Podcast
Questions and Answers
What type of insurance contract covers injuries sustained by a bus line passenger while traveling across the United States?
What type of insurance contract covers injuries sustained by a bus line passenger while traveling across the United States?
Which statement is inaccurate regarding an Accidental Death and Dismemberment Policy?
Which statement is inaccurate regarding an Accidental Death and Dismemberment Policy?
How best can a Limited Accident Policy be defined?
How best can a Limited Accident Policy be defined?
If Raymond, who has an Accidental Death and Dismemberment Policy, dies from coronary artery disease, what benefit can his beneficiary expect?
If Raymond, who has an Accidental Death and Dismemberment Policy, dies from coronary artery disease, what benefit can his beneficiary expect?
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Which statement about Medicare is NOT accurate?
Which statement about Medicare is NOT accurate?
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What type of benefit might be included in an Accidental Death and Dismemberment policy?
What type of benefit might be included in an Accidental Death and Dismemberment policy?
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Which scenario would be covered by a Limited Accident Policy?
Which scenario would be covered by a Limited Accident Policy?
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What is the principal benefit covered by an Accidental Death and Dismemberment Policy?
What is the principal benefit covered by an Accidental Death and Dismemberment Policy?
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Which of the following is NOT provided under Part A of Medicare?
Which of the following is NOT provided under Part A of Medicare?
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Which statement about Medicare Part B is INCORRECT?
Which statement about Medicare Part B is INCORRECT?
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What is the primary purpose of Medicaid?
What is the primary purpose of Medicaid?
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What does Part A of Medicare represent?
What does Part A of Medicare represent?
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Which type of care is described as being provided in a setting other than an acute care unit?
Which type of care is described as being provided in a setting other than an acute care unit?
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Which of the following injuries is NOT excluded from coverage?
Which of the following injuries is NOT excluded from coverage?
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Which Long-Term Care definition is incorrectly matched?
Which Long-Term Care definition is incorrectly matched?
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What service is NOT typically included in LTC policies offering homecare?
What service is NOT typically included in LTC policies offering homecare?
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An insurer must provide which of the following if offering Medicare Supplements?
An insurer must provide which of the following if offering Medicare Supplements?
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Which of the following is NOT considered a Long-Term Care facility?
Which of the following is NOT considered a Long-Term Care facility?
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Which optional LTC service is specifically designed to relieve caregivers?
Which optional LTC service is specifically designed to relieve caregivers?
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What is the correct definition of a preexisting condition in LTC policies?
What is the correct definition of a preexisting condition in LTC policies?
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Which salary amount will determine Louise's maximum disability benefit?
Which salary amount will determine Louise's maximum disability benefit?
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What should an insurer include when canceling a contract?
What should an insurer include when canceling a contract?
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What action will the insurer take if Hank's age was misrepresented?
What action will the insurer take if Hank's age was misrepresented?
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How long must you wait after proof of loss before taking legal action against an insurer?
How long must you wait after proof of loss before taking legal action against an insurer?
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What allows an insurer to request a physical exam or autopsy at their expense?
What allows an insurer to request a physical exam or autopsy at their expense?
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Why did the insurer deduct $200 from Susan’s claim after her injury?
Why did the insurer deduct $200 from Susan’s claim after her injury?
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What is the correct sequence of the grace period for individual medical expense policies?
What is the correct sequence of the grace period for individual medical expense policies?
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Which term and definition do not match correctly?
Which term and definition do not match correctly?
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Which clause specifies coverage limits for Jim's policy?
Which clause specifies coverage limits for Jim's policy?
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What happens if Abigail submits a claim for a preexisting condition during the probationary period?
What happens if Abigail submits a claim for a preexisting condition during the probationary period?
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Why do insurers include provisions in contracts?
Why do insurers include provisions in contracts?
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When can an insurer cancel a policy without notice?
When can an insurer cancel a policy without notice?
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What is the minimum period for which a claim must be open before it can be legally enforced?
What is the minimum period for which a claim must be open before it can be legally enforced?
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Under which provision might the insurer deny a claim based on employment-related injuries?
Under which provision might the insurer deny a claim based on employment-related injuries?
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What constitutes the entire contract between the insurer and insured?
What constitutes the entire contract between the insurer and insured?
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How many days does the insured have to notify the insurer of any loss under the Notice of Claim Provision?
How many days does the insured have to notify the insurer of any loss under the Notice of Claim Provision?
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What is the maximum period allowed for proving loss according to the Proof of Loss Provision?
What is the maximum period allowed for proving loss according to the Proof of Loss Provision?
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Which of the following is not classified as a Mandatory Uniform Provision?
Which of the following is not classified as a Mandatory Uniform Provision?
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What should be considered when submitting proof of loss for an insured in a coma?
What should be considered when submitting proof of loss for an insured in a coma?
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What happens if an insured does not notify the insurer of a change in occupation?
What happens if an insured does not notify the insurer of a change in occupation?
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At whose option are the Optional Uniform Provisions included in the insurance contract?
At whose option are the Optional Uniform Provisions included in the insurance contract?
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If liability is denied due to intoxication, which provision is being applied?
If liability is denied due to intoxication, which provision is being applied?
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What is the insurer's liability in the case of injury during the commission of an illegal act?
What is the insurer's liability in the case of injury during the commission of an illegal act?
