Accident And Health Flashcards
1
Q
Medicare part A hospital coverage is how long
A
They only provide full coverage for the first 60 days
2
Q
How much does medigap cover under core benefits
A
20%
3
Q
When are most health claims paid
A
Immediately
4
Q
Hom guarantee association limit per person
A
500k
5
Q
If employer is notified of group cancellation how many days does he have to inform everyone
A
10
6
Q
Days if insurer denies claim under a LTC
A
60
7
Q
Lifetime,per cause, and annual maximums are examples of
A
Benefit limits
8
Q
What is the most strict definition of total disability
A
Any occupation
9
Q
Health care FSA contribution is limited to
A
2550-5000
10
Q
What is the negative rider that excludes body parts
A
Impairment rider
11
Q
What is the time of payment of claims provision
A
Insurers must pay claims upon written proof of loss
12
Q
If someone is insure by both workers comp and a major medical who will pay a work related injury
A
Workers comp
13
Q
Another name for a basic policy that covers hospital expenses
A
Hospital indemnity plan
14
Q
How many days notify hmo if a baby is born
A
31 days
15
Q
Farthest back and insurer can name a pre existing condition
A
6 months
16
Q
Which policy can exclude accident or sickness
A
Workers comp
17
Q
Which insurers must participate in the life and health guarantee association
A
All admitted insurers
18
Q
Annual maximum for mental health impatient services
A
10 days
19
Q
Qualify for Medicaid while still owning assets provisional contract
A
Asset disregard
20
Q
Notice of claim provision states an insurance company must receive notice of claim by
A
20 days
21
Q
In a DI policy how many days under payment of claims provision
A
30
22
Q
What is the insurance clause
A
Face of the policy and provides the members of the policy
23
Q
Entire contrac
A
Policy riders endorsements and the application
24
Q
Time limit on certain defense
A
If a company does not list a préexisting condition within 2 or 3 years from the date of issuethen they cannot void or deny a claim
25
Grace period
Allows insured 7 days on weekly premium minimum 10 day on monthly premium and 31 days on longer modes ex qtr semi or annual
26
Reinstatement
if a policy lapses a new application will be required a conditional receipt will be given if the application is not approved the insurance company has 45 days to tell the insured or it automatically is reinstated
27
notice of claims
the company requires written notice of loss within 20 days
28
cliam forms
once the insured provides notice to company of a claim the company must provide the necessary forms within 15 days
29
proof of loss
written proof of loss must be given to the company within 90 days after the date of loss
30
time payment of claims
claims will be paid immediately upon proof of loss the exception DI incomce and LTC periodic payments for loss of time coverage shall commence not later than 30 days after receipt of proof
31
payment of claims
company pays claims to insured then beneficiary then estate
32
physical examination and autospy
company at own expense examine physical remains state law has priority on autopsy
33
LHSOcoverage
Under a Limited Health Service Organization limited services include ambulance, dental, vision, dental, pharmaceutical and podiatric care
34
Regardless of contract if an insurer goes insolvent, the maximum that will be paid for disability benefits is:
300,000
35
In the event of Group Health Insurance being discontinued or replaced, in the event of total disability, coverage must extend up to ______ in an HMO provided the insured still has benefit limits available under contract.
12 months
36
If an employer is notified of discontinuance of a group carrier, the policyholder has ______ to notify covered enrollees.
10 days
37
Six months into a policy year, the insured has satisfied all deductible and coinsurance requirements and no longer has to share in out of pocket expenses. This is known as
Stop Loss Limit
38
Which of the following provisions is required to be included in an individual disability policy?
Change of Beneficiary
39
The Free Look provision begins on
the policy delivery date
40
A policyholder can change the mode of premium
Anytime
41
If a business owner elects not to have coverage for workers under workers' compensation, they must have which of the following policies?
: 24-hour coverage
42
T has just returned back to work after a total disability but is only able to work half the day. T's policy pays the difference between what the employer pays T and what T earned prior to disability. T has:
rESIDUAL DIABILITY
43
If an insured has a Basic Surgical policy, the amount of benefit paid for a covered loss is specified in the:
Benefit SChedule
44
Flexible Spending Accounts are funded:
By the employee through pre-tax salary reduction
45
An Insurer must furnish an insured with Proof of Loss forms within a maximum of how many days after receiving notice of claim?
