Podcast
Questions and Answers
What is the shortest grace period allowed for weekly premium policies?
What is the shortest grace period allowed for weekly premium policies?
Which statement is true regarding changes to a health insurance policy?
Which statement is true regarding changes to a health insurance policy?
What happens if the premium is not paid by the end of the grace period?
What happens if the premium is not paid by the end of the grace period?
How long is the grace period for monthly premium policies?
How long is the grace period for monthly premium policies?
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Which of the following is directly tied to the premium payment mode?
Which of the following is directly tied to the premium payment mode?
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Within how many days must the insured provide notice of a claim after a loss occurs?
Within how many days must the insured provide notice of a claim after a loss occurs?
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What is the usual timeframe for an insurer to send claims forms after receiving notice of a claim?
What is the usual timeframe for an insurer to send claims forms after receiving notice of a claim?
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What happens if the claims forms are not provided by the insurer?
What happens if the claims forms are not provided by the insurer?
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What is the maximum time allowed for submitting proof of loss after a loss occurs?
What is the maximum time allowed for submitting proof of loss after a loss occurs?
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Under which condition does the one-year limit for submitting proof of loss not apply?
Under which condition does the one-year limit for submitting proof of loss not apply?
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When are claims typically required to be paid following the submission of proof of loss?
When are claims typically required to be paid following the submission of proof of loss?
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What is the standard minimum time frame for paying disability income benefits?
What is the standard minimum time frame for paying disability income benefits?
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To whom are claims payments made if the insured is deceased and there is no designated beneficiary?
To whom are claims payments made if the insured is deceased and there is no designated beneficiary?
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What does the facility of payment clause allow insurers to do?
What does the facility of payment clause allow insurers to do?
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What is the insurer's duty regarding proof of loss?
What is the insurer's duty regarding proof of loss?
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What rights does the insurer have concerning physical examinations?
What rights does the insurer have concerning physical examinations?
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What happens to pending claims if the insured has assigned benefits to a hospital?
What happens to pending claims if the insured has assigned benefits to a hospital?
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Regarding claims payments, which statement is NOT correct?
Regarding claims payments, which statement is NOT correct?
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Which group is responsible for claims forms and the time of payment of claim?
Which group is responsible for claims forms and the time of payment of claim?
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What is the time limit for an insurer to deny a claim based on misstatements made in the application?
What is the time limit for an insurer to deny a claim based on misstatements made in the application?
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What must the insured do before bringing legal action against an insurer?
What must the insured do before bringing legal action against an insurer?
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In the case of a misstatement of age, how are policy benefits adjusted?
In the case of a misstatement of age, how are policy benefits adjusted?
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What action can an insurer take if fraud is discovered at any point during the policy's term?
What action can an insurer take if fraud is discovered at any point during the policy's term?
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How long does a claimant have to file a lawsuit after the proof of loss?
How long does a claimant have to file a lawsuit after the proof of loss?
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What can a claim for loss occurring after 2 years not be denied based on?
What can a claim for loss occurring after 2 years not be denied based on?
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What does the entire contract provision guarantee in a health insurance policy?
What does the entire contract provision guarantee in a health insurance policy?
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Who has the authority to make changes to an individual health insurance policy?
Who has the authority to make changes to an individual health insurance policy?
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Which statement is true regarding the wording in individual health insurance policies?
Which statement is true regarding the wording in individual health insurance policies?
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What is the primary purpose of the provisions established under the NAIC law?
What is the primary purpose of the provisions established under the NAIC law?
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Which of the following must be included in the contract as per the entire contract provision?
Which of the following must be included in the contract as per the entire contract provision?
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What is a mandatory requirement of individual health insurance policies under the NAIC law?
What is a mandatory requirement of individual health insurance policies under the NAIC law?
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What happens if the premium is not paid by the end of the grace period?
What happens if the premium is not paid by the end of the grace period?
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Under which condition is reinstatement automatic?
Under which condition is reinstatement automatic?
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What is the coverage condition for accidents after reinstatement?
What is the coverage condition for accidents after reinstatement?
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What must the policyholder do if the beneficiary designation is irrevocable?
What must the policyholder do if the beneficiary designation is irrevocable?
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What is the insurer’s right regarding the reinstatement application?
What is the insurer’s right regarding the reinstatement application?
