Podcast
Questions and Answers
All of the following are functions of an insuring clause EXCEPT
All of the following are functions of an insuring clause EXCEPT
Which of the following is NOT a required provision in an accident and health insurance policy?
Which of the following is NOT a required provision in an accident and health insurance policy?
What type of changes can be made to a guaranteed renewable health insurance policy?
What type of changes can be made to a guaranteed renewable health insurance policy?
The premium rates of the policyowner
Under a health insurance policy, the provision that states the kind of benefits provided and the circumstances under which they will be paid is called the?
Under a health insurance policy, the provision that states the kind of benefits provided and the circumstances under which they will be paid is called the?
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The legal action provision in a health contract is limited to no more than ___ years.
The legal action provision in a health contract is limited to no more than ___ years.
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In what situation does a waiver of premium provision keep a health insurance policy in force without premium payments?
In what situation does a waiver of premium provision keep a health insurance policy in force without premium payments?
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A health insurance policy paid on a quarterly basis has a grace period of
A health insurance policy paid on a quarterly basis has a grace period of
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Bruce is involved in an accident and becomes totally and permanently disabled. His insurance policy continues in force without payment of further premiums. Which policy provision is responsible for this?
Bruce is involved in an accident and becomes totally and permanently disabled. His insurance policy continues in force without payment of further premiums. Which policy provision is responsible for this?
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The entire contract includes the actual policy and the
The entire contract includes the actual policy and the
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In contrast to a guaranteed renewable policy, a noncancellable policy
In contrast to a guaranteed renewable policy, a noncancellable policy
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The type of policy where the insurer can send a notice to the insured that the policy has been cancelled in the middle of the term is called
The type of policy where the insurer can send a notice to the insured that the policy has been cancelled in the middle of the term is called
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Disability income plans which require that the insurer can NEVER change or alter premium rates are usually considered
Disability income plans which require that the insurer can NEVER change or alter premium rates are usually considered
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Which of the following actions may an insurance company NOT do in a health policy that contains a guaranteed renewable premium benefit?
Which of the following actions may an insurance company NOT do in a health policy that contains a guaranteed renewable premium benefit?
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This MANDATORY health policy provision states that the policy, including endorsements and attached papers, constitutes
This MANDATORY health policy provision states that the policy, including endorsements and attached papers, constitutes
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In group health care, what is the purpose of the coordination of benefits provision?
In group health care, what is the purpose of the coordination of benefits provision?
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The time limit for filing claim disputes is addressed in which provision of an accident and health policy?
The time limit for filing claim disputes is addressed in which provision of an accident and health policy?
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Richard owns an insurance policy that is renewable only at the option of the insurance company. His policy is considered to be
Richard owns an insurance policy that is renewable only at the option of the insurance company. His policy is considered to be
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States that have 'no loss no gain' laws require a replacing policy to
States that have 'no loss no gain' laws require a replacing policy to
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Craig submits a $500 claim for medical expenses. With a past due premium of $100, the insurer pays $400. Which of the Uniform Optional Provisions covers this situation?
Craig submits a $500 claim for medical expenses. With a past due premium of $100, the insurer pays $400. Which of the Uniform Optional Provisions covers this situation?
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A health insurance policy where the insurer has the right to terminate the policy for reasons other than the insured's health is called
A health insurance policy where the insurer has the right to terminate the policy for reasons other than the insured's health is called
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Which of the following is NOT a required uniform provision in individual health policies?
Which of the following is NOT a required uniform provision in individual health policies?
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David submits a $500 claim for medical expenses. There is a past-due amount owed for insurance premiums of $200. As a result, the insurer only pays $300 for the claim. This deduction came as a result of which provision?
David submits a $500 claim for medical expenses. There is a past-due amount owed for insurance premiums of $200. As a result, the insurer only pays $300 for the claim. This deduction came as a result of which provision?
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Which of the following is NOT a common exclusion for a medical expense policy?
Which of the following is NOT a common exclusion for a medical expense policy?
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A clause that allows an insurer the right to terminate coverage at any anniversary date is called a(n)
A clause that allows an insurer the right to terminate coverage at any anniversary date is called a(n)
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The misstatement of age provision in a health policy states that if an insured gives the wrong age at the time of application, what action can the insurance company take?
The misstatement of age provision in a health policy states that if an insured gives the wrong age at the time of application, what action can the insurance company take?
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Under the Payment of Claims provision, when are benefits typically payable after proof of loss is received?
Under the Payment of Claims provision, when are benefits typically payable after proof of loss is received?
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An insurer must furnish to a claimant forms for filing proof of loss within ___ days upon receiving a notice of claim.
An insurer must furnish to a claimant forms for filing proof of loss within ___ days upon receiving a notice of claim.
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Study Notes
Insurance Policy Provisions
- Insuring Clause: Describes the type of benefits and the conditions for payment; not primarily about the free-look period.
- Required Provisions: Change of occupation is not mandatory for accident and health insurance policies.
- Premium Changes: Only premium rates can be altered in a guaranteed renewable policy.
Policy Benefits and Provisions
- Waiver of Premium Provision: Maintains policy coverage without premium payments if the insured becomes totally disabled.
- Grace Period: Policies requiring quarterly payments have a 31-day grace period.
- Legal Action Provision: Limits time to initiate legal actions regarding claims to 5 years.
Claims and Payments
- Claims Disputes: Addressed under the legal actions provision.
- Unpaid Premiums: Claims may be reduced by outstanding premium amounts, covered by the unpaid premium provision.
- Filing Proof of Loss: Insurer must provide claim forms within 15 days after receiving a notice of claim; benefits are payable immediately after proof of loss.
Policy Types
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Renewability Options:
- A noncancellable policy never allows premium increases.
- An optionally renewable policy can only be renewed at the insurer's discretion.
- A conditionally renewable policy can be terminated for non-health reasons.
- Cancelation Notification: A cancelable policy permits the insurer to notify termination mid-term.
Coverage Coordination
- Coordination of Benefits: Ensures proper payment distribution between primary and secondary insurers when there's a claim.
Exclusions and Adjustments
- Common Exclusions: Physical therapy is generally not excluded from medical expense policies.
- Misstatement of Age Provision: Allows for benefits adjustment based on inaccuracies in age provided at application.
Special Clauses
- Optional Renewability Clause: Gives insurers the right to end coverage at any policy anniversary.
- "No Loss No Gain" Laws: Require replacing policies to cover ongoing claims from the original policy.
Key Claim Scenarios
- Claims reduced by past-due premiums exemplify the importance of the unpaid premium provision, affecting both David and Craig in specific claims.
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