Accident & Health Provisions

Question 1

Reinstatement

Answer 1

A 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.

Question 2

Grace Period

Answer 2

Cannot be less than 7 days for a weekly premium, 10 days for a monthly premium, and 31 days for all other modes.

Question 3

Change of Beneficiary

Answer 3

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.

Question 4

Notice of Claim

Answer 4

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.

Question 5

Claim Forms

Answer 5

The company must supply claim forms within a specified number of days (generally 15).

Question 6

Proof of Loss

Answer 6

Claimant must submit proof of loss within 90 days or as soon as possible within reason, not to exceed one year.

Question 7

Time of Payment of Claims

Answer 7

Must be paid immediately upon written proof of loss. 60, 45, or 30 days. If disability income, they must be paid not less frequently than monthly.

Question 8

Payment of Claims

Answer 8

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.

Question 9

Facility of Payment Clause

Answer 9

Some policies allow the insurer to expedite payments of urgently needed claims and pay a specified limit in benefits to a relative or individual who is considered to be equitably entitled to payment.

Question 10

Physical Examination and Autopsy

Answer 10

Gives the insurer the right to examine the insured while a claim is pending.

Question 11

Time Limit on Certain Defenses

Answer 11

No statement or misstatement will be used to deny a claim after the policy has been in force for 2 years.

Question 12

Legal Actions

Answer 12

Insured must wait 60 days but not longer than 3 years to commence legal action against insurer.

Question 13

Change of Occupation (Optional)

Answer 13

If the insured makes a change to a more hazardous occupation, benefits will be adjusted to the amount the premiums would have purchased. If the change is to a less hazardous job, the insured can apply for a premium deduction.

Question 14

Other Insurance with This Insurer

Answer 14

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.

Question 15

Insurance with Other Insurers

Answer 15

Expense incurred basis - each insurer will pay a proportionate share of any claim.

Question 16

Relation of Earnings to Insurance

Answer 16

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 premium returns are required, in no event may the benefit amount be reduced to less than 200 monthly.

Question 17

Unpaid Premium

Answer 17

Upon payment of a claim, any past due premiums will be deducted.

Question 18

Insuring Clause

Answer 18

First page of the policy - identifies the basic agreement, lists the insured, insurer, and states what kind of loss or peril is covered.

Question 19

Consideration Clause

Answer 19

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.

Question 20

Policy Continuation

Answer 20

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.

Question 21

Noncancellable

Answer 21

The insurer cannot cancel