REVIEW 2

Exceptions disclosure

An advertisement for health insurance cannot use language to imply broad insurance coverage (e.g., "all," "complete," "comprehensive" or "this policy will pay your hospital bill") without disclosing any exceptions, reductions or limitations to the coverage.

LTC marketing requirements

In the marketing of LTC insurance policies, an insurer must provide each applicant with a completed rate information form; the name, address and telephone number of the Senior Health Insurance Counseling Program (SHIP); and an explanation of the contingent benefit on lapse provision; but NOT a list of policy-approved care providers.

24 hours every 2

Incorrect. An individual producer must successfully complete 24 hours of approved continuing education within the two-year period before the renewal date in order to renew his license. Any approved continuing education course will fulfill the requirement, regardless of the licensee's line of authority, but a course can only be taken once during each reporting period. Up to 24 hours of course work can be carried forward into the next reporting period.

90% dnd 365 days

A Medicare supplement policy must cover 90 percent of Medicare Part A eligible expenses, up to a lifetime maximum benefit of 365 days, once Part A benefits are exhausted.

Days 61-90

A Medicare supplement policy must cover Medicare Part A eligible expenses (i.e., those expenses determined to be reasonable by Medicare) for hospitalization from the 61st to the 90th day of any benefit period (i.e., the unit of time used to measure the availability of Part A benefits).

6 months

A Medicare supplement policy which replaces another Medicare supplement policy which has been in effect for at least six months cannot provide for a waiting period (e.g., elimination periods, probationary periods) because of a pre-existing condition. If the original policy has been in effect less than six months, that period of time for which the applicant was covered can be credited to any waiting period.

10%

A commission or compensation (including bonuses, gifts, finder's fees, etc.) payable to a producer for the sale of an LTC policy cannot exceed 50 percent of the premium for the first year; 10 percent of the renewal premium for the second through fifth renewal years; and the amount which would be paid for renewal of an existing policy, for a replacement policy. In this case, 10 percent of $500 is $50.

3 years

A copy of any basic or revised illustration must be maintained by the insurer at least three years after the policy is no longer in force.

60 days to 3 years

A legal action brought under a policy cannot be filed earlier than 60 days after the written proof of loss has been furnished or later than three years after the time the written proof of loss was required to be furnished.

Established relationship

A licensee must give an initial privacy notice to a consumer prior to disclosing the consumer's nonpublic personal financial information to a nonaffiliated third party (i.e., a company not controlling, controlled by or under common control with the licensee); and to a customer no later than when a customer relationship is established.

30 days

A licensee must report to the Department the results of an administrative action taken against him by another state or by another Pennsylvania government agency within 30 days of the final order.

HIV testing

An HIV-related test cannot be performed without the prior written consent of the subject. That consent can only be given after the insurer provides to the subject, in writing a disclosure of how the test results will affect approval of the application for insurance, and/or the applicant's risk classification; information explaining the test; a description of the insurer's confidentiality standards; a statement that the subject may want to seek some counseling before undergoing the test; and information about alternative HIV testing and counseling.

Non forfeiture benefit

A nonforfeiture benefit must be offered with an LTC policy, and a policy with nonforfeiture benefits must have the same coverage as one issued without those benefits so far as eligibility, benefit triggers and benefit lengths.

Illegal inducement

A person cannot offer anything of value to a prospective insured as an inducement to buy an insurance policy, including stocks, bonds, securities, dividends and profits. This is illegal inducement.

$5,$10,$15,000

A person who transacts insurance without a license can be prosecuted for insurance fraud and fined up to $5,000 for the first violation, $10,000 for the second violation, and $15,000 for each subsequent violation.

20 days

A policyholder is entitled to review a newly issued policy during a free-look period and return it for a full refund of the premium if he is not satisfied with it. The policy must prominently state this provision on its first page. On a policy replacing another insurer's policy, the policyholder has 20 days from the date of delivery in which to return the policy.

