AD Banker Health Insurance

Contract of Adhesion

1 party writes the contract with NO input from the other party. "Take it or leave it"

What is an association ?

100 members having a purpose other than buying insurance

For Group Insurance the employer with a self funded plan can hire a ?

3rd Party Administrator

Small employer , how many employees to be considered ? (Not AZ)

50 or less

What's a broker ?

A licensed person who works on behalf of applicant

Conditional Contract

Both parties must follow rules to make contract enforceable

(FCRA) Who informs the applicant about credit report ?

Consumer reporting Agency

In Medicare it has expanded to any age who have been

Diagnosed with chronic or permanent kidney failure n end stage renal disease Social Security Income for 24 months

Actuarial

Gather statistical info + determines probability of loss and set premium rates

Difference between Loss , Peril, Hazard

H - condition that increases loss P - cause of loss ex: fire windstorm L - reduction/decrease of value.

In an emergency situation get in contact with a

HMO

What's an Optional Uniform Provisions

It's to protect the insurer and included at the insurer's

Difference between Basic Expense and Major Expense

Major benefits provides for BIG illness while basic is like non emergency benefits -Medical,Hospital,Surgical

What's the difference between Private and Government Insurers ?

Majority is Private. Goverment is more like a help of aide.

What's another Title for Medicare Part C + what plans do they include

Medicare advantage HMO / PPO / Private Fee for Service Plans n Special Needs

Do you have to pay a premium for part A?

No but you have to pay a deductible

What are the Policy Renewal Provisions ?

Non cancellable - rates never increase , insurer cannot change the plan Guaranteed Renewable - no proof of insurability Conditionally Renewable - specific conditions to renew Optionally Renewable - insurer decides to renew Cancellable - lowest premium paid InsurER can cancel at anytime Period of Time - policy written only for a certain period of time

Adverse Selection example

Only those living in earthquake prone areas, seek to buy earthquake insurance OR those in the poorest of health seeking to acquire life/health insurance

What words can't you use in advertising

Only, Just, Merely, Minimum (words that describe restrictions)

What is a physician certification for LTC

Stating that the patient is ill and needs long term care

If a policy is issued based on an incomplete application it's assumed that

The insurer waives the right to challenge a claim based on incomplete application

ERISA

Think mother Teresa , provides benefits by using funds

What is the purpose of the Fair Credit Reporting Act ?

To determine the financial and moral status of applicant

For advertising you have to name the source T/F

True

Short Term Medical is for People when they need quick insurance because of loss of employment T/F

True

Subrogation

When a claim is paid by insurer but they can take legal action because of a dangerous 3rd party

Disability Income insurance is

When you are working but you might get hurt or sick outside of work, you can purchase a disability income policy

For Medicare Supplement application form T/F Does a question about replacement have to appear ?

Yes it does True

Individual disability benefits are based off

of % of income

Difference between Moral And Morale Hazard

Moral - dishonest ex insured burns down their house to collect insurance payout. Morale - attitude of confusion toward loss that increase chance of loss ex ignoring stop sign, not wearing seatbelt.

What does insurability mean ?

Applicant could meet insurERs underwriting requirements

Does the agent report come part of the contract?

No it remains confidential

For Medicare supplement, Can pre-existing conditions be excluded from coverage ?

No they can not

Do basic plans have a deductible?

No they don't

To qualify long term care

Policy has to be guaranteed renewable

Difference between Preferred / Standard / Substandard Risssssk

Preferred - lower rate Standard - rate as quoted Substandard - coverage as was but a higher premium

How do you get a conditional receipt

Premium is paid at time of application

If you lose limbs or a limb what 2 sums are those ?

Principal sum (head of school 100%) Capital sum (50% dismemberment)

Difference between Private and Government

Private is commercial companies that sell to the public Government is Social Security, Medicare, Medicaid, Tricare

Characteristics of Disability Income Policy

Probationary - Elimination - specific amount of time disabled before benefits kick in Benefit - amount of time you can receive payments

Underwriting

Process of classifying, rating a risk for the purpose of ya or nay on insurance coverage.

Who's responsibility is it to make sure the application is filled out completely

Producer

What are Mandatory Uniform Provisions ?

Provisions that must be included in every individual Accident n Health insurance policy.

With Group underwriting, what's the difference in Experience n Community rating ?

Experience is in the history of claims of group (the past) Community is examining particular geographic region

Fiduciary

A Legal trust between 2 or more parties , handles money for another person when dealing with premiums.

Policy Renewal Provisions means

A healthy policy with conditions to make sure coverage is continuous.

What is a multiple indemnity rider

A rider that provides additional benefits to an insurance policy for losses due to an accident.

There's 12 Mandatory Uniform Provisions

Entire Contract Clause Time Limit on Certain Defenses (incontestable) Grace Period Reinstatement Notice of Claim (within 20 days) Claim Form Provision (within 15 days) Proof of Loss (within 90 days) Time of Payment of Claims (immediately) Payment of Claims Physical Exam / Autopsy Legal Actions (wait 60 days) Change of Beneficiary

Difference between Occupational n Nonoccupational for qualifying benefits

Occupational covers disability due to injury n sickness on or off the job No occupational covers disability OFF the job only

Dental Care Titles Difference between Preventive / Basic / Major

P - routine check ups, X-rays, cleaning B - fillings, periodontics, root canals M - crowns, dentures, bridge work, ortho

Which parts of Medicare are Federal Government n Private Insurance providers ?

