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Questions and Answers
What does the entire contract provision state about changes to a health insurance policy?
What does the entire contract provision state about changes to a health insurance policy?
Which of the following is NOT a requirement of the NAIC's Uniform Individual Accident and Sickness Policy Provisions Law?
Which of the following is NOT a requirement of the NAIC's Uniform Individual Accident and Sickness Policy Provisions Law?
What is the primary purpose of including standard provisions in individual health insurance policies?
What is the primary purpose of including standard provisions in individual health insurance policies?
Which of the following statements about modifications to health insurance policies is correct?
Which of the following statements about modifications to health insurance policies is correct?
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What is the minimum grace period for weekly premium policies?
What is the minimum grace period for weekly premium policies?
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What happens if the premium isn't paid by the end of the grace period?
What happens if the premium isn't paid by the end of the grace period?
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How does the NAIC's law ensure the rights of policyholders?
How does the NAIC's law ensure the rights of policyholders?
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Which of the following can insurers not do under the provisions of the NAIC law?
Which of the following can insurers not do under the provisions of the NAIC law?
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Under what condition can reinstatement be automatic?
Under what condition can reinstatement be automatic?
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What is the coverage period for sickness after a policy is reinstated?
What is the coverage period for sickness after a policy is reinstated?
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How long does a company have to respond to a reinstatement application before it is automatically approved?
How long does a company have to respond to a reinstatement application before it is automatically approved?
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Which aspect of a policy is tied directly to the grace period?
Which aspect of a policy is tied directly to the grace period?
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What action can the policyowner take regarding the beneficiary?
What action can the policyowner take regarding the beneficiary?
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Which of the following is NOT true about the grace period?
Which of the following is NOT true about the grace period?
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What is required for a policyowner to change a beneficiary designation under a non-irrevocable designation?
What is required for a policyowner to change a beneficiary designation under a non-irrevocable designation?
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What is the maximum time frame allowed for submitting a proof of loss after a claim occurs?
What is the maximum time frame allowed for submitting a proof of loss after a claim occurs?
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Within how many days must the insurer supply claims forms after receiving a notice of claim?
Within how many days must the insurer supply claims forms after receiving a notice of claim?
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If an insurer fails to provide claims forms, what is the alternative requirement for the claimant?
If an insurer fails to provide claims forms, what is the alternative requirement for the claimant?
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What stipulation applies to the time of payment of claims related to disability income benefits?
What stipulation applies to the time of payment of claims related to disability income benefits?
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What is the insured's duty regarding notice of claim after a loss occurs?
What is the insured's duty regarding notice of claim after a loss occurs?
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What happens if the claimant is not legally competent to comply with the one-year limit for submitting proof of loss?
What happens if the claimant is not legally competent to comply with the one-year limit for submitting proof of loss?
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In a scenario where a beneficiary designation is irrevocable, what must the policyholder do to make a change?
In a scenario where a beneficiary designation is irrevocable, what must the policyholder do to make a change?
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What is the impact of a claim for loss incurred after 2 years from policy issuance?
What is the impact of a claim for loss incurred after 2 years from policy issuance?
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What is the time frame for a claimant to seek legal action against an insurer after proving a loss?
What is the time frame for a claimant to seek legal action against an insurer after proving a loss?
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How are benefits adjusted when there is a misstatement of age on an application?
How are benefits adjusted when there is a misstatement of age on an application?
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What happens to benefits if an insured changes to a more hazardous occupation?
What happens to benefits if an insured changes to a more hazardous occupation?
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What can an insured do if they change to a less hazardous occupation?
What can an insured do if they change to a less hazardous occupation?
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What is the primary consideration for insurers when assessing the risk of applicants?
What is the primary consideration for insurers when assessing the risk of applicants?
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To whom are benefits of an insurance policy payable while the insured is alive?
To whom are benefits of an insurance policy payable while the insured is alive?
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What happens to benefits if the insured passes away and there is no beneficiary?
What happens to benefits if the insured passes away and there is no beneficiary?
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What does the facility of payment clause allow the insurer to do?
What does the facility of payment clause allow the insurer to do?
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Under what circumstances can an insurer deny a claim after a policy has been in force for two years?
