Accident & Health Insurance Provisions Flashcards
Reinstatement
reinstatement is automatic if the policy premium is accepted.
an application may be required along with conditional receipt which can be approved or disapproved.
coverage is automatically reinstated if not refused within 45 days from the date of the conditional receipt.
Grace Period
cannot be less than
7 days for a weekly premium
10 days for a monthly premium
31 for all other modes
Change of Beneficiary
beneficiary may be changed at any time with written request to the insurer. however if the designation is irrevocable written consent is required from the beneficiary.
Notice of claim
notice is required within 20 days of the loss or as soon as reasonably possible. Notice to the agent is the same as notice to the insurer.
Claim Forms
the company must supply claim forms within a specified number of days (generally 15)
Proof of Loss
Claimant must submit proof of loss within 90 days or as soon as possible within reason not to exceed one year
time of payment of claims
must be paid immediately upon written proof of loss. 60, 45, 30 days
if disability income they must be paid not less frequently than monthly.
Payment of claims
all benefits are paid to the insured if living. if deceased claims that are pending are paid to the beneficiary or the estate unless assigned to a hospital or doctor who has rendered services
facility of payment clause
some policies allow the insurer to expedite payments of urgently needed claim and pay a specified limit in benefits to a relative or individual who is considered to be equitably entitled to payment
Physical Examination and Autopsy
gives the insurer the right to examine the insured while a claim is pending
TIme limit on certain defenses
no statement or misstatement will be used to deny a claim after the policy has been in force for 2 years
Legal Actions
insured must wait 60 days but not longer than 3 years to commence legal action against insurer
Change of occupation (optional)
if the insured makes a change to a more hazardous occupation benefits will be adjusted to the amount he premiums would have purchased.
if the change is to a less hazardous job the insured can apply for a premium deduction
Other insurance with this insurer
the provision provides for a pro rata benefit reduction and a return of premiums when there are multiple policies with the same company when the benefits exceed a stated maximum
Insurance with other insurers
expense incurred basis - each insurer will pay a proportionate share of any claim
Relation of earnings to insurance
if the total amount of benefits for a single loss under all policies exceeds the monthly earnings of the insured or average monthly earnings for the immediate prior 2 years the insurer will be liable for the proportionate amount of the benefit. if premiums returns are required in no event may the benefit amount be reduced to less than 200 monthly
Unpaid premium
upon payment of a claim any past due premiums will be deducted
Insuring clause
first page of the policy - identifies the basic agreement lists
the insured, insurer, states what kid of loss or peril is covered
consideration clause
makes it clear that both parties to the contract must give some valuable consideration; the insured pays the premium and the insurer promises to pay in accordance with the contract
policy continuation
optional renewable - the insurer may cancel the policy for any reason
conditionally renewable - insurer may terminate the contract only at renewal for certain conditions stipulated in the contract
guaranteed renewable - the insured has unilateral right to renew the policy, however the insurer may still increase the premium
noncancellable
the insurer cannot cancel the policy nor can the premium be increased beyond what is stated in the policy
pre existing conditions
coverage usually does not apply to prior conditions for which the insured received medical advice or treatment within a certain amount of time before the date of application
