Health Insurance Policy 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?
claim will be denied
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
consideration clause
A disability policy that must be renewed, cannot be cancelled until age 65, and may not have a increase in premium is
noncancellable policy
Policy where the insurance company cannot cancel and premiums cannot be increased
noncancellable policy
Best describes a short-term medical expense policy
nonrenewable
Provision that requires a policyowner to notify an insurer of a claim within a specified time
notice of claims
The insurer may review the policy annually and determine whether or not to renew it
optionally renewable health policies
Mandatory provision
payment of claims
Provision tat defines to whom the insurer will pay benefits to is called
payment of claims
Describe waiver of premium provision in accident and health policy
premiums are waived after the insured has been totally disabled for a specified period of time
Characteristic of a conditionally renewable health insurance policy
premiums may increase at the time of renewal
Guaranteed Renewable Health insurance policy
premiums normally increase at time of renewal
When _______ has been furnished, periodic benefit payments must be made no more less frequently than monthly
proof of loss
Accident are covered fully covered immediately and illnesses require 10 day wait with
reinstatement
Proof of loss
statement must be provided to an insurance company to show that a loss actually occurred
Purpose of the insuring clause
states the scope and limits of 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
Provision that allows the insurer to reduce the max benefits payable under the policy
change of occupation
Notice of claim provision states that the insured must notify the insurance company within ____ of a claim
20 days
Required Provision 3 states that the minimum grace period for all policies (except those with monthly or weekly premium modes) is
31 days
Health insurance will automatically be placed back in force if the insurer fails to notify an applicant within ______ that the reinstatement was denied
45 days
Bart is injured and provides notice of a health claim to his insurer He later receives the required claims forms. Within how many days of the loss must Bart file proof of loss with the insurance company
90
Accident and health policyowners may not
adjust the premium payments
Best describes what the legal action provisions of an accident and health policy requires
an insured must wait at least 60 days after proof of loss is submitted
After the insurance company receives a written request, an insured may have health insurance benefits paid to
anyone designated by the insurer
When does the probationary period become effective in a health insurance contract
at the policy inception
Health insurance benefits not covered due to an act of war
excluded by the insurer in the contract provision
With AD&D policies, what is the purpose of the grace period
gives policyowner additional time to pay past due premiums
Provision that specifies how long a policyowner's health coverage will remain in effect if the policyowner does not pay the premium when it is due
grace period
Type of renewability that guarantees premium rates and renewability
guaranteed renewable
After a policy has been in force for two years, it enters the _______, in which the insurer may not deny a claim based on information not disclosed at the time of the application
incontestable period
Provision that specifies the health care services a policy will provide
insuring clause
Time limit on certain defenses provision
limits the time an insurer can void a contract or deny a claim for material misrepresentations on the application.
Insuring clause
the clause in an accident and health policy which defines the benefit amounts the insurer will pay
Amy owns a disability income policy, with a noncancellable policy, with a noncancellable renewal provision. What is guaranteed
the coverage and the premium rate are guaranteed
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
the insured must wait 60 days after written proof of loss before legal action can be brought against the company
False statement about a noncancellable policy
the premium rate can be increased over time
Accident and health policy provision that addresses preexisting conditions
time limit and 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
Prevents delayed claim payments made by the insurer
time of payments
According to Required Provision 4, when an insured applies for reinstatement of a health policy and receives a conditional receipt, how long does the insurer have to approve or deny
within 45 days of the date of application