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What occurs under the Other Insurance With This Insurer Provision if multiple contracts are held with the insurer?
What occurs under the Other Insurance With This Insurer Provision if multiple contracts are held with the insurer?
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When can an insurer enforce a waiting period after converting or replacing an existing coverage?
When can an insurer enforce a waiting period after converting or replacing an existing coverage?
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In connection with the Change of Occupation Provision, what incorrect statement might an insured believe?
In connection with the Change of Occupation Provision, what incorrect statement might an insured believe?
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Under the Notice of Claim Provision, which of the following would NOT be appropriate notice?
Under the Notice of Claim Provision, which of the following would NOT be appropriate notice?
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What term describes a condition for which treatment was received within 6 months before coverage became effective?
What term describes a condition for which treatment was received within 6 months before coverage became effective?
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Study Notes
Contract Coverage for Injuries and Accidents
- Bus Line Injuries: A passenger traveling across the US should purchase Limited Accident Insurance to cover injuries. A blanket policy is not specific enough.
- Accidental Death and Dismemberment (AD&D): This policy pays a specific amount for specific injuries. It may be a rider on another policy (health/disability/life). Benefits include payment for loss of sight in both eyes or any two limbs, while a smaller amount might be paid for one eye or one limb. Crucially, AD&D does not cover death from illness, such as coronary artery disease.
- Limited Accident Insurance: This policy specifically pays for injuries that occur from certain events and causes, during specific activities.
Medicare Coverage
- Medicare Primary Payor: Medicare is not always the primary payor. Employer group health plans with 20 or more employees are primary and pay first.
- Medicare Eligibility: Medicare is a federal health program for people 65 and older, and others who have received Social Security Disability Benefits for at least two years.
- Enrollment Period: The initial Medicare enrollment period lasts 7 months, starting 3 months prior to eligibility.
- Provider Qualifications: Medicare-participating hospitals and providers must be licensed by the state.
Medicare Parts
- Medicare Part A (Hospital Insurance): This covers hospital care (inpatient), skilled nursing facility care after a hospital stay, and some home health care but does not cover outpatient hospital treatment.
- Medicare Part B (Medical Insurance): This is an optional part, offered when a person is eligible for Part A. It covers routine physical exams and dialysis for those with kidney failure, while outpatient service benefits are determined by a national fee schedule. It does not cover long-term care.
Other Insurance Programs
- Medicaid (Medi-Cal): This is a federal and state program assisting those unable to pay for medical needs.
- Long-Term Care: This is coverage for a variety of health care services in settings outside a hospital's acute care unit. This can include home healthcare, respite care, and custodial care facilities. However, home care in a planned program by a physician is not exactly long-term care; instead, it is a form of home convalescent care.
- Exclusions in LTC: Intentionally self-inflicted injuries, elective cosmetic surgery, and care in a government facility are exclusions. Non-occupational injuries are NOT exclusions.
- Medicare Supplement: If an insurer sells Medicare Supplement plans, they must offer Plan A.
- LTC Facilities: Skilled nursing facilities, intermediate care facilities, and custodial care facilities are examples of approved facilities. Sanitariums for weight loss are not.
Policy Provisions
- Entire Contract: The policy, application, and endorsements make up the entire contract.
- Proof of Loss: Proof of loss is required within 90 days of the loss, or within the shortest possible time but not to exceed one year, unless there is legal incapacity.
- Notice of Claim: Submit a notice of claim within 20 days of the loss.
- Mandatory Uniform Provisions: (Examples) Payment of Claims, Reinstatement, Physical Exam and Autopsy
- Optional Uniform Provisions: These are included at the insurer's option and must conform to state insurance codes. (Examples): Unpaid Premiums, Intoxicants and Narcotics
- Change of Occupation: A change in occupation (e.g., job duty) may trigger rate changes or other adjustments. Failure to notify the insurer about a change to a more hazardous occupation does not cause contract cancellation.
- Illegal Act: Injury while committing a crime isn't covered.
- Other Insurance with This Insurer: Only one policy of the same type pays.
- Relations of Earnings to Insurance: Disability benefits are based on the insured's earnings at the time the disability commenced or their average earnings in the two years before the disability, whichever is higher.
- Cancellation: Insurers can typically cancel contracts with written notice within 5 to 31 days.
- Misstatement of Age: If an insured misstates their age, the insurer may refund any excess premiums paid beyond the correct age.
- Legal Actions: If dissatisfied with a claim payment, legal action must be taken after 60 days.
- Physical Examination/Autopsy: A physical exam or autopsy is possible at the insurer's expense, and if not prohibited by law.
- Unpaid Premiums: Insurers can deduct unpaid premiums from claims payout.
- Grace Periods: Weekly payments have a 7-day grace period, monthly payments have a 10-day grace period, all others have a 31-day grace period.
- Preexisting Conditions: Conditions for which advice or treatment was received within 6 months of coverage start are considered preexisting. Insurers may reduce or deny claims for these during a probationary period.
- Concurrent Review or Mandatory Second Surgical Options: These procedures help reduce health care costs and prevent overpayment of claims .
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Description
Explore the intricacies of accident insurance, including Limited Accident Insurance and Accidental Death and Dismemberment (AD&D) policies. Additionally, understand Medicare's role as a primary payor and eligibility criteria. Test your knowledge on these important insurance topics.
