6 Health Policy Provisions

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

15 [days]. Under the Claims Forms provision, an insurer must provide an insured with claim forms within a MAXIMUM of 15 days after receiving notice of a loss.

According to the Mandatory Uniform Policy Provisions, what is the maximum amount of time after the premium due date during which the policy remains in force even though the premium has not been paid?

31 days. In this question we are looking for time factor, which it does not gives it. So we look at the word 'maximum' to get the hint. According to the Mandatory Uniform Policy Provisions, the maximum amount of time after the premium due date during which the policy remains in force even though the premium has not been paid is 31 days.

Which of the following statements describes what an Accident and Health policy owner may NOT do?

Adjust the premium payments. Because the owner of an Accident and Health policy may not change the premium amount.

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

At the policy's inception. The probationary period begins when a policy goes into effect. During this period, no benefits will be paid under the policy.

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. Because After a policy has been in force for 2 (sometimes 3) years, it enters the incontestable period, in which the insurer may not deny a claim based on information not disclosed at the time of application.

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. A health insurance contract is valid only if the insured provides consideration in the form of the full minimum premium and the statements made in the application.

Which health policy clause stipulates that an insurance company must attach a copy of the application to the policy to ensure that it is part of the contract?

Entire Contract The Entire Contract provision states that the health insurance policy, together with a copy of the signed application and attached riders and amendments, constitutes the entire contract.

Health insurance benefits NOT covered due to an act of war are

Excluded by the insurer in the contract provisions. Because an exclusion is a provision that entirely eliminates coverage for a specified risk, such as an act of war or aviation.

An insurer receives proof of loss for an acceptable medical expense claim under an Individual Health Insurance Policy. Under the Time of Payment of Claims provision, the insurer MUST pay the benefits

Immediately. Because under the Time of Payment of Claims provision, the insurer must pay the benefits immediately after receiving proof of loss.

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

Insuring [clause]. In an Accident & Health policy, the insuring clause states the amount of benefits to be paid.

The Notice of Claims provision requires a policy owner to

Notify an insurer of a claim within a specified time. The Notice of Claims provision spells out the insured's duty to provide the insurer with reasonable notice in the event of a loss.

Which of these is considered a mandatory provision?

Payment of Claims. Payment of Claims is considered a mandatory provision and directs where the claim benefits will go. The others are considered optional provisions.

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

Premiums may increase at time of renewal. A Conditionally Renewable Health Insurance policy can increase premiums at time of renewal.

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

Proof of Loss A Proof of Loss statement must be provided to an insurance company to show that a loss actually occurred.

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. In this situation, coverage may be restored under the reinstatement provision.

With Optionally Renewable Health policies, the insurer may

Review the policy annually and determine whether or not to renew it. Because with an Optionally Renewable policy, the insurance company may review the policy annually and choose whether or not to renew it.

The insuring clause

The purpose of the insuring clause is to specify the scope and limits of the coverage provided.

An assignment of benefits of a Health Policy

Transfers payments to someone other than the policy owner. Because an assignment of benefits of a Health Policy transfers payments to someone other than the policy owner.

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

protect the producer. The Legal Actions provision is designed to do all of these EXCEPT protect the producer.