Regular review

All Medicare supplement advertising in any medium (e.g., print, radio, television) must be submitted to the Commissioner for review or approval and be maintained by the insurer until the next regular review by the Department.

Immunity

All are immune. IFPA board members and/or its employees are immune from civil or criminal prosecution for receiving or disclosing information related to insurance fraud. The attorney general and employees or agents of the Section are immune for the publication of any official report or bulletin. Ordinary citizens are immune from any prosecution for supplying insurance fraud information to the IFPA or the Insurance Fraud Section, or by complying with a court order.

1 year

An in-force illustration is an illustration presented once a policy has been in force for more than one year.

No fingerprints needed

An individual licensed as an insurance producer in another state who moves to Pennsylvania can apply for a resident license by submitting an application to the Department within 90 days of moving to this state; paying the nonrefundable application fee; providing proof of licensure in his home state in the lines of authority for which he is applying, or a letter of clearance from his former home state insurance commissioner, indicating his license was in good standing; and showing he has not committed any act prohibited under the Code. He does NOT need to supply fingerprints and a background check fee.

30 days

An insurance licensee or license applicant must not misappropriate, convert or improperly withhold money or property in a transaction; knowingly accept insurance business negotiated by an unlicensed person; fail to pay required state income taxes; or fail to notify the Department of a change of address within 30 (and not 14) days of the change.

5 days

An insurer can cancel a policy at any time by giving written notice to the insured and stating when the cancellation will be effective (the effective date can be no less than five days after the notice), and refunding any unearned premiums to the insured. In this case, Infinity did not give Brian sufficient notice.

10 days

An insurer must advise an eligible person who ceases to be enrolled in its plan of his rights to secure a Medicare supplement policy within 10 working days of the insurer receiving notice of the cancellation/disenrollment.

5% for 10&20

Costs in the surrender complex index are adjusted based on a 5% interest rate each year and show a 10- and 20-year comparison.

2 for 90 days

For purposes of an LTC policy, a chronically ill individual is an individual unable to perform at least two ADLs for at least 90 days; and/or requiring substantial assistance/ supervision from another to protect against threats to the individual's safety or health due to severe cognitive impairment

180 days

If a resident individual licensee or a designated licensee of a business entity dies or becomes disabled, the Department can issue a temporary producer license, which is valid for up to 180 days. The temporary license can be issued to a surviving spouse court-appointed representative of the individual licensee or to an owner, partner or employee of the business entity to operate the business until the business is sold or transferred; new personnel is trained, licensed and/or designated to run the business; or the licensee recovers and returns to the business.

Original age

If premium rates for an original LTC policy were based on the issue age of the insured, the premium for the converted policy will be based on his age at the time the original policy was issued.

6 months

If the applicant has received treatment for a medical condition during the six months prior to the date of enrollment, that condition can be designated as a pre-existing condition and excluded from coverage for the first six months of the supplement policy. However, the period of the exclusion is reduced by the period of continuous creditable coverage prior to the application and eliminated entirely if the applicant had six months of prior creditable coverage

$5,000-50,000

In addition to any penalties imposed by the Department, the Commissioner can ask a court to fine a licensee up to $5000 per violation, up to a maximum fine of $50,000 in any six-month period, if the licensee had knowledge that the act was a violation.

2 years

In regard to annuities, after a policy has been in force for two years from the date of issue, the insurer cannot contest the policy's validity or deny a claim because of statements made as a condition of issuing the policy.

90 days

In regard to group policies, a pre-existing condition limitation can be applied only to a disease or physical condition for which medical care or treatment has been sought within 90 days immediately prior to an individual becoming covered under the group contract.

3rd degree

Insurance fraud is a third-degree felony, punishable by imprisonment and/or a fine in the amount of $5,000 for the first violation, $10,000 for the second violation, and $15,000 for each subsequent violation. If a court finds a pattern of insurance fraud violations, an insurer who sues in a civil case may collect up to triple its damages.

