Health Insurance Exam

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T calls to file a claim on his health insurance policy. Within how many days must the insurer provide T's proof of loss forms?

15 days

when an employees coverage terminated under a group health policy, the employee must be offered continuation coverage for:

18 months

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

20

renewing a producers license requires __ hours of continued education every 2 years

24

Under the affordable care act (ACA), health coverage is provided for dependents up to the age of

26

insurance policies are offered on a "take it or leave it" basis, which makes them:

contracts of adhesion

when an employee is required to pay a portion of the premium for an employer/employee group health plan, the employee is covered under which of the following plans?

contributory

a business overhead expense policy:

covers business expenses such as utilities and rent

the section of an insurance contract which limit coverage are called

exclusions

What is the reimbursement of benefits for the treatment of a beneficiary's injuries caused by a third party

subrogation

if a producer completes an insurance application, collects the initial premium, and issues the appropriate receipt ...

coverage will be contingent upon the insurer's underwriting policies

Circulation of a maliciously critical statement about any insurer's financial condition to injure the insurer is called:

defamation

S is the policyowner of a Major Medical policy. The premiums are paid monthly and due on the 1st of each month. S fails to make September's payment and is hospitalized October 15th. When S files the claim for this hospitalization, the insurer will likely:

deny the claim

what is an example of misrepresentation

describing a universal life policy as a security

what contact permits the remaining partners to buy-out the interest of a disabled business partner

disability buy-sell

K becomes ill after traveling overseas and is unable to work for 3 months. What kind of policy would cover her loss of income?

disability income

in the event of an illness, a _____ _____ policy would reimburse an insured for loss of earnings/income

disability income

how would you inaccurately describe the tax treatment of premiums and benefits of individual accident and health insurance

disability income policy premiums are tax-deductible

a catastrophic illness would be best covered by which health insurance plan

major medical

under a guaranteed renewable health policy the insurer:

may cancel the policy for nonpayment only

the primary difference between the CO partnership LTC policy and other LTC policies is

medicaid asset protection

a verbal or written statement which misleads a policy's features, benefits, or coverage is considered:

misrepresentation

what is considered a mandatory provision

payment of claims

P is a new employee and will be obtaining non-contributory group Major Medical insurance from her employer. Which of the following actions must she take during the open enrollment period?

sign an enrollment card

Which mode of payment is NOT used by health insurance policies?

single premium

how are group accident and health policies issued to an employer

the employer will receive the policy and employees receive a certificate

a company that has not been authorized to operate in CO is known as

a non-admitted insurer

P received Disability income benefits for 3 months then returns to work. She is able to work one month before her condition returns, leaving her disabled once again. What would the insurance company most likely regard this second period of disability as?

a recurrent disability

a "reimbursement policy" pays what amount of covered long-term care expenses

actual covered expenses up to the daily limit

what type of care isn't covered in a long-tern care policy ~acupuncture ~skilled care ~home health care ~custodial care

acupuncture

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

after the insured has become totally disabled as defined in the policy

Under what circumstance will the benefits under COBRA continuation coverage end?

all group health plans are terminated by the employer

what is not required to be disclosed to an applicant for health insurance

any contingent compensation received

an applicant's medical information received from the MIB may be furnished to the

applicants physician

what is the initial source of underwriting for an insurance policy

application containing statements from the insured

When does a Probationary Period provision become effective in a health insurance contract?

at the policy's inception

B's policy provides coverage on an in-hospital basis only and contains a limited daily room and board benefit. Which of these policies does B have?

basic hospital

what type of policy would pay an employee's salary if the employer was injured in a bicycle accident and out of work for six weeks

business overhead expense

a health reimbursement arrangement must be established

by the employer

what policy feature allows an insured to defer current health charges to the following year's deductible instead of the current year's deductible

carryover provision

S wants to open a tax-exempt Health Savings Account. To qualify for this type of account, Federal law dictates that S must be enrolled in a

high-deductible health plan

paying insurance premiums on a more frequent basis will cause the policy to have

higher premiums

all accident and health policies issued in CO that provide major medical services must offer policyholders the opportunity to purchase

home health care coverage

T sends proof of loss to her insurer for an acceptable medical expense claim under her individual Health Insurance policy. Upon receipt, the insurer must pay the benefits

immediately

The first portion of a covered Major Medical insurance expense that the insured is required to pay is called the

initial deductible

Information obtained from a phone conversation to the proposed insured can be found in which of these reports?

inspection report

what is not a required provision for an accident and health policy

insurance with other insurers

what information is not included in the CO supplement to the summary of benefits and coverage form

insurer's prior year financials

The ___ clause identifies which losses resulting from an accident or sickness are insured by the policy

insuring

Which health policy clause specifies the amount of benefits to be paid?

insuring

Stranger originated life insurance (STOLI) has been found to be in violation of which of the following contractual element?

legal purpose/ insurable interest

an insurer can deny a claim under a long-term care insurance policy for any material misrepresentation made by the insured if it has been in effect for

less than 6 months

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 desribes this policy is called

noncancellable

J has a Disability Income policy that does NOT provide benefits for losses occurring as the result of his employment. What kind of coverage is this?

nonoccupational coverage

In an insurance contract, the insurer is the only party who makes a legally enforceable promise. What kind of contract is this?

unilateral

R has become disabled and owns an individual disability income policy. When is R eligible to receive disability benefits

upon satisfying the elimination period requirement

which of the following phrases refers to the fees charged by a healthcare professional

usual, customary, and reasonable expenses

a business overhead expense policy covers what id a business owner becomes disabled

utilities and office rent

The commissioner may issue an emergency cease and desist order without a hearing for all of these circumstances EXCEPT ~selling insurance w/o a license ~engaging in fraudulent activity ~endangering the public ~writing controlled business

writing controlled business

All of these are characteristics of a health reimbursement arrangement (HRA) EXCEPT ~it is entirely funded by the employee ~it is entirely funded by the employer ~reimbursement for eligible medical expenses are allowed ~it can be offered with other health plans

HRA's are not entirely employee funded - they are employer funded

a life insurance arrangement which circumvents insurable interest statutes is called:

Investor-originated life insurance

what parts of a health insurance policy are guaranteed to be true

warranties

a producer who violates a cease and desist order may, after a hearing, be fined up to

$500

Under what system do a group of doctors and hospitals in a designated area contract with an insurer to provide services at a prearranged cost to the insured?

PPO (preferred provider organization)

the insuring clause:

States the scope and limits of the coverage

M applies for a health insurance policy and pays the initial premium. When the agent completes the application, a conditional receipt is left with the applicant. The insurance company's underwriting department request's M's medical record and determines that M has had asthma for many years. What will not be probable underwriting outcome

changing the policys provisions

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?

claims will be denied

the situation in which a group of physicians are salaried employees and conduct business in an HMO facility is called:

closed panel

How to best describe a hospital indemnity policy?

coverage that pays a stated amount per day of a covered hospitalization

An agent takes an individual Disability Income application, collects the appropriate premium, and issues the prospective insured a conditional receipt. The next step the insurance company will take is to

determine if the applicant is an acceptable risk by completing standard underwriting procedures

M becomes disabled and is unable to work for six months. M dies soon after from complications arising from this disability. M has a Disability Income policy that pays $2,000 a month. What BEST describes what is owed to her estate?

earned, but unpaid benefits

what health provision best describes: "a producer does not have the authority to change a policy or waive any of its provisions"

entire contact provision

what is not included in the policy face

exclusions

long term care policies will usually pay for eligible benefits using which of the following methods

expense incurred

insurer's must advise applicants in writing that an investigative consumer report may be conducted according to the

fair credit reporting act

This type of deductible provision waives the deductible for all family members after some of them have satisfied individual deductibles within the same year:

family maximum deductible

with AD&D policies what is the purpose of the grace period

gives the policyowner additional time to pay overdue premiums

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

Generally how long is a benefit period for a major medical expense plan

one year

the benefits under a disability buy-out policy are

payable to the company or another shareholder

The insured and the insurance company will share the cost of covered losses under which health policy feature

payment of claims provision

what coverage exclusions or limitations is permitted under a long-term care policy issued in CO

preexisting conditions

what is true about guaranteed renewable health policies

premiums normally increase at time of renewal

T is covered by two health insurance plans: a group plan through his employer and his spouse's plan as a dependent. When T submits a claim, his employer's plan is considered what type of carrier under the Model Group Coordination of Benefits provision?

primary carrier

what is the consideration given by an insurer in the consideration clause of a life policy

promise to pay a death benefit to a named beneficiary

with optionally renewable health policies the insurer may:

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

D is an architect receiving Disability Income benefits who is not able to return to work full time, but can work on a part-time basis. Which of these features would allow D to continue receiving benefits?

residual benefit clause

A prepaid application for and individual disability income insurance was recently submitted to an insurer. When the insurer received the medical information bureau (MIB) report, the report showed that the applicant had suffered a stroke 18 months age, something that was not disclosed on the application. What action would the insurance company not take.

send a notice to the MIB that the applicant was declined

P is an employee who quits her job and wants to convert her group health coverage to an individual policy. After the expiration of COBRA laws, what is TRUE?

she will need to provide evidence of insurability

the percentage of an individual's primary insurance account (PIA) determines the benefits paid in which of the following programs?

social security disability income

In regards to maternity care, which of the following is not required to be covered in the State of Colorado?

standard newborn circumcision

Why must an accident & health insurance applicant answer all questions on the application?

statements and representations on the application are part of the consideration for issuing a policy

What should an insured do if the insurer does not send claims forms within the time period set forth in a health policy's Claims Forms provision?

submit the claim in any form

Under an individual health insurance policy, the time limit on certain defenses provision states that nonfraudulent misstatements first become incontestable two years from ...

the date the policy was issued

the ____ period is considered to be the time period after a health policy is issued, during which no benefits are provided for illness

the probationary period

What actions can an insurance company not take to insure a substandard applicant for disability income coverage?

they cannot lengthen the contestability period

essential benefits without annual and lifetime limits are required on any health policy purchased ...

through the federal marketplace

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

time limit on certain defenses

What is the elimination period of an individual disability policy?

time period a disabled person must wait before benefits are paid

what is the purpose of coordination of benefits (COB) provision

to avoid duplication of benefit payments


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