Health Insurance - Chapter 6: 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

guaranteed renewable

Periodic health claim payments MUST be made at least?

monthly

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

A disability income policy that only the policyowner can terminate and which the rates will never go up is considered to be?

noncancellable

The provision that defines to whom the insurer will pay benefits to is called?

payment of claims

What is considered a mandatory provision?

payment of claims

What is considered to be a characteristic of a Conditionally Renewable Health Insurance Policy?

premiums may increase at the time of renewal

The Legal Actions provision of an insurance contract is designed to do all of the following ?

provide the insurer adequate time to research a claim, protect the insured from having claim research delayed, give the insured guidelines for pursing legal action against an insurer

When an insurance company sends a policy to the insured with an attached application, the element that makes the application part of the contract between the insured and the insurer is called the

entire contract provision

The sections of an insurance contract which limit coverage are called

exclusions

An insured must notify an insurer of a medical claim within ___ days after an accident?

20 Days

M's insurance company denied a reinstatement application for her lapsed health insurance policy. The company did not notify M of this denial. How many days from the reinstatement application date does the insurance company have to notify M of the denial before the policy will be automatically placed back in force?

45 Days

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?

Consideration clause -- which is the full minimum premium and the statements made in the app

T owns an Accident & Health policy and notifies her insurance company that she has chosen a less hazardous occupation. Under the Change of Occupation provision, which of the following actions may her insurance company take?

Increase her policy's coverage amount

J, an Accidental Death and Dismemberment (AD&D) policy holder, dies after injuries sustained in an accident. J's age as stated on the application five years ago was found to be understated by ten years. Which of the following actions will the insurance company take?

The insurer will adjust the benefit to what the premiums paid who have purchase at the insureds actual age

What 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?

guaranteed renewable

What is the purpose of the Time of Payment of claims provision?

prevents delayed claim payments made by the insurer

Which of the following is considered to be the time period after a Health Policy is issued, during which no benefits are provided for illness?

probationary period

What must the policyowner provide to the insurer for validation that a loss has occurred?

proof of loss

The Legal Actions provision of an insurance contract is designed to do all of the following EXCEPT

protect the producer

insurers may request a hearing within ________ if their policy is rejected

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?

31 Days

A disability income policyowner recently submitted a claim for a chronic neck problem that has now resulted in total disability. The original neck injury occurred before the application was taken 5 years prior. The neck injury was never disclosed to the insurer at the time of application. How will the insurer handle this claim?

Claim will be paid and coverage will remain in force. (after 2-3 years policy's enter into the incontestable period, where insurer cannot deny a claim based on info not disclosed at time of app!)

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?

Reinstatement

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?

Waiver of Premium Rider

In health insurance policies, a waiver of premium provision keeps the coverage in force without premium payments:

after an insured has become totally disabled as defined by the policy

what is included in the policy face?

free look provision, name of the insurer, name of the insured

Which provision specifies how long a policyowners health coverage will remain in effect if the policyowner does not pay the premium when it is due?

grace period

What is the initial requirement for an insured to become eligible for benefits under the waiver of premium provision?

insured must be under a physicians care

If an individual is covered under an accidental death policy and dies, an autopsy can be performed EXCEPT when?

the state prohibits this by law

The policy provision that entitles the insurer to establish conditions the insured must meet while a claim is pending is

time limit on certain defenses

Which Accident and Health policy provision addresses preexisting conditions?

time limit on certain defenses

what is not included in the policy face?

exclusions

what accurately describes the waiver of premium provision in an accident and health policy?

premiums are waived after the insured has been totally disable for a specific period of time

The insuring clause does what?

states the scope and limits of the coverage

With Optionally Renewable Health policies, the insurer may

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