-individual accident and health insurance policy provisions

reductions

a decrease in benefits because of certain specified conditions.

guaranteed renewable

has all the same features of the non-cancelable provision does, with the exception that the insurer can increase the policy premium on the policy anniversary date. However, the premiums can only be increased on a class basis, not on an individual policy.

what type of policy allows the insurance company to cancel a policy at any time?

cancelable. cancelable policy may be cancelled at any time with proper written notice from the insurer and a refund of any unearned premium. The insurer must continue to honor any claims submitted before the cancellation date.

exclusions

exclusion specify for what the insurance will not pay. these are causes of loss that are specifically excluded from coverage. the most common are injury or loss that result from any of the following... War, military duty, self-inflicted injury, Dental expense, cosmetic medical expenses, eye refractions or care and government facilities. In addition, most policies will temporarily suspend coverage while an insured resides in a foreign country or while serving in the military.

under the uniform acquired provisions proof of loss under a health insurance policy normally should be filed within how many days?

90 days

exclusions... Substance abuse

as with mental and emotional disorders, outpatient treatment of substance abuse is usually limited to a maximum limit.

misstatement of age

if the insured Miss stated his or her age or gender at the time of the application, the benefits paid under the policy would be adjusted to what the premium paid would have been if purchased at the correct age.

reinstatement

if the premium has not been paid by the end of the policies grace period, the policy will lapse, terminate. This provision stipulates under what conditions the insured May reinstate coverage. Reinstatement is automatic if the company or an authorized representative accept the policy premium and does not require reinstatement application. However, if a reinstatement application is required and a conditional receipt is issued for the payment of the policy premium the company May approve or disapprove the reinstatement application. Coverage is automatically reinstated if not refused within 45 days from the date the conditional receipt was issued. Accidents will be covered immediately following the reinstatement, however sickness is covered only after 10 days. This helps to protect the insurer from adverse selection.

what are the following circumstances would be a reason for the insurance company to cancel a non-cancelable health insurance policy.

insured does not pay the premium the insured reaches the maximum age limit specified in the policy within two years of the application, the insurance covers a misrepresentation.

the provision which prevents the insured from bringing any legal action against the company for at least 60 days after proof of loss is known as?

legal actions.

under an individual Disability Policy the minimum schedule of time in which claim payments must be made to an insured is?

monthly. If a claim involves disability income benefits, the policy must pay those benefits not less frequently than monthly. In all other cases a company May specify the time period of 45 or 60 days for payment of claims.

coinsurance

most major medical policies include a coinsurance provision that provides for sharing of expenses between the insured and the insurance company. after the insured satisfies the policy deductible, the insurance company will usually pay the majority of the expenses, typically 80%, with the insured paying the remaining 20%. Other coinsurance Arrangements exist such as 90/10, 75/25, or 50/50. The larger percentage that is paid by the insured the lower the required premium will be. The purpose of the coinsurance provision is for the insurance company to control cause and discouraged over utilization of the policy.

term Health policy

non-renewable, the owner has no rights of renewal

renewable at option of insurer

optional renewability is similar to conditional renewability, except that the insurer May cancel the policy for any reason, on certain homogeneous classes ( not individuals within a class). renewability is at the option of the insurer. the insurer can only decide not to renew a policy on the policy anniversary or premium to date, renewal date. If the insurer elects to renew coverage, it may also increase the policy premium.

optional renewability

optional renewability is similar to conditional renewability, except that the insurer May cancel the policy for any reason, uncertain homogeneous classes, not individuals within a class. Renewability is at the option of the insurer. the insurer can only decide not to renew a policy on the policy anniversary or premium due date, renewal date. If the insurer Alec to renew coverage, may also increase the policy premium.

what provision would prevent an insurance company from paying a reimbursement claim to someone other than the policy owner

payment of claims

which renewability provision are you most likely to see on a travel accident policy?

period of time. the period of time, term, provision means that the policy will only last a certain. Of time and cannot be renewed. It will be canceled at the end of the term for which it was purchased. I travel accident only policy will only provide coverage during the dates the insured is traveling.

