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What are the components of your policy that outline specific benefits, terms, conditions, or other important features?
What are the components of your policy that outline specific benefits, terms, conditions, or other important features?
Provisions
What provision states that the policy and a copy of the application, along with any riders or amendments, constitute the entire contract?
What provision states that the policy and a copy of the application, along with any riders or amendments, constitute the entire contract?
Entire Contract
What is the time period after a premium is due during which the policyholder can make a payment without losing coverage?
What is the time period after a premium is due during which the policyholder can make a payment without losing coverage?
Grace Period
What provision limits the time during which the insurer can deny a claim or void the policy due to a misstatement by the insured?
What provision limits the time during which the insurer can deny a claim or void the policy due to a misstatement by the insured?
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What provision outlines the conditions under which a lapsed policy can be reinstated?
What provision outlines the conditions under which a lapsed policy can be reinstated?
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What provision specifies the time frame within which the insured must notify the insurer of a claim?
What provision specifies the time frame within which the insured must notify the insurer of a claim?
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What provision obligates the insurer to provide claim forms to the insured within a specified time frame?
What provision obligates the insurer to provide claim forms to the insured within a specified time frame?
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What is a statement of facts about a loss for which the insured is making a claim called?
What is a statement of facts about a loss for which the insured is making a claim called?
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What provision provides for immediate payment of the claim after the insurer receives notification and proof of loss?
What provision provides for immediate payment of the claim after the insurer receives notification and proof of loss?
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What provision specifies to whom claims payments are to be made?
What provision specifies to whom claims payments are to be made?
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What provision allows an insurer, at its own expense, to have an insured physically examined when a claim is pending or to have an autopsy performed where not prohibited by law?
What provision allows an insurer, at its own expense, to have an insured physically examined when a claim is pending or to have an autopsy performed where not prohibited by law?
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What provision states that the insured cannot take legal action against the company in a claim dispute until after 60 days from the time the insured submits proof of loss?
What provision states that the insured cannot take legal action against the company in a claim dispute until after 60 days from the time the insured submits proof of loss?
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What provision outlines the conditions under which the insured, as policy owner, may change the beneficiary designation?
What provision outlines the conditions under which the insured, as policy owner, may change the beneficiary designation?
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What provision adjusts benefits or premiums if the insured's age or gender was misstated on the application?
What provision adjusts benefits or premiums if the insured's age or gender was misstated on the application?
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What provision allows the insurer to adjust benefits or premiums if the insured changes to a more hazardous occupation?
What provision allows the insurer to adjust benefits or premiums if the insured changes to a more hazardous occupation?
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What provision states that the insurer is not liable for coverage on injuries that are sustained during illegal activities?
What provision states that the insurer is not liable for coverage on injuries that are sustained during illegal activities?
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What provision allows the insurer to change policy benefit if the insured's income has decreased?
What provision allows the insurer to change policy benefit if the insured's income has decreased?
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What clause states the scope and limits of the coverage?
What clause states the scope and limits of the coverage?
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What provision permits policy owners 30 days in which to examine their new policy at no obligation?
What provision permits policy owners 30 days in which to examine their new policy at no obligation?
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What clause states the amount and frequency of premium payments?
What clause states the amount and frequency of premium payments?
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What is the period of time between the effective date of a health insurance policy and the date coverage for all or certain conditions begins?
What is the period of time between the effective date of a health insurance policy and the date coverage for all or certain conditions begins?
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What is the amount of time that lapses after a disabling event before the insurance company begins to pay benefits?
What is the amount of time that lapses after a disabling event before the insurance company begins to pay benefits?
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What provision waives premium payments during a period of total disability?
What provision waives premium payments during a period of total disability?
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What provision specifies conditions or circumstances not covered by the policy?
What provision specifies conditions or circumstances not covered by the policy?
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What are medical conditions that existed before the policy's start date called?
What are medical conditions that existed before the policy's start date called?
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What is the percentage of costs shared by the insured and insurer, typically after the deductible is met?
What is the percentage of costs shared by the insured and insurer, typically after the deductible is met?
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What is the amount the insured pays first before benefits are paid by the plan?
What is the amount the insured pays first before benefits are paid by the plan?
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What are medical expenses covered by the policy called?
What are medical expenses covered by the policy called?
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What is a fixed amount the insured pays for covered services, often at the time of service?
What is a fixed amount the insured pays for covered services, often at the time of service?
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What are the requirements for certain procedures or services requiring prior approval from the insurer to be covered?
What are the requirements for certain procedures or services requiring prior approval from the insurer to be covered?
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What are charges deemed reasonable for services in a geographical area, used to determine the amount covered by the insurer?
What are charges deemed reasonable for services in a geographical area, used to determine the amount covered by the insurer?
