Illinois Accident and Health Producer General Exam SIMULATOR

Which of the following types of organizations are prepaid group health plans, where members pay in advance for services of participating physicians and hospitals that have agreements

A Health Maintenance Organization (HMO) is a prepaid group health plan, where members pay in advance for the services of participating physicians and hospitals that have agreements.

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

20

And insured must notify and insurer of a medical claim within __ days after an accident

20 days

Insurer may request a hearing within ___ if their policy is rejected

20 days

Insurers may request a hearing within ______ days if their policy is rejected.

20 days

And 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

All of the following statements about major medical benefits are true, except

Benefits have no maximum limit

Which type of policy would pay An employee salary if the employer was injured in a bicycle accident and out of work for six weeks

Business overhead expense

What type of policy would only provide coverage for specific types of illnesses (cancer, stroke, etc)?

Dread disease insurance

Most prepaid dental plans cover

Oral examinations

What does a guaranteed insurability rider provide a disability income policy owner

The ability to periodically increase the amount of coverage without evidence of insurability

Group dental plans will frequently place a limit on annual benefits in order to minimize

adverse selection

A(n) ______ of benefits of a health policy transfers payments to someone other than the policyowner

assignment

P loses an arm in a farm accident and is paid $10,000 from his Accidental Death and Dismemberment policy. This benefit is known as the

capital sum

Jerry has an indemnity plan which covers dental expenses. Typically, these type of plans

cover preventative care once every six months

An accident policy will most likely pay a benefit for a(n)

off-the-job accident

P loses an arm in a farm accident and is paid $10,000 from his Accidental Death and Dismemberment policy. This benefit is known as the

capital sum Capital sum is the amount payable for the accidental loss of eyesight or for an accidental dismemberment. It is usually a percentage of the principal sum and varies according to the severity of the injury

Which of the following does restorative dental treatment cover

crowns

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

1 year

List some limited benefit plans

1. Dental policies 2. Critical illness policy 3. Cancer policy

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 records and determines that M has had asthma for many years. All of the following are probable underwriting outcomes

1. Deny coverage 2. Approve with higher premiums 3. Attach a rider excluding specified coverages

All of the following statements about major medical benefits are true

1. The deductible can be expressed as a fix dollar amount 2. the benefit period begins only after a specified amount of expensive have accrued 3. benefits are generally expressed as a percentage of eligible expenses

XYZ Company pays the entire premium for its group health plan. The MINIMUM percentage of eligible employees that must be covered is

100%

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 Health insurance will automatically be placed back in force if the insurer fails to notify an applicant within 45 days that the reinstatement application was denied.

And 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 in the policy

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

At the policy's inception

Long term care policies will Usually pay for eligible benefits using which of the following methods

Expense incurred Most long-term care policies pay on a reimbursement (or expense-incurred) basis, up to the policy limits.

Which of these is considered a true statement regarding Medicaid

Funded by both state and federal governments

Which of the following best describes how a policy that uses the "accidental bodily injury" definition of an accident differs from one that uses the "accidental means" definition

Less restrictive a policy that uses the "accidental bodily injury" definition of an accident is less restrictive than one that uses the "accidental means" definition

The provision in a group Health Policy that allows the insured to post pone coverage for a covered illness 30 days after the policies affect that day is referred to as the

Waiting period

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 records and determines that M has had asthma for many years. All of the following are probable underwriting outcomes, EXCEPT:

Changing the policy's provisions

Which of the following reimburses it's insureds for a covered medical expenses

Commercial insurers

Which of these is not considered a preventative service in a dental plan

Fillings (A Restorative Service. Oral Examinations, teeth cleaning, and fluoride treatments are preventative services).

T applied for a Disability Income policy and has a history of back injuries. The insurer issued the policy with a statement that excludes coverage for back injuries. This statement is called a(n)

Impairment Rider

The first portion of a Covered major medical insurance expense that the insured is required to paid is called the

Initial deductible

The clause in an Accident and Health policy which defines the benefit amounts the insurer will pay is called the

Insuring clause

The health insurance program which is administered by each state and funded by both the federal and state governments is called

Medicaid- is funded by both the federal and state governments and administered by individual states.

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

Payment of Claims provision

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

Payment of claims provision

Which Long Term Care insurance statement is true?

Pre-existing conditions must be covered after the coverage has been in force for six months

K is the insured and P is the sole beneficiary on a life insurance policy. Both are involved in a fatal accident where K dies before P. Under the Common Disaster provision, which of these statements is true?

Proceeds will be paid to P's estate

Which type of policy pays benefits to a policyholder covered under a Hospital Expense policy?

Reimbursement- When benefits are paid to a policyowner covered under a Hospital Expense policy, the policy is known as reimbursement.

J has an Accidental Death and Dismemberment policy with a principal sum of $50,000. While trimming the hedges, J cuts off one of his fingers. What is the MAXIMUM J will receive from his policy?

The maximum sum payable would be the capital sum, or $25,000.

A catastrophic Illness would be best covered by which of the following health insurance plans

major medical

Which of these circumstances is a Business Disability Buy-Sell policy designed to help in the sale of a business?

Business owner becoming disabled A Business Disability Buy-Sell policy is designed to assist in the sale of a business when one of the owners becomes disabled.

Health providers are compensated by a preferred provider organization (PPO) for normal dental procedures by what means?

Decreased fee schedules

Common exclusions to continuation of group coverage include

Dental care, other prescription drugs

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 Because S Failed to pay the premium within the policies 10 day grace period, the insurer will likely deny the claim

M is insured under a basic Hospital/Surgical Expense policy. A physician performs surgery on M. What determines the claim M is eligible for?

Determined by the terms of the policy

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?

Guaranteed renewable

Which of the the following are typically excluded from medical expense policies

Intentionally self inflicted injuries

Pre-hospitalization authorization is considered an example of

managed care

Z owns a Disability Income policy with a 30-day Elimination period. Z contracts pneumonia that leaves him unable to work from January 1 until January 15. Z then becomes disabled from an accident on February 1 and the disability lasts until July 1 the same year. Z will become eligible to receive benefits starting on

March 1st

Periodic health claim payment must be made at least

Monthly

Which of the following is covered by a basic dental indemnity plan

Non-surgical periodontal treatment

Which of the following actions is required by an insured who leaves the primary area of medical coverage and seeks medical care

Obtain prior approval from the insurer for the medical service

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, which of the following statements is TRUE?

She does NOT need to provide evidence of insurability Under COBRA, conversion of group accident and health coverage to an individual policy does not require evidence of insurability. However, this only applies during the cobra period. Once cobra laws expire enrollment in an individual policy requires evidence of insurability

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 A new employee must sign an enrollment card during the open enrollment period.

Which of the following costs with a basic hospital/surgical policy likely cover

Surgically removing a facial birthmark

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

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

R becomes disabled and owns an individual Disability Income policy. When is R eligible to receive disability benefits?

Upon satisfying the elimination period requirement

An Insurance company normally has 2 years to contest information provided on an accident and health application. This 2 year period begins on the date that the

insurer dates the policy

Which of these types of coverage is best described as a short term medical policy

interim coverage

Which of the following is not a limited benefit plan

life insurance policy

Which type of plan normally includes hospice benefits?

managed care plans