Health Insurance Policies Quiz

Policy Provisions and Clauses

• Insurers can deny a claim if the insured misrepresented information, even if a time limit clause exists.
• A clause limiting insurer defenses within a set time does not automatically guarantee a claim payment.

Pre-existing Conditions in Medicare Supplements

• Pre-existing conditions disclosed within three months of policy issuance may not impact claim coverage.
• Policies often have limitations on coverage of pre-existing conditions.

Advertising Violations

• Insurers cannot advertise misleading information about coverage, like guaranteeing full pre-existing condition coverage, as that could be false advertising.

Coordination of Benefits

• The primary health plan in coordination of benefits is determined by the plan with the earlier birthday for a covered child.
• Other factors may be taken into account, but the earlier date resolves the issue in this case.

Group Health Continuation

• COBRA provides temporary continuation of group health coverage for employees who leave employment, lasting up to 18 months if not disabled.

Policy Delivery Responsibilities

• Agents must ensure insureds understand policy provisions, especially mandatory preauthorization requirements, otherwise the insurer may deny claims under the provision.

Replacement of Policies

• Agents must inform clients about exclusions or changes in coverage in new policies to avoid issues.

Guaranteed Issue Requirements

• Insurers may be required to cover individuals with pre-existing conditions in group health insurance situations, depending on regulations or group size.

Long-Term Care Disclosure

• Insurers must provide an Outline of Coverage and Buyer’s Guide, detailing policy exclusions, to applicants for long-term care policies. It is not enough for the policy to be verbally explained, but written documentation is required.

Florida Guaranty Fund Limitations

• Florida's Guaranty Fund provides a limit to the amount it will pay for covered medical expenses resulting from an insurer's bankruptcy.

Sliding Violation

• Selling a policy with additional coverage without adequately disclosing costs constitutes sliding, a violation of insurance practices.

Unfair Claims Practices

• Delaying claim processing without justification is considered an unfair claim settlement practice, a violation of Florida Statutes.

Medicaid and Long-Term Care

• Medicaid benefits often interact with long-term care policies. The specifics, like order of benefit payments and coverage, are different depending on the details of the policy.

Policy Renewability

• A "guaranteed renewable" long-term care policy means insurers may change the policy or conditions but must provide advance notice (the policy cannot be canceled if premiums are paid).

HMO vs. PPO

• PPO plans offer more flexibility to choose out-of-network providers.

Employer-Sponsored Plan Termination

• Employers legally need to make coverage continuation possible either through group rates, or by providing individual conversion policies for affected employees.

Fraudulent Acts

• Suspending or revoking an agent's license are penalties for fraudulent claims submission.

Outline of Coverage

• Agents must provide the Outline of Coverage and Buyer’s Guide for long-term care policies at the time of delivery.

Activities of Daily Living (ADLs)

• Long-term care claims are often evaluated based on the inability to perform specific Activities of Daily Living (ADLs).

Discount Medical Plan Organizations (DMPOs)

• DMPOs provide discounts, not full coverage. A clarification concerning payment for services by the organization is needed.

Test your knowledge on key provisions and regulations of health insurance policies. This quiz covers topics such as claim denials, pre-existing conditions, advertising practices, and coordination of benefits. Perfect for anyone looking to understand the intricacies of health insurance.