Accident/Health Policy Clauses

Question 1

Renewable at Insurer’s Option

Answer 1

Insurer is not obligated to renew the policyholder or keep premiums the same if person becomes ill

Question 2

Renewable at insurer’s option cannot be cancelled for…

Answer 2

Bad health during the policy period

Question 3

Conditionally Renewable

Answer 3

Insurer can’t non-renew due to health but might non-renew for other changes in the person’s level of risk

Question 4

Guaranteed Renewable

Answer 4

Policyholder can renew and can’t be charged more at renewal due to personal health

Question 5

Where is guaranteed renewable most common?

Answer 5

Medical insurance

Question 6

Can increases happen in guaranteed renewable?

Answer 6

Yes, non-discriminatory

Question 7

Non-cancelable

Answer 7

Policyholder can renew and can’t be charged more for any reason unless increases were specifically scheduled in the policy language

Question 8

Where is non-cancelable possible?

Answer 8

Disability insurance and valued policies

Question 9

Some products might only be guaranteed renewable or non-cancelable until when?

Answer 9

Certain age, typically 65

Question 10

Probationary Period: Individual

Answer 10

Might delay coverage for illness (not accidents) for 15 or 30 days after policy issued

Question 11

Probationary Period: Group

Answer 11

Might delay the ability to enroll in a group plan for one or several months

Question 12

Mandatory Provisions

Answer 12

Must appear in all accident/health policies sold to individuals

Question 13

Mandatory Provisions protect…

Answer 13

Consumers

Question 14

Optional Provisions

Answer 14

Don’t need to be included but, when used, can’t be less consumer-friendly than set by law

Question 15

Optional provisions protect…

Answer 15

Insurers

Question 16

Entire Contract is what kind of provision?

Answer 16

Mandatory

Question 17

Contract between consumer and insurer consists only of…

Answer 17

Policy, application, and other documents literally attached to the policy (riders)

Question 18

Changes to the entire contract must be…

Answer 18

In writing and require insurance company’s official sign off (not just agent)

Question 19

Incontestable Clause is what kind of provision?

Answer 19

Mandatory

Question 20

Incontestable Clause: Insurer has how many years to rescind coverage based on inaccurate application info?

Answer 20

2 years

Question 21

Incontestable Clause: Insurer can still rescind, deny, or cancel coverage based on…

Answer 21

Lies related to claims

Question 22

What kind of provision is a grace period?

Answer 22

Mandatory

Question 23

Grace Period

Answer 23

Keeps insurance from lapsing is premiums aren’t paid

Question 24

Grace Period: Insurer may need to pay if losses occur during grace period but…

Answer 24

Can deduct unpaid premiums from settlement

Question 25

Grace Period: weekly payments

Answer 25

7 days

Question 26

Grace Period: monthly payments

Answer 26

10 days

Question 27

Grace Period: annual or other payments

Answer 27

31 days

Question 28

What type of provision is a reinstatement?

Answer 28

Mandatory

Question 29

Reinstatement

Answer 29

Insured may be allowed to regain individual health insurance by paying 60 days over overdue premium and completing new application

Question 30

Reinstatement: Insurer often has how many days to reject applicant?

Answer 30

45 days

Question 31

Reinstatement: If no action is taken in 45 days, what does that mean?

Answer 31

Person is covered

Question 32

What kind of provision is a claims provision?

Answer 32

Mandatory

Question 33

Notice of claims must be provided to the insurer within how many days?

Answer 33

20 days

Question 34

Insurer must provided "proof-of-loss" forms within how many days?

Answer 34

15 days

Question 35

Insured must return proof-of-loss forms within how many days of loss?

Answer 35

90 days

Question 36

Upon receiving proof of loss, insurer must...

Answer 36

Pay within a reasonable time

Question 37

Benefits due at regular intervals MUST be...

Answer 37

Monthly

Question 38

What kind of provision is legal action?

Answer 38

Mandatory

Question 39

Suits against the insurer can't be initiated until...

Answer 39

60 days after providing proof of loss and must be within 3 years

Question 40

What kind of provision is a physical exam or autopsy?

Answer 40

Mandatory

Question 41

Insurer has the right to conduct medical exams to determine...

Answer 41

Benefit eligibility at own expense

Question 42

Insurer has the right to an autopsy in cases of...

Answer 42

Alleged accidental death from injury, not illness

Question 43

What kind of provision is unpaid premiums?

Answer 43

Optional

Question 44

If consumer hasn't paid all premiums, unpaid amounts can be deducted from...

Answer 44

Insurance Settlement

Question 45

What kind of provision is conformity of state statutes?

Answer 45

Optional

Question 46

Conformity of State Statutes

Answer 46

Coverage will adjust automatically if required by state law

Question 47

What kind of provision is misstatement of age or gender?

Answer 47

Optional

Question 48

If incorrect age or gender...

Answer 48

Benefits will be adjusted accordingly

Question 49

Adjustments can still occur even if...

Answer 49

2 year contestability period has expired

Question 50

What kind of provision is change of occupation?

Answer 50

Optional

Question 51

Change of Occupation

Answer 51

Applies to disability insurance when insured is doing different job than at a time of application

Question 52

If a more hazardous job...

Answer 52

Benefits can be reduced

Question 53

If a less hazardous job...

Answer 53

Benefits will be unchanged but some premium can be refunded

Question 54

What type of provision is earnings to insurance?

Answer 54

Optional

Question 55

Earnings to Insurance: Clarifies that disability can never be...

Answer 55

Greater than income immediately prior to disability OR average income over 2 years prior to disability, whichever is greater

Question 56

Earnings to Insurance: Applies even if insured has...

Answer 56

Multiple policies

Question 57

What kind of provision is illegal occupation?

Answer 57

Optional

Question 58

Illegal Occupation

Answer 58

No coverage while hurt during illegal activity