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?
- Common Carrier Insurance
- Blanket
- Liability Insurance
- Limited Accident (correct)
Which statement is inaccurate regarding an Accidental Death and Dismemberment Policy?
Which statement is inaccurate regarding an Accidental Death and Dismemberment Policy?
- It pays benefits for loss of sight in one eye.
- It provides a specified payment for a specified injury. (correct)
- It generally includes a Principal payment for death and dismemberment.
- It may be written separately or added to another type of policy.
How best can a Limited Accident Policy be defined?
How best can a Limited Accident Policy be defined?
- Provides specific benefits for specific injuries from specific causes. (correct)
- Only applicable for a limited time post-accident.
- Includes broad coverage for various accidents.
- Restricts coverage to a geographical area.
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?
Which statement about Medicare is NOT accurate?
Which statement about Medicare is NOT accurate?
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?
Which scenario would be covered by a Limited Accident Policy?
Which scenario would be covered by a Limited Accident Policy?
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?
Which of the following is NOT provided under Part A of Medicare?
Which of the following is NOT provided under Part A of Medicare?
Which statement about Medicare Part B is INCORRECT?
Which statement about Medicare Part B is INCORRECT?
What is the primary purpose of Medicaid?
What is the primary purpose of Medicaid?
What does Part A of Medicare represent?
What does Part A of Medicare represent?
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?
Which of the following injuries is NOT excluded from coverage?
Which of the following injuries is NOT excluded from coverage?
Which Long-Term Care definition is incorrectly matched?
Which Long-Term Care definition is incorrectly matched?
What service is NOT typically included in LTC policies offering homecare?
What service is NOT typically included in LTC policies offering homecare?
An insurer must provide which of the following if offering Medicare Supplements?
An insurer must provide which of the following if offering Medicare Supplements?
Which of the following is NOT considered a Long-Term Care facility?
Which of the following is NOT considered a Long-Term Care facility?
Which optional LTC service is specifically designed to relieve caregivers?
Which optional LTC service is specifically designed to relieve caregivers?
What is the correct definition of a preexisting condition in LTC policies?
What is the correct definition of a preexisting condition in LTC policies?
Which salary amount will determine Louise's maximum disability benefit?
Which salary amount will determine Louise's maximum disability benefit?
What should an insurer include when canceling a contract?
What should an insurer include when canceling a contract?
What action will the insurer take if Hank's age was misrepresented?
What action will the insurer take if Hank's age was misrepresented?
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?
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?
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?
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?
Which term and definition do not match correctly?
Which term and definition do not match correctly?
Which clause specifies coverage limits for Jim's policy?
Which clause specifies coverage limits for Jim's policy?
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?
Why do insurers include provisions in contracts?
Why do insurers include provisions in contracts?
When can an insurer cancel a policy without notice?
When can an insurer cancel a policy without notice?
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?
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?
What constitutes the entire contract between the insurer and insured?
What constitutes the entire contract between the insurer and insured?
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?
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?
Which of the following is not classified as a Mandatory Uniform Provision?
Which of the following is not classified as a Mandatory Uniform Provision?
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?
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?
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?
If liability is denied due to intoxication, which provision is being applied?
If liability is denied due to intoxication, which provision is being applied?
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?
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?
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?
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?
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?
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?
Flashcards
What is a Limited Accident Policy?
What is a Limited Accident Policy?
This type of policy provides specific benefits for specific injuries from specific causes, such as travel accidents.
What is Common Carrier Insurance?
What is Common Carrier Insurance?
This insurance type is specifically designed to cover individuals who use public transportation for travel, protecting them against injuries during their commute.
What is an Accidental Death and Dismemberment Policy (AD&D)?
What is an Accidental Death and Dismemberment Policy (AD&D)?
This policy provides a lump sum payment if the insured dies or experiences a specific type of dismemberment due to an accident.
How does a Limited Accident Policy differ from an AD&D?
How does a Limited Accident Policy differ from an AD&D?
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Who is eligible for Medicare?
Who is eligible for Medicare?
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How does Medicare relate to private insurance?
How does Medicare relate to private insurance?
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What is the initial enrollment period for Medicare?
What is the initial enrollment period for Medicare?
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How is Medicare funded?
How is Medicare funded?
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What are Medicare Part A and Part B?
What are Medicare Part A and Part B?
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Is Medicare Part A premium free?
Is Medicare Part A premium free?
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Is Medicare Part B required?
Is Medicare Part B required?
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What does Medicare Part B cover?
What does Medicare Part B cover?
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What is Medicaid?
What is Medicaid?
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What is long-term care insurance?
What is long-term care insurance?
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What is an example of an inclusion in long-term care insurance?
What is an example of an inclusion in long-term care insurance?
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What is residential care?
What is residential care?
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What is respite care?
What is respite care?
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What is Core Benefit Plan A in Medicare Supplement insurance?
What is Core Benefit Plan A in Medicare Supplement insurance?
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What is required of long-term care facilities?
What is required of long-term care facilities?
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What is a preexisting condition in long-term care insurance?
What is a preexisting condition in long-term care insurance?
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What is Medicare Supplement insurance?
What is Medicare Supplement insurance?
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What is Medicare + Choice?
What is Medicare + Choice?
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What is covered under Medicare Part A?
What is covered under Medicare Part A?
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What is the role of the Entire Contract provision?
What is the role of the Entire Contract provision?
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How soon does the insured need to notify the insurer of a loss?
How soon does the insured need to notify the insurer of a loss?
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How long does the insured have to provide proof of loss?
How long does the insured have to provide proof of loss?
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Can an insurer cancel a policy due to the insured's age?
Can an insurer cancel a policy due to the insured's age?
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What is a preexisting condition in health insurance?
What is a preexisting condition in health insurance?
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What is the role of the Optional Uniform Provisions?
What is the role of the Optional Uniform Provisions?
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Under what circumstances might the Intoxicants and Narcotics provision be invoked?
Under what circumstances might the Intoxicants and Narcotics provision be invoked?
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Can the insurer deny coverage if the insured is injured during an illegal act?
Can the insurer deny coverage if the insured is injured during an illegal act?
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What happens to benefits if the insured changes to a more hazardous occupation?
What happens to benefits if the insured changes to a more hazardous occupation?
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Can the insured benefit from a change to a less hazardous occupation?
Can the insured benefit from a change to a less hazardous occupation?
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What happens if an insured has multiple policies with the same insurer and suffers a loss?
What happens if an insured has multiple policies with the same insurer and suffers a loss?
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Is the insurer required to comply with state statutes?
Is the insurer required to comply with state statutes?
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Can the insurer request a physical exam or autopsy?
Can the insurer request a physical exam or autopsy?
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What is the role of the Reinstatement provision?
What is the role of the Reinstatement provision?
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What does the Payments of Claims provision address?
What does the Payments of Claims provision address?
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Other Insurance With This Insurer
Other Insurance With This Insurer
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Relations of Earnings to Insurance
Relations of Earnings to Insurance
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Cancellation
Cancellation
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Misstatement of Age
Misstatement of Age
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Legal Actions Provision
Legal Actions Provision
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Physical Exam & Autopsy
Physical Exam & Autopsy
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Unpaid Premiums
Unpaid Premiums
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Grace Period
Grace Period
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Noncancellable
Noncancellable
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Optionally Renewable
Optionally Renewable
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Guaranteed Renewable
Guaranteed Renewable
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Cancellable
Cancellable
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Insuring Clause
Insuring Clause
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Probationary Period
Probationary Period
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Provisions to Reduce Claims
Provisions to Reduce Claims
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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.