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What are caps on the benefits payable by the insurer over the policyholder's lifetime, annually, or per incident?
What are caps on the benefits payable by the insurer over the policyholder's lifetime, annually, or per incident?
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What is added to a policy to either expand coverage or waive coverage of certain conditions?
What is added to a policy to either expand coverage or waive coverage of certain conditions?
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What provision allows a policyholder to purchase specified amounts of additional insurance without the evidence of insurability?
What provision allows a policyholder to purchase specified amounts of additional insurance without the evidence of insurability?
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What provision provides the option to increase coverage amounts at future dates without additional medical exams?
What provision provides the option to increase coverage amounts at future dates without additional medical exams?
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What type of health insurance policy cannot be canceled by the company and must be renewed until a certain age with no change in premium?
What type of health insurance policy cannot be canceled by the company and must be renewed until a certain age with no change in premium?
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What kind of policy can be terminated by the company?
What kind of policy can be terminated by the company?
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What type of policy must be renewed (as long as premiums are paid) until the insured reaches a specified age?
What type of policy must be renewed (as long as premiums are paid) until the insured reaches a specified age?
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Study Notes
Policy Provisions, Clauses, and Riders
- Provision: Outlines benefits, terms, conditions, and policy features.
- Entire Contract: Policy, application, riders, and amendments form the complete agreement. Pre-contract statements are not used to change the contract.
- Grace Period: Time after a premium is due for payment without losing coverage (less than 30 days).
- Time Limit on Certain Defenses: Limits the time an insurer can deny a claim due to a misstatement by the insured.
- Reinstatement: Conditions for restoring a lapsed policy, requiring overdue premiums and proof of insurability.
- Notice of Claim: Specified time frame for notifying the insurer of a claim (typically within 20 days).
- Claim Forms: Insurer must provide claim forms within a set timeframe (usually 15 days).
- Proof of Loss: Statement of facts about the loss, usually within 90 days.
- Time of Payment of Claims: Payment timeframe after the insurer receives notification and proof of loss (within 45 days).
- Payment of Claims: Details on who receives claim payments.
- Physical Exam and Autopsy: Insurer can physically examine/perform autopsy, at own expense, if a claim is pending.
- Legal Actions: Insured can't sue the insurer until 60 days after submitting proof of loss.
- Change of Beneficiary: Policyholder can change beneficiaries at any time, unless irrevocably named.
- Misstatement of Age or Gender: Policy adjusts benefits or premiums based on misstated age/gender.
- Change of Occupation: Insurer can adjust benefits/premiums if the insured's occupation changes to a more hazardous one.
- Illegal Occupation: No coverage for injuries during illegal activities.
- Relation of Earning to Insurance: Insurer can adjust benefits if insured's income decreases - portion of premium may be refunded
- Insuring Clause: Defines the coverage scope and limits.
- Free Look: Policyholder has 30 days to examine the policy without obligation (like a free trial).
- Consideration Clause: States the premium amount and payment schedule.
- Probationary Period: Time between policy start and when all/certain conditions are covered.
- Elimination Period: Time after an event before benefits begin (around 30 days).
- Waiver of Premium: Waives premium payments during total disability, keeping the policy active.
- Exclusions and Limitations: Conditions or circumstances not covered by the policy.
- Preexisting Conditions: Conditions present before policy start, often excluded or with a waiting period.
- Coinsurance: Percentage of costs shared by the insured and insurer.
- Deductibles: Amount the insured pays before benefits are given by the plan.
- Eligible Expenses: Medical expenses covered by the policy.
- Co-payments: Fixed amount the insured pays for covered services.
- Pre-authorizations and Prior Approval requirements: Some procedures need prior insurer approval for coverage.
- Usual, Reasonable, and Customary (URC) Charges: Reasonable charges for services in an area, determining insurer coverage.
- Lifetime, Annual, or per cause maximum benefit limits: Caps on lifetime, annual, or per-incident benefit payouts.
- Riders: Add-ons to policies, expanding or waiving conditions.
- Impairment/Exclusions: Hazards leading policies to not pay benefits.
- Guaranteed Insurability (GIB): Option to increase coverage amount without further medical exams.
- Future Increase Option: Increases coverage amount at future dates without additional medical exams.
- Noncancelable: Policy the insurer must renew with no premium change until a certain age.
- Cancelable: Policy that the insurer can terminate.
- Guaranteed Renewable Policies: Policies renewed until a specified age (like 60 or 65).
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Description
Test your knowledge of key insurance policy provisions, clauses, and riders. This quiz covers essential concepts like grace periods, claim processes, and reinstatement conditions. Perfect for students and professionals looking to reinforce their understanding of insurance fundamentals.