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How many days does the insurer have to refuse a conditional receipt before coverage is reinstated?
How many days does the insurer have to refuse a conditional receipt before coverage is reinstated?
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What happens if an insured person is injured while engaged in an illegal occupation?
What happens if an insured person is injured while engaged in an illegal occupation?
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Under the relation of earnings to insurance provision, how is the benefit amount calculated?
Under the relation of earnings to insurance provision, how is the benefit amount calculated?
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What is the minimum benefit that can be provided to the insured?
What is the minimum benefit that can be provided to the insured?
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If benefits exceed the monthly earnings of the insured, what is the insurer required to do?
If benefits exceed the monthly earnings of the insured, what is the insurer required to do?
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When may the benefits be reduced on a pro rata basis?
When may the benefits be reduced on a pro rata basis?
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What happens to the benefits if the insured changes to a more hazardous occupation?
What happens to the benefits if the insured changes to a more hazardous occupation?
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In which scenario can an insured apply for a rate reduction?
In which scenario can an insured apply for a rate reduction?
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Why is occupation an important consideration in underwriting health insurance?
Why is occupation an important consideration in underwriting health insurance?
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What do health insurance policies typically include regarding changes in occupation?
What do health insurance policies typically include regarding changes in occupation?
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If an insured misstates their age on an insurance application, what occurs?
If an insured misstates their age on an insurance application, what occurs?
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Study Notes
Mandatory Provisions
- Uniform Individual Accident and Sickness Policy Provisions Law set by NAIC is adopted nationally, standardizing individual health insurance policies.
- Provisions define rights and responsibilities of both insurers and policyholders; modifications must not be less favorable to the insured.
Entire Contract
- Health insurance policy, signed application, and amendments form the complete contract.
- Changes require written consent from both parties and must be documented by company executives.
Grace Period
- Grace period allows time post-due date for premium payment before policy lapses:
- 7 days for weekly premiums
- 10 days for monthly premiums
- 31 days for other modes
- Coverage remains active during the grace period.
Reinstatement
- Failure to pay premiums by the end of the grace period leads to policy lapse.
- Coverage reinstatement is automatic if premiums are accepted without an application; otherwise, company must respond to reinstatement applications within 45 days.
- Accidents are covered immediately after reinstatement; coverage for sickness begins after 10 days.
Change of Beneficiary
- Policyholders may change the beneficiary anytime via written request without consent, unless designation is irrevocable.
Claims Procedures
- Notice of claim must be provided within 20 days of loss; agent notice equals insurer notice.
- Insurers must supply claims forms within a specified period (commonly 15 days).
- Proof of loss must be submitted within 90 days or within one year if legally competent.
Time of Payment of Claims
- Claims paid immediately upon written proof of loss; common payment timelines include 60, 45, or 30 days.
- Disability benefits must be disbursed at least monthly.
Payment of Claims
- All benefits payable to the insured during their lifetime; if deceased, benefits go to beneficiaries or the estate.
- Insurers may expedite claim payments to those with equitable entitlement through a facility of payment clause.
Physical Examination and Autopsy
- Insurer may examine the insured during claim processing and conduct autopsies as permitted by law.
Time Limit on Certain Defenses (Incontestable)
- No claims denied based on statements in the application after two years of policy duration, barring fraud.
- Conditions or diseases not excluded cannot be used as grounds for claim denial for losses occurring after two years.
Legal Actions
- Legal claims against the insurer can only be made after 60 days and up to three years after proof of loss.
Misstatement of Age or Gender
- Benefits will be adjusted based on what the premiums would have purchased at the correct age if a misstatement occurs.
Change of Occupation
- Insurer adjusts benefits based on the hazard level of the insured's occupation; benefits may be reduced for more hazardous jobs.
- Policyholders can request a rate reduction for moves to less hazardous occupations.
Insurance Clauses
- Benefits denied for injuries sustained during illegal acts or occupations.
- Relation of earnings provision limits benefits to the insured's average income over the past 24 months; insurer must return unpayable premium amounts if benefits exceed average earnings while ensuring a minimum benefit of $200 per month.
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Description
Test your knowledge on the Uniform Individual Accident and Sickness Policy Provisions Law, established by the NAIC. This quiz covers key provisions that are standard in individual health insurance policies across states. Understand how these provisions relate to life insurance as well.
