Podcast
Questions and Answers
What action is the insurer likely to take if a claim arises two years after policy issuance and there is a misrepresentation found in the policy?
What action is the insurer likely to take if a claim arises two years after policy issuance and there is a misrepresentation found in the policy?
What occurs when a 68-year-old with a Medicare Supplement policy incurs expenses for a pre-existing condition disclosed within three months of issuance?
What occurs when a 68-year-old with a Medicare Supplement policy incurs expenses for a pre-existing condition disclosed within three months of issuance?
What violation has occurred if an insurer advertises its health insurance policies as guaranteeing full coverage for all pre-existing conditions?
What violation has occurred if an insurer advertises its health insurance policies as guaranteeing full coverage for all pre-existing conditions?
In a situation where a child is covered under both parents' health plans, which policy is primary if the father's birthday is in February and the mother's is in June?
In a situation where a child is covered under both parents' health plans, which policy is primary if the father's birthday is in February and the mother's is in June?
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If an employee leaves their job and wishes to continue their health coverage under COBRA, how long can the coverage be extended if they are not disabled?
If an employee leaves their job and wishes to continue their health coverage under COBRA, how long can the coverage be extended if they are not disabled?
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What could happen if an agent delivers a health insurance policy but fails to explain a mandatory provision requiring preauthorization?
What could happen if an agent delivers a health insurance policy but fails to explain a mandatory provision requiring preauthorization?
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What is the best action for an agent who realizes that a new health insurance policy excludes maternity benefits while replacing an existing policy?
What is the best action for an agent who realizes that a new health insurance policy excludes maternity benefits while replacing an existing policy?
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What is likely to occur if a misrepresentation is discovered after a claim is filed two years post-issuance of an insurance policy?
What is likely to occur if a misrepresentation is discovered after a claim is filed two years post-issuance of an insurance policy?
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What requirement must an insurer fulfill when a small employer applies for group health insurance with employees having pre-existing conditions?
What requirement must an insurer fulfill when a small employer applies for group health insurance with employees having pre-existing conditions?
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What document must an insurer provide to an applicant regarding long-term care policy exclusions?
What document must an insurer provide to an applicant regarding long-term care policy exclusions?
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If a Florida health insurer goes bankrupt, how much will the Florida Guaranty Fund pay on a claimant's $300,000 in covered medical expenses?
If a Florida health insurer goes bankrupt, how much will the Florida Guaranty Fund pay on a claimant's $300,000 in covered medical expenses?
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What violation occurs when an agent sells a life insurance policy that includes accidental death coverage without explaining the additional cost?
What violation occurs when an agent sells a life insurance policy that includes accidental death coverage without explaining the additional cost?
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What Florida statute is violated when an insurer repeatedly delays claims processing without justification?
What Florida statute is violated when an insurer repeatedly delays claims processing without justification?
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How does a long-term care policy interact with Medicaid if the insured qualifies for Medicaid benefits after purchasing the policy?
How does a long-term care policy interact with Medicaid if the insured qualifies for Medicaid benefits after purchasing the policy?
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What does it mean for a long-term care policy to be labeled 'guaranteed renewable'?
What does it mean for a long-term care policy to be labeled 'guaranteed renewable'?
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For a Florida resident prioritizing flexibility in choosing out-of-network providers, which plan should they select?
For a Florida resident prioritizing flexibility in choosing out-of-network providers, which plan should they select?
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What must an insurer do for employees when an employer terminates a group health plan for financial reasons under Florida law?
What must an insurer do for employees when an employer terminates a group health plan for financial reasons under Florida law?
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What penalty may the Department of Financial Services impose on an agent guilty of submitting false insurance claims on behalf of clients?
What penalty may the Department of Financial Services impose on an agent guilty of submitting false insurance claims on behalf of clients?
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Study Notes
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.
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Description
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.
