Chapter 8 - Health Insurance Policy Provisions

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: optionally renewable conditionally renewable guaranteed renewable noncancellable

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? conditionally renewable noncancellable guaranteed renewable optionally renewable

guaranteed renewable

What is considered to be a characteristic of a Conditionally Renewable Health insurance policy? - premiums may increase at tine if renewal - premiums may increase at any time - policy may be renewed at the discretion of this insured - policy may be amended by insurer at any time

- premiums may increase at time of renewal

Which of the statements about a Guaranteed Renewable Health Insurance policy is CORRECT? - premiums normally decrease at the time of renewal - premiums normally increase at the time of renewal - policy can renewed at any time by the company - policy can be cancelled at any time by the category

- premiums normally increase at the time of renewal

What must the policyowner provide to the insurer for validation that a loss has occurred? - proof of coverage - proof of claim - proof of loss - proof of payment

- proof of loss

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? entire contract clause MIB clause Insuring clause consideration clause

consideration clause

Which of the following health policy provisions states that the producer does NOT have the authority to change the policy or waive any of its provisions? -time limit on certain defenses - reinstatement - entire contract - change of beneficiary

entire contract

Which of the following BEST describes a short-term medical expense policy? conditionally renewable noncancellable guaranteed renewable nonrenewable

nonrenewable

The provision that defines to whom the insurer will pay benefits to is called entire contract proof of loss claim forms payment of claims

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? Free-look reinstatement grace period consideration

reinstatement

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? The reinsurer the insured the insurer the guaranty association

the insured

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... insuring time limit on certain defenses grace period free look

time limit on certain defenses

The policy provision that entitles the insurer to establish conditions the insured must meet while a claim is pending is: grace period physical examination & autopsy entire contract time limit on certain defenses

time limit on certain defenses

Which Accident and Health policy provision addresses preexisting conditions? proof of loss legal actions time limit on certain defenses payment of claims

time limit on certain defenses

Which of the following statements describes what an accident and health policy owner may NOT do? - file a covered claim - assign ownership - cancel the coverage - adjust the premium payments

- adjust the premium payments

When does a Probationary Period provision become effective in a health insurance contract? - at the policy's inception - 30 days after the policy's inception - when a claim is submitted - when a covered loss occurs

- at the policy's inception = when policy goes into effect

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? - claim will be denied and policy terminated - claim will be partially paid - claim will be paid - claim will be denied

- claim will be denied

Which fo the following policy provisions prohibits an insurance company from incorporating external documents into an insurance policy? - waiver - exceptions and reductions - incontestable - entire contract

- entire contract

With Accidental Death and Dismemberment policies, what is the purpose of the Grace Period? - gives the policy owner additional time to pay overdue premiums - gives the policy owner additional time to file a lawsuit - gives the policy owner additional time to file a claim - gives the policy owner additional time to file proof of loss

- gives the policy owner additional time to pay overdue premiums

Which health policy clause specifies the amount of benefits to be paid? - insuring - consideration - free look - payment mode

- insuring

The clause identifying which losses resulting from an accident or sickness are insured by the policy is called the: - entire contract provision - consideration clause - benefit clause - insuring clause

- insuring clause

Which of the following health insurance policy provisions specifies the health care services a policy will provide? - insuring clause - usual, customary, and reasonable clause - consideration clause - benefit clause

- insuring clause

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 describes this policy is called: - non cancellable - conditionally renewable - cancellable - guaranteed renewable

- non cancellable = insurance company CANNOT cancel

What is the purpose of the time of payment of claims provision? - requires the insured to wait 60 days after submitting proof of loss before filing a lawsuit - prevents delayed claim payments made by the insurer - requires a probation period for each claim filed by the insured - protects the insurer from frivolous lawsuits

- prevents delayed claim payments made by the insurer

With Optionally Renewable Health policies, the insurer may: - renew the policy only if no claims have been filed the previous year - renew the policy only with the insured's consent - review the policy whenever they please and determine whether or not to renew it - review the policy annually and determine whether or not to renew it

- review the policy annually and determine whether or not to renew it

The insuring clause... - specifies the additional time given to pay past due premiums - states the scope and limits of the coverage - states the amount of premium to be collected - prohibits the insured from suing the insurer for at least 60 days after filing a written proof of loss

- states the scope and limits of the coverage

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? - Accidental death and dismemberment rider - disability income rider - guaranteed insurability rider - waiver of premium rider

- waiver of premium rider

If an individual has an Accidental Death and Dismemberment policy and dies, an autopsy can be performed in all these situations, EXCEPT: - when the cause of death is uncertain - when the state prohibits this by law - when consent for the autopsy is not obtained - when foul play was a contributing factor

- when the state prohibits this by law (some sates prevent )

An insurer must provide an insured with claim forms within __ days after receiving notice of a loss. 5 10 15 20

15 = under the claims forms provision, an insurer must provide an insured with claim forms within a MAX of 15 days after receiving a notice of loss

Insurers may request a hearing within ___ if their policy is rejected: 20 days 30 days 60 days 90 days

20 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? 7 10 20 31

31 day ... for policies paid for on an annual basis