15 days
46
Guaranteed Insurability Rider
allows the insured to buy more coverage at future dates without proving insurability, based on attained age rate.
47
corridor deductible
If an insured has comprehensive major medical coverage, all money owed after the basic plan has paid first dollars but before the major medical policy will pay benefits is known as the corridor/integrated deductible.
48
Who establishes the regulations, eligibility, and benefit coverage for Medicaid
federal gov
49
The only way an insurer can legally discriminate against an individual during underwriting is based on:
actuarial principles
50
A basis of prepayment in which a fixed amount of money is prepaid per individual and found in some managed care plan is known as
per capita payment
51
Under law, a LTC policy must provide consecutive coverage for at least
12 months
52
what can stop you from being able to enroll in medicare
To enroll in Medicare under age 65 a person must be either at the end stage of renal failure or collecting Social Security disability for 2 years or more. Individual disability policies do not fulfill requirements to be insured under Medicare.
53
The date the coverage will legally begin is:
Issue Date
54
V's agent told her that by paying the premium initially upon application, the insurer will provide coverage immediatley. V has just be given a:
unconditional reporrt
55
H has a group major medical coverage through his employer. H's premiums paid are
ax deductible to the extent that H's premiums and unreimbursed expense exceed 7.5% of adjusted gross income when itemizing deductions
56
who is eligible for survival benfits under social security
Survivor benefits are for people who have had an insured worker die. Widows who are disabled ages 50-59, children up until age 18/19 if still in high school and dependent parents age 62 or older are eligible for social security benefits.
57
what is an insurance policy purchsed in direct response
a purchase of insurance with no agent where there is no legal requirement for an outline of coverage or policy checklist to be given at application,
58
T has worked for the same company for the last 20 years. T decides that it is time to retire and will elect to continue health benefits under an association that she is part of. If the new group has preexisting conditions, how many days from losing her old group plan does she have before there is a significant gap in coverage?
63 days
59
which date must someone report felonies
30 days from when they are entered (first date)
60
HMO law grace period
10 days
61
A producer earned a fee of $500 and a commission for the sale of an insurance product. Forty-five days after coverage began the insured cancelled the policy. What, if any, refund is the insured entitled to in this instance?
$250When a policy has been written under which the producer was paid a service fee and a commission, a prorated refund is payable within 30 days if the policy is cancelled within 90 days from the inception of the contract. In this case 45 days is half of 90 days and half of the service fee ($250) must be refunded.
62
the most an hmo will guarantee to pay
500000
63
What is a DI
relates to becoming ill or injured away from the job
64
individual DI
income is free from income tax benefits are paid after and elimination period also have probationary period which will tak 10-30 days to cover sickness have idemnity periods (benefit period) and range from 1 2 or 5 years
65
Business overhead expense
does not pay workers salary is a DI for a business elim period is short benefits can only be collected for a year or two premiums are tax deductible
66
Business disability buyout
cross purchase when two business owners take out a DI policy on each other and it covers there business if one goes down have long elim periods of a year or 2
67
Group Disability income policy
When employees of a company receive coverage for disability income as a result of their employment
68
AD&D
death pays a principal (Full) sum Dismemberment pays a capital (less than the principal) double dismemberment is presumptive disability
69
Major Medical POlicy
deals with prolonged coverage for serious illness is the one that requires a deductible and coinsurance also contains a stop loss limit and a corridor deductible the most expensive plan
70
HMO
Lower cost local geographic area based NEED REFERRAL insured is a "subscriber" doctors get paid Capitation(per head) of people under them no deductibles
71
Preferred Provider Organization PPO
An employer/ insurance co contracts with a hospital. Do not need referrals but it is more expensive has deductibles
72
Point of service POS
chracteristics of HMO and PPO no deductible and small copays(HMO) and freedom to choose(PPO)
73
FSA Flexible spending account
EMployer takes money out of your check pre tax dollars and adds it into a saving account that allows for you to prepare against catastrophic events
74
HIgh deductible health plan
Easy to get but requires a 1300 to 6550 deductible for singles and a 2600 13100for families
75
Medicare
offers medical care for almost everyone is over 65 yeas old