15 days

It is a violation of the Act for which the Department may assess an administrative fine of up to $100 a day if a licensee fails to pay all fees due to the Department within 15 days of receiving notice of the failure.

viatical settlement

No one involved in a viatical settlement may influence the health care treatment of the viator. However, contact with the insured is allowed to ascertain his health status as follows: for a life expectancy of more than one year, once every three months; and for a life expectancy of less than one year, once a month.

4 admissions and 7 days of treatment per admission in a lifetime.

Specifically for detoxification treatment, the policy must provide coverage for at least four admissions and at least seven days of treatment per admission in a lifetime. There is no prohibition against granting more coverage than the state minimum. Insurers are bound by law and have no authority to change the requirement to a lesser standard. Answer "D" refers to residential facility treatment not including detoxification treatment.

Subrogation

Subrogation is a principle that allows an insurer to take over the insured's right to sue a party that caused his loss in order to recover money it paid on a claim from the party at fault. Since the insurer only pays the amount of a claim in excess of the insured's deductible, the insured is left unreimbursed for his deductible and without recourse against the party at fault. Therefore, the law requires an insurer, if requested, to include the insured's deductible in its subrogation demand.

Commissioner's regulation

The Commissioner's regulation of insurance rates apply to all lines of property and casualty insurance except reinsurance; aircraft or aircraft liability insurance; workers' compensation insurance; insurance issued to self-insurers to cover losses exceeding $10,000 from a single event; and insurance of vessels, their cargoes, or other marine risks not classified as inland marine insurance.

5 years

The Department must examine every licensed insurer's books at least once every five years but may conduct an examination of any person involved in the insurance business at any time it deems it appropriate.

Guide to Health Insurance

The Guide to Health Insurance for People with Medicare must be provided to certificate holders of Medicare-eligible age who are covered under an accident and sickness policy or contract, whether or not it is marketed as a Medicare supplement product.

Frequently enough

The Unfair Insurance Practices Act (the Act) classifies a series of activities, including failing to promptly and fairly settle a claim when its liability is clear, as unfair claim settlement practices when they are performed frequently enough to be considered a regular business practice.

Not pregnancy complications

The list of permitted general exclusions in an accident and sickness policy includes mental disorders, suicide or intentionally self-inflicted injury, and normal pregnancy, childbirth and miscarriage, but not pregnancy complications.

Permitted exclusions

The list of permitted hospital/basic/major medical exclusions in an accident and sickness policy includes eye/hearings exams and devices (hearing aids, glasses, etc.), routine exams, dental services, EXCEPT in connection with accidental injury, and expenses coverable by Medicare.

Simultaneously

The offer of additional benefits must be prominently made and provided simultaneously to the marketing of the Medicare supplement policy. If the applicant chooses to purchase the additional benefits, the plan will be effective no later than 15 days after the effective date of the Medicare supplement policy.

5 years

The producer must list on the application form any health insurance policies he has sold to the applicant which are currently in force; and/or in the past five years, which are no longer in force. In this case, the producer must list both policies he sold Barry.

10 days

Within 10 working days of receipt of notification of a claim by itself or its agent, an insurer must pay the claim; or acknowledge receipt in writing, or acknowledge receipt by some other means, with a dated notation of the acknowledgment in the claim file.

Reporting periods 10 & 30

licensee must report to the Department within 30 days of the final order, any administrative action taken against him by another state or by another Pennsylvania government agency; and within 30 days of being charged, any criminal charges brought against him. Additionally, a licensee must inform the Department of a change of address within 30 days of the change. However, an insurer operating under a management contract or exclusive general agency contract must provide to the Department the name of its manager or exclusive general agent within 10 days of the effective date of the contract and again within 10 days of the date of the renewal of the manager's or exclusive general agent's license.

simplified privacy notice

simplified privacy notice may be provided if the licensee does not intend to disclose any nonpublic personal financial information to any affiliates or nonaffiliated third parties.