy provision allows the insurer to non renew health coverage if certain events occur?

Conditionally renewable

An applicant for an individual health policy failed to complete the application properly. Before being able to complete the application and pay the intitularse premium, she is confined to a hospital. This will not be covered by insurance because she has not met the conditions specified in the

Consideration clause

An insured has medical insurance coverage through two different providers, both covering the same expenses on an expense-incurred basis. Neither company knows in advance that the insured has coverage through any other insurers. The insured submits a claim to both. How should the claim be handled?

Each insurers should pay a proportionate share of the claim.

Items stipulated in the contract that the insurer will not provide coverage for are found in the

Exclusions

What is the consideration clause usually located in the policy?

First page

What health policy provision allows the insured a period of time to examine the policy and determine whether or not to keep it?

Free-look period

Which renewal provision gives the insured the right to renew the policy for the life of the contract but allows the insurer to alter premiums?

Guaranteed renewable

How does the premium mode affect the total premium paid for insurance for the year?

Higher frequency of premium payments will result in higher premiums

What is identified in the insuring clause?

Identifies the insured and the insurance company

If the insured misstates his/her age, how will benefits be paid?

If the insured misstated his or her age at the time of the application, the benefits paid will be those, which the premium paid, that would have been purchased at the correct age.

What are the grace periods for an individual policy?

In most cases the grace period can be not less than 7 days for weekly pay policies (industrial policies), 10 days for monthly pay policies, and 31 days for all other modes.

A nonpayment of premiums may result in

Lapsed policy

In what way could changing your a more dangerous occupation affect a persons insurance policy?

More hazardous- benefits will be reduced to that which premiums paid would have purchased assuming the more hazardous occupation

When an individual needs to file a health insurance claim, what are his/her responsibilities?

Notice is required within 20 days of the loss, or as soon as reasonably possible.

What health policy provision defines the insured's duty to provide the insurer with reasonable notice in the event of a loss?

Notice of Claim

Who has the authority to change a policy provision?

Only an executive officer of the company, not an agent, has authority to make any changes to the policy.

What is the difference between a conditionally renewable policy and one whose renewability is optional?

Optional renewability is similar to conditional renewability, except that the insurer may cancel the policy for any reason whatsoever

What health policy renewability provision allows the insurer to terminate coverage for any reason, and to increase the premiums for any class of insureds?

Optionally renewable

What health policy provision states to whom the claim benefits must be paid?

Payment of Claims

Rose bought three policies from the same insurer. Her benefits have exceeded the maximum allowed by the insurer. Which of the following will happen?

Pro rata benefit reduction

Insurers may change which of the following on a guaranteed renewable health insurance policy?

Rates by class

What provision can reduce the disability benefit based upon the insureds current income?

Relation of Earnings to Insurance

What health policy provision describes the insured's right to cancel coverage?

Renewability provision

What does the free look period allow the insured to do?

Return the policy for a full refund of premium within a specified time period (usually 10 days)

The insured on a health policy misstated his age on the insurance application. If this misrepresentation is discovered, what will happen to the policy?

The benefit amount payable under the policy will be adjusted to the insured's correct age.

If a premium has not been paid by the end of the grace period, what will happen to the policy?

The grace period is 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.

What is the difference between guaranteed renewable and non-cancelable policy?

The guaranteed renewable policy is similar with the exception that the insurer can increase the policy premium on the policy anniversary date.

An insured submitted a notice of claim to the insurer, but never received claims forms. He later submits proof of loss, and explains the nature and extent of loss in a hand-written letter to the insurer. Which of the following would be true?

The insured was in compliance with the policy requirements regarding claims.

What will determine the length of the grace period in a health insurance policy?

The mode of the premium payment

What is included in the "entire contract"?

The netire contract provision states that the health insursnce policy, together with a copy of the signed application and any attsched endirsements, constitutes the entire contract.

Which provision states to whom the claims are to be paid?

The payment of claims provision specifies to whom claims payments are to be made

If a health insurance policy has a 31-day grace period, what does that mean?

The policy remains in effect for 31 days after the premium is due and not paid

What will happen to a health insurance policy if the premium has not been paid by the end of the grace period?

The policy will be cancelled

What does the "other insurance with this insurer" provision try to protect against?

This provision provides for a pro rats benefit reduction and return of premium in the event of multiple policies with the same company when the benefits exceed a stated maximum.

An insured notified the insurance company that he has become disabled. What provision states that claims must be paid immediately upon written proof of loss?

Time of payment of claims

When can an irrevocable beneficiary be changed?

With the written consent of the beneficiary

According to the Reinstatement provision, once a lapsed policy is reinstated, how soon will coverage be available for accidents?

immediately

Who decides which optional provisions would be included in a health policy?

insurance company

Who pays the expense for an autopsy under the physical examination and autopsy provision?

insurer

What health policy provision prevents the insured from bringing a lawsuit against the insurance company for at least 60 days after proof of loss is provided?

legal actions

Under an individual disability income policy, the benefits must be paid on at least what schedule?

monthly

Under an individual disability policy, the MINIMUM schedule of time in which claim payments must be made to an insured is

monthly

What renewability provision will most likely appear on a travel accident policy?

period of time