Reinstatement provision

permits the owner to reinstate a lapsed policy

all the following are correct about the required provisions of a health insurance policy.

proof of loss forms must be sent to the insurance within 15 days of notice of claim. A grace period of 31 days is found in an annual pay policy. The entire contract clause means the signed application, policy, endorsements, and attachments constitute the entire contract.

what is the notice of claim provision?

spelled out the insurance duty to provide the insurer with reasonable notice in the event of a loss. Notice is required within 20 days of the lost, or as soon as reasonably possible. Notice to the agent equals notice to the insurer.

change of beneficiary

the change of beneficiary provision stipulates that the policy owner may change the beneficiary at any time by providing a written request to the insurer, unless the beneficiary is designated as irrevocable. The consent of the beneficiary is not required. If the beneficiary designation is irrevocable, the policyholder must first obtain the permission of the beneficiary before any change can be made.

consideration clause

the consideration clause, which is usually located on the first page of the policy, makes it clear that both parties to the contract must give some valuable consideration. The payment of the premium and the statements in the application are the consideration given by the applicant. the insurance consideration is a promise to pay in accordance with the contract terms.

what are the features of a non-cancellable policy?

the guarantee to renew coverage usually applies until the insured reaches a certain age. The insured has the right to renew the policy for the life of the contract. The premiums cannot be increased beyond the amount stated in the policy.

non-cancelable

the insurance company cannot cancel a non-cancelable policy nor can the premium be increased beyond what is stated in the policy, note that the policy make offer an increase in a certain area such as age 65 but that must be stated in the original contract. The insured has the right to renew the policy for the life of the contract, the insurance cannot increase their premium above the amount for which the policy was originally issued however the guaranteed to renew coverage usually only applies until the insurance reaches age 65, at which time the insured is usually eligible for Medicare. For disability income Insurance the policy will be renewed Beyond age 65 only if the insured can provide evidence that he or she has continued to work in a full-time job.

uniform optional provisions

the insurance company has the option of including any of the following optional provisions. an insurance company made from change the wording of the optional policy Provisions as long as the rewording is not less favorable to the policyholder.

under health insurance policy, benefits, other than death benefits, I have not otherwise been assigned will be paid to?

the insured. If no beneficiary has been named payment proceeds are to be paid to the deceased insureds estate. claims other than death benefits are to be paid to the insured or the insured's estate, unless otherwise assigned by the insured

guaranteed renewable health insurance policy

the insurer me increase premiums on a class basis only and not on an individual policy.

the expense for an autopsy covered under the physical exam and autopsy provision is paid by who?

the insurer. We're not forbidden by state law, the insurer, and its own expense, may cause an autopsy to be performed on a deceased insured.

insuring clause

the insuring agreement or Clause is usually located on the first page of the policy. It is simply a general statement that identifies the basic agreement between the insurance company and the insured. It identifies the insured and the insurance company and States what kind of loss, Peril, is covered.

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

the longer the elimination period The lower the cost of coverage

which Provisions would prevent an insurance company from paying a reimbursement claim to someone other than the policy owner?

the payment of claims

payment of claims

the payment of claims provision specifies to whom claims payments are to be made. All benefits are payable to the insured while he or she is living. if the insured is deceased, claims that are pending or paid to the beneficiary.

renew provision

the provision that describes the insured's right to cancel coverage. renewability Provisions are included in each health insurance contract and outlines both the insurers and insured's right to cancel or renew coverage. this is considered to be very important provision required by HIPAA, the federal health insurance portability and accountability Act.

the insuring clause

the types of losses covered the identities of the insurance company and the insured. That insurance against loss is provided.

what is the probationary period?

the waiting period new employees must satisfy before becoming eligible for benefits.

which of the following statements is most correct concerning the changing of an irrevocable beneficiary?

they can be changed only with the written consent of that beneficiary.

legal actions

this provision limits the time in which a claimant May seek recovery from an insurer under a policy. The insured must wait 60 days, but not later than three years, in Most states, after proof of loss, before legal action can be brought against the company.

under the physical exam and autopsy provision how many times can an insurer have the insured examined, at its own expense, while the claim is pending?

unlimited. The physical exam and autopsy provision allows the insured to examine the insured as much as is reasonably necessary while the claim is being processed, provided that the insurer pays the expenses.

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

upon receipt of notice of claim, the company must have like claims forms to the insurer within a specific number of days.

exclusions... mental and emotional disorders

usually the lifetime benefit for major medical coverage limits the amount payable for mental or emotional disorders. The benefit is usually expressed as a separate lifetime benefit and there is frequently a limit on the number of outpatient visits per year. The benefit may also pay maximum limit per visit. These limitations usually do not apply to inpatient treatment.

conditionally renewable

with a conditionally renewable policy, the insurer May terminate the contract only at renewal for certain conditions that are stipulated in the contract. For example, one condition maybe that the insured must be employed to collect disability payments. in addition, the policy premiums may be increased. The company may not deny renewal due to claims experience.

when does the insured need to claim proof of loss

within 90 days of the loss or as soon as reasonably possible, but not to exceed 1 year.