Part A Hospital (government) Part B Medical Insurance n Outpatient expenses (government) Part C combo A n B (private insurance providers) Part D Prescription drug coverage (private insurance providers)

What does principal of indemnity mean

Prenup you get the money that you had before marriage.

Blue Cross n Blue Shield are

Prepaid plans and have an agreement with physicians

What treatments have to do with Ambulatory Care ?

Preventative care Health education Family Planing Dental/vision

HMO is similar to Blue Cross because of prepaid but they focus on what?

Prevention care and members pay a copayment

What reduces medical expenses in a HMO

Preventive medicine through physical exams n diagnostic procedures Reducing # of unnecessary hospital admissions

Legal interpretations Affecting Contracts are (9)

Principal of Indemnity- prenup Utmost of Good faith Representations Misrepresentations Warranties - guaranteed true Concealment - holding back of material fact Fraud - intentional deception Waiver Estoppel -judicial denial

Medicare Part B exclusions for example

Prescription Drugs / Long Term Care

Long term care exclusions can be..

Acute care Rest cures Intentionally self inflicted injuries Mental disorders Injury arising out of committing a felony

Other Standard Provisions and Clauses for Individual n Group Insurance Contracts

Right to Examine (Free Look) Insuring Clause - insured /insurer / amount of coverage Consideration Clause - promise to pay premium Owner's Right Pre-existing Condition Provision Probationary Period Elimination Period Wavier of Premium 1st DollarCoverage Coordination of Benefits Eligible Expense Military Suspension Provision

With Basic Health Insurance Policy the hospital expense pays for what kind of room and board ?

Semi-private

Part A includes the following coverage like rooms blood? What kind

Semi-private room n board Operating room cost Prescription drug + anesthesia Hospital supplies Blood AFTER 1st 3 pints

Difference between individual n Group

Single person purchase insurance for family, not dependent on employer. Most expensive, require proof of insurability. Group has Employer sponsored, underwriting the whole group then that makes the average premium. Proof of insurability not required.

What are Long Term Facilities n Levels of care ?

Skilled Nursing Care - 24 hr supervised nurse Intermediate care - daily care provided by licensed medical professional Custodial care - non medical care with assistance

T/F Producers must report any material facts that may affect underwriting ?

True

For Cobra , how many employees for cobra to work ?

20 or more

How many people for a group health plan to be primary ?

20 people

Who is required to report any activity of laundering money ?

Agents/Brokers

Prepaid is like an

All you can eat buffet

What are the 10 Optional Uniform Provisions

Change of Occupation Misstatement of Age Other Insurance with this Insurer -more than 1 policy with same insurance Insurance with Other Insurers - has a same policy with different insurance companies Relationship of Earnings to Insurance Unpaid Premiums Conformity with Statue Statues Illegal Occupation/Act Intoxicants and Narcotics Cancellation - with written notice

There's 3 different Authorities, What are they ? + meaning

EIA) Express Implied Apparent

Aleatory Contract

Exchange of value is unequal

Who oversees the operation of management

Executives

What is coverage based on

Financial loss due to an accident , sickness or death.

Misstatement of material fact by a person who knows or believe that statement to be false

Fraud/ Fraudulent Act

2 Types of Policies for Disability Income Insurance

Indemnity Policy - pays an income benefit 60% Income Replacement Policy - receive benefits because of loss of income due to an accident

What does guaranteed renewable mean

Insurer has to keep giving coverage as long as premium is still getting paid

Part A provides coverage for inpatient charges +

Skilled nursing, home health care and hospice

Worker compensation benefits are mandated by

The state

An insurable interest must exist at the time of

Application

Limited Policies like Accidental Death n Dismemberment How many days within the date of accident that they will get a prin or cap SUM?

90days

For employer group insurance, after waiting period , how many days does Employee have to enroll ?

30 days

If the employee gets 100% for group disability then what does spouse and kids get ?

50%

Part A coverage up to how many days ?

90 days 1-60 fully covered 60-90 copayment

For Dental scheduled means _______ and non schedule means _______

Basic and Comprehensive plans

What are 6 of activities of daily living ?

Bathing/Continence/Dressing/Eating/Toileting/Transferring

Dental care types Endodontics - Orthodontics - Periodontics - Prosthodontics -

E - root canals O- teeth alignment P - gum problem n disease P - bridgework dentures

A long-term care policy may only be canceled how?

By the insurer for nonpayment of premium

A legal contract has 4 elements between the parties

Competent Parties Legal Purpose Agreement (offer-acceptance) Consideration (exchange of money for a promise)

What's the difference between contributory and noncontributory?

Contributory plans is when 75% participation to pay premium from employees n employer Non plans means 100% participation from employer

Gramm-Leach-Bliley Act has to do with?

In insurance it's about a privacy notice

Domestic is same state Foreign is another state Alien is outside of US so what's non/admitted insurer ?

Is an insurer approved or authorized to write business in the specific state.

What does Ambulatory have to do with anything ?

It's facilities that care about cost effectiveness of outpatient services

Medical Info Bureau

It's not for profit , service for underwriting Help lower cost of insurance

Difference between Supplemental Major Medical and Comprehensive Major Medical Policy ?

Supplemental covers when the basic plan is exhausted into a Major plan with a mandatory Corridor deductible. Comprehensive is when the coverage has both Basic n Major in 1 single policy.