Health insurance policy provisions
With accidental death and dismemberment policies, what is the purpose of the grace period
Gives the policyowner additional time to pay past due premiums
A Disability Income policy that only the policyowner can terminate and which the rates will never go up is considered to be
noncancellable
The Notice of Claims provision requires a policy owner to
notify an insurer of a claim within a specified time
The legal actions provision of an insurance contract is designed to do all of the following, EXCEPT?
protect the producer
What is the purpose of the time of payment of claims provision
Prevents delayed claim payments made by the insurer
What must the policyowner provide to the insurer for validation that a loss has occurred?
Proof of Loss
Insurers may request a hearing within ___ if their policy is rejected
20 days
Under an individual health insurance policy, the Time Limit of Certain Defenses provision states that non-fraudulent misstatements first become incontestable two years
from the date that the policy was issued
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
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
What type of renewability guarantees premium rates and renewability?
noncancellable
Which of the following BEST describes a short-term medical expense policy?
nonrenewable
A(n) _____ of benefits of a health policy transfers payments to someone other than the policyowner
assignment
According to the Time Payment of Claims provision, the insurer must pay Disability Income benefits no less frequently than which of the following options?
monthly
Periodic health claim payments MUST be made at least
monthly
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
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
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
"A producer does not have the authority to change a policy or waive any of its provisions". The health provision that best describes this statement is called the
Entire contract
The sections of an insurance contract which limit coverage are called
Exclusions
Which of the following provisions specifies how long a policyowner's health coverage will remain in elect if the policyowner does not pay the premium when it is due?
Grace period
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
If an individual is covered under an accidental death policy and dies, an autopsy can be performed in all these situations, EXCEPT
When the state prohibits this by law
With Optionally Renewable Health policies, the insurer may
review the policy annually and determine whether or not to renew it
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
After an insured gives notice of loss, what must he/she do if the insurer does not furnish forms?
File written proof of loss
An insurer must provide an insured with claim forms within __ days after receiving notice of a loss.
15
An insured must notify an insurer of a medical claim within how many days after an accident?
20
Which of the following statements describes what an accident and health policyowner may NOT do?
Adjust the premium payments
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 in the policy
Which of the following statements BEST describes what the legal actions provision of an accident and health policy requires?
An insured must wait at least 60 days after Proof of Loss has been submitted before a lawsuit can be filed
When does a Probationary Period provision become effective in a health insurance contract?
At the policy's inception
When an insured changes to a more hazardous occupation, which disability policy provision allows an insurer to adjust policy benefits and rates?
Change of occupation provision
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
Which of the following policy provisions prohibits an insurance company from incorporating external documents into an insurance policy?
Entire Contract
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
What is the initial requirement for an insured to become eligible for benefits under the waiver of premium provision
Insured must be under a physician's care
S filed a written Proof of Loss for a Disability Income claim on September 1. The insurance company did not respond to the claim. S can take legal action against the insurer beginning
November 1
C is the policyowner of a comprehensive individual major medical policy. C pays an annual premium which is due September 1. If C forgets to pay the premium and is hospitalized September 10, how will the insurer handle this claim?
Pay the claim in full minus the premium due
The provision that defines to whom the insurer will pay benefits to is called
Payment of Claims
Which of these statements accurately describes the waiver of premium provision in an accident and health policy
Premiums are waived after the insured has been totally disabled for a specified time period
What is considered to be a characteristic of a conditionally renewable health insurance policy?
Premiums may increase at time of renewal
The insuring clause
States the scope and limits of the coverage
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
G is involved in an automobile accident as a result of driving while intoxicated and suffers numerous injuries. According to the Intoxicants and Narcotics exclusion in G's policy, who is responsible for paying the medical bills?
The insured
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 would have purchased at the insured's actual age
Health insurance benefits NOT covered due to an act of war are
excluded by the insurer in the contract provisions
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
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
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
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
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
X is insured with a disability income policy that provides coverage until age 65. This policy allows the insurer to change the premium rate for the overall risk class assigned. Which of these renewability features does this policy contain?
Guaranteed renewable
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 ____ clause identifies which losses resulting frOm an accident or sickness are insured by the policy.
Insuring
Under a guaranteed renewable health insurance policy, the insurer
May cancel the policy for nonpayment only
Which of these is considered a mandatory provision
Payment of Claims
The insured and insurance company will share the cost of covered losses under which health policy feature?
Payment of Claims provision
Which of the following statements about a Guaranteed Renewable Health Insurance policy is CORRECT?
Premiums normally increase at time of renewal
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
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
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
Which of the following is NOT included in the policy face?
Exclusions
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
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
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
Which health policy clause specifies the amount of benefits to be paid?
Insuring
The clause in an Accident and Health policy which defines the benefit amounts the insurer will pay is called the
Insuring clause
Which of the following health insurance policy provisions specifies the health care services a policy will provide?
Insuring clause