Under what circumstances can an insurer deny a claim after a policy has been in force for two years?
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What is required from the insured during a claim process according to the duties outlined?
What is required from the insured during a claim process according to the duties outlined?
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What right does the insurer have regarding physical examinations during a claim?
What right does the insurer have regarding physical examinations during a claim?
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Which provision prevents the insurer from using certain statements to deny a claim after a specific time period?
Which provision prevents the insurer from using certain statements to deny a claim after a specific time period?
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What does the insurer typically require in regard to an autopsy?
What does the insurer typically require in regard to an autopsy?
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Under what circumstance will liability be denied to the insured?
Under what circumstance will liability be denied to the insured?
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What is the minimum benefit that can be reduced to under the relation of earnings to insurance provision?
What is the minimum benefit that can be reduced to under the relation of earnings to insurance provision?
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What happens if the total benefits exceed the insured's average monthly earnings?
What happens if the total benefits exceed the insured's average monthly earnings?
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How is the insurer's liability calculated if there are multiple policies involved?
How is the insurer's liability calculated if there are multiple policies involved?
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In the event of reduced benefits, what does the insurer require to return?
In the event of reduced benefits, what does the insurer require to return?
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Study Notes
Mandatory Provisions Overview
- The Uniform Individual Accident and Sickness Policy Provisions Law is adopted in all states, standardizing provisions in individual health insurance policies.
- Provisions define rights and duties of insurers and policyholders, allowing for rewording if it favors the policyholder.
Entire Contract
- The policy, signed application, and amendments constitute the entire contract.
- Changes require written agreement from both the insurer and policyholder, enforced only by an executive officer.
Grace Period
- A grace period allows for late premium payment without policy lapse.
- Minimum grace periods are:
- 7 days for weekly policies
- 10 days for monthly policies
- 31 days for other payment modes.
- Coverage remains active during the grace period.
Reinstatement
- Policies lapse if premiums are unpaid after the grace period.
- Reinstatement may be automatic if the insurer accepts the premium without a new application.
- If a new application is needed, coverage reinstated within 45 days; accidents covered immediately, sickness after 10 days.
Change of Beneficiary
- Policyholders can change beneficiaries at any time with a written request.
- Consent from beneficiaries is not needed unless their designation is irrevocable.
Claims Procedures
- Insured must provide notice of claim within 20 days or as soon as possible; notice to an agent is considered notice to the insurer.
- Insurers must provide claims forms within 15 days of notice.
- Proof of loss must be submitted within 90 days of loss.
- Claims payable within specified times (30, 45, or 60 days); disability payments must be monthly.
Payment of Claims
- Claims are payable to the insured while living; upon death, to the beneficiary or estate.
- Some policies may expedite urgent claim payments through a facility of payment clause.
Physical Examination and Autopsy
- Insurers may require physical exams at their expense as necessary during a claim.
- Autopsies may also be conducted unless restricted by law.
Time Limit on Certain Defenses (Incontestable)
- No application misstatements (except fraud) can deny a claim after 2 years of policy issuance.
- Insurers may deny claims for fraud at any time.
Loss Incurred or Disability After 2 Years
- Claims for losses or disabilities starting after 2 years cannot be denied due to pre-existing conditions.
Legal Actions
- Claimants must wait 60 days and have a maximum of 3 years to initiate legal action after proof of loss.
Misstatement of Age or Gender
- Claims benefits may adjust based on the corrected age or gender as per premiums paid.
Change of Occupation
- Insurers may adjust benefits if an insured changes to a more hazardous occupation, reverting to what premiums would have covered for that risk.
- Policyholders can request rate reductions if moving to a less hazardous occupation.
Illegal Occupation
- Liability is denied for injuries sustained during illegal activities or occupations.
Relation of Earnings to Insurance
- Benefits can be limited to the average income over the last 24 months.
- Excess benefits for all policies result in pro-rata reductions, not to fall below $200 per month, with unused premiums returned.
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Description
This quiz focuses on the key provisions of the Uniform Individual Accident and Sickness Policy Provisions Law, as established by the NAIC. It covers standard regulations that apply to individual health insurance policies across all states, highlighting similarities with life insurance. Test your understanding of these important insurance concepts.