Health Policy Provisions, Clauses, and Riders

Under the uniform required provisions, proof of loss under a health insurance policy normally should be filed within

90 days of a loss

which provision allows the policyholder a period of time, while coverages is in force, to examine a health insurance policy and determine whether or not to keep it?

Free look period

In respect to the consideration clause, which of the following is consideration on the part of the insurer?

promising to pay in accordance with the contract terms

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

rates by class

an insured has endured multiple surgeries and hospitalizations for an illness during the last few months. her insurer no longer bills her for medical expenses. which of the following allows for that?

stop-loss limit

which of the following terms describes the specified dollar amount beyond which the insured no longer participates in the sharing of expenses?

stop-loss limit

How soon following the occurrence of a covered loss must an insured submit written proof of such loss to the insurance company?

within 90 days or as soon as reasonably possible, but not to exceed 1 year

An insured pays a monthly premium of $100 for her health insurance. What would be the duration of the grace period under her policy?

10 days

the section of a health policy that states the causes of eligible loss under which an insured is assumed to be disabled is the

Insuring Clause

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

If the insured under a disability income insurance policy changes to a more hazardous occupation after the policy has been issued, and a claim is filed, the insurance company should do which of the following?

adjust the benefit in accordance with the increased risk

when an insured purchased her disability income policy, she misstated her age to the agent. she told the agent that she was 30 years old, when in fact, she was 37. if the policy contains the optimal misstatement of age provision

amounts payable under the policy will reflect the insureds correct age

the premium charged for exercising the Guaranteed insurability rider is based upon the insureds

attained age

the provision that provides for the sharing of expenses between the insured and the insurance company is

coinsurance

a waiver of premium provision may be included with which kind of health insurance policy?

disability income

An insured is hospitalized with a back injury. Upon checking his disability income policy, he learns that he will not be eligible for benefits for at least 30 days. This indicates that his policy is written with a 30-day

elimination period

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

exclusions

which of the following riders would NOT increase the premium for a Policyowner?

impairment rider

in the event of loss, after a notice of claim is submitted to the insurer, who is responsible for providing claims forms and to which party?

insurer to the insured

With respect to the consideration Clause, which of the following would be considered consideration on the part of the applicant insurance?

Payment of Premium

which of the following does the insuring Clause NOT specify?

A list of available doctors

a man is injured while robbing a convenience store. How does his major medical policy handle the payment of his claim?

Claim is denied if his policy contains the illegal occupation provision

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

Monthly

which of the following statements is true regarding coinsurance?

The larger the percentage that is paid by the insured, the lower the required premium will be

a policy with a 31-day grace period implies

The policy will not lapse for 31 days if the premium is not paid when due

In a group health policy, a probationary period is intended for people who

join the group after the effective date

a guaranteed renewable health insurance policy allows the

policyholder to renew the policy to a stated age, with the company having the right to increase premiums on the entire class

Under a health insurance policy, benefits, other than death benefits, that have not otherwise been assigned, will be paid to

the insured

Insured Z's health insurance policy year begins in January. His policy contains a carry-over provision. In November, he has a small claim which is less than his deductible. Which of the following is true?

the insured may carry her the amount of this year's expenses to next year, which will help satisfy next years deductible

When Linda suffered a broken hip, she notified her agent, in writing, within 12 days of the loss. However, her agent did not notify the insurance company until 60 days after the loss. Which of the following statements correctly explains how this claim would be handled?

the insurer is considered to be notified since the notification to agent equals notification to the insurer

which of the following is NOT a feature of a noncancellable policy?

the insurer may terminate the contract only at renewal for certain conditions

which of the following is true regarding elimination periods and the cost of coverage?

the longer the elimination period, the lower the cost of coverage

the insuring clause of a disability policy usually states all of the following EXCEPT

the method of premium payment

when an insurer issues an individual health insurance policy that is guaranteed renewable, the insurer agrees

the renew the policy until the insured has reached age 65

according to the rights of renewability rider for cancellable policies, all of the following are correct about the cancellation of an individual insurance policy EXCEPT

unearned premiums are retained by the insurance company

Under the Physical Exam and Autopsy provision, how many times can an insurer have the insured examined, at its own expense, while a claim is pending?

unlimited

a medical expense policy that establishes the amount of benefit paid based upon the prevailing charges which fall within the standard range of fees normally charged for a specific procedure by a doctor of similar training and experience in that geographic area is known as

usual, customary and reasonable