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Questions and Answers
Under the misstatement of age provision in a health insurance policy, what can a company do if it discovers that an insured gave a wrong age at the time of application?
Under the misstatement of age provision in a health insurance policy, what can a company do if it discovers that an insured gave a wrong age at the time of application?
Which of the following is a standard optional provision for health policies?
Which of the following is a standard optional provision for health policies?
When the provision concerning unpaid premiums applies, if a premium payment is overdue when a claim for benefits is made, what may the insurer do?
When the provision concerning unpaid premiums applies, if a premium payment is overdue when a claim for benefits is made, what may the insurer do?
Under a provision known as time payment of claims, after receiving proof of loss, when are all benefits other than those that are paid in periodic installments supposed to be paid?
Under a provision known as time payment of claims, after receiving proof of loss, when are all benefits other than those that are paid in periodic installments supposed to be paid?
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What type of policy gives the insurer the option to terminate the policy on a date specified in the contract?
What type of policy gives the insurer the option to terminate the policy on a date specified in the contract?
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Under a cancelable health insurance policy, coverage may be terminated by whom?
Under a cancelable health insurance policy, coverage may be terminated by whom?
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If an individual health contract is issued on a conditionally renewable basis, the insurer has a right to refuse renewal for what reason?
If an individual health contract is issued on a conditionally renewable basis, the insurer has a right to refuse renewal for what reason?
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After an insured gives notice of loss, what must he/she do if the insurer does not furnish forms?
After an insured gives notice of loss, what must he/she do if the insurer does not furnish forms?
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The reinstatement provision in a health insurance policy is considered what?
The reinstatement provision in a health insurance policy is considered what?
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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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When an insured changes to a more hazardous occupation, which policy provision allows an insurer to adjust policy benefits and rates?
When an insured changes to a more hazardous occupation, which policy provision allows an insurer to adjust policy benefits and rates?
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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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The type of policy where the insurer can send a notice to the insured that the policy has been canceled in the middle of the term is called what?
The type of policy where the insurer can send a notice to the insured that the policy has been canceled in the middle of the term is called what?
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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 what?
A health insurance policy where the insurer has the right to terminate the policy for reasons other than the insured's health is called what?
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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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According to the Affordable Care Act, a grandfathered group health plan MUST cover what?
According to the Affordable Care Act, a grandfathered group health plan MUST cover what?
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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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States that have 'no loss no gain' laws require a replacing policy to do what?
States that have 'no loss no gain' laws require a replacing policy to do what?
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A health insurance policy that allows an insurer to change the policyowner's premiums, but NOT cancel the policy is called a(n)?
A health insurance policy that allows an insurer to change the policyowner's premiums, but NOT cancel the policy is called a(n)?
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All of the following are functions of an insuring clause EXCEPT?
All of the following are functions of an insuring clause EXCEPT?
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A company may change the wording of a uniform policy provision in its health insurance policies only if the?
A company may change the wording of a uniform policy provision in its health insurance policies only if the?
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Suppose an insurance contract contains inconsistent or contradictory provisions. A court is likely to rely on what?
Suppose an insurance contract contains inconsistent or contradictory provisions. A court is likely to rely on what?
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Because the design and wording of a policy are in the hands of the insurer, insurance policies are said to be what?
Because the design and wording of a policy are in the hands of the insurer, insurance policies are said to be what?
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The consideration clause in health insurance usually lists the insured's consideration given for the policy as what?
The consideration clause in health insurance usually lists the insured's consideration given for the policy as what?
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What type of health insurance policy may NOT be changed in any way by the insurer, up to a specified age, so long as the premiums are paid?
What type of health insurance policy may NOT be changed in any way by the insurer, up to a specified age, so long as the premiums are paid?
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Which one of the following makes health insurance claim handling more convenient for the insured?
Which one of the following makes health insurance claim handling more convenient for the insured?
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After an insured gives notice of loss, what must he/she do if the insurer does not furnish forms?
After an insured gives notice of loss, what must he/she do if the insurer does not furnish forms?
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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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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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Richard owns an insurance policy that is renewable only at the option of the insurance company. His policy is considered to be what?
Richard owns an insurance policy that is renewable only at the option of the insurance company. His policy is considered to be what?
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Study Notes
Health Insurance Policy Provisions
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Adjusting Benefits: If a health insurance company discovers an insured has misstated their age, it can adjust benefits accordingly.
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Misstatement of Age Provision: This is a standard optional provision that affects health policies.
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Overdue Premiums: Insurers may deduct overdue premium amounts from benefits, especially when a claim is made while premiums are unpaid.
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Time Payment of Claims: Benefits, except those in periodic installments, must be paid immediately upon receiving proof of loss.
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Optionally Renewable Policies: Insurers can terminate these policies on a specified date outlined in the contract.
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Cancelable Coverage: In a cancelable health insurance policy, either the insured or the insurer can terminate the coverage.
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Conditionally Renewable Basis: Insurers can refuse renewal based on specific reasons stated in the contract, not just changes in health status.
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Proof of Loss Requirements: If the insurer does not provide claim forms after a loss notice, the insured must file written proof of loss.
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Reinstatement Provision: This is a mandatory provision in health insurance policies.
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Coordination of Benefits: This provision determines how payment is shared between primary and secondary insurers during a claim.
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Change of Occupation Provision: This allows insurers to adjust benefits and rates if an insured changes to a more hazardous occupation.
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Legal Actions Provision: Stipulates the time limit for filing claim disputes in an accident and health policy.
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Cancelable Policies: Policies that insurers can cancel mid-term by sending a notice to the insured.
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Guaranteed Renewable Policies: These allow insurers to adjust premiums but prohibit cancellation as long as premiums are paid.
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Free-Look Period: Functions of an insuring clause do not primarily address the free-look period but rather details conditions and benefits.
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Modification of Policy Provisions: Changes to uniform policy provisions must be no less favorable to the insured.
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Hierarchy of Contract Provisions: Courts may prioritize handwritten provisions over typewritten and printed materials in case of inconsistencies.
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Contracts of Adhesion: Health insurance policies are considered contracts of adhesion due to the insurer's control over contents and resolution of ambiguities in favor of the insured.
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Consideration Clause: Typically lists the insured’s consideration as payment of the first premium and the application.
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Noncancelable Policies: Insurers cannot change these policies as long as premiums are paid until a specified age.
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Assignment of Medical Payments: This facilitates easier claim handling by assigning medical expense payments directly to service providers.
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Guaranteed Renewable Premiums: In policies with guaranteed renewable premiums, insurers cannot increase premiums individually or cancel policies under certain conditions.
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Optionally Renewable Policies: Richard's insurance policy, which is renewable only at the insurer's discretion, falls under this category.
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Description
Test your knowledge on health insurance policy provisions with these flashcards. This quiz covers important concepts like adjusting benefits and the misstatement of age. Learn how these provisions impact coverage and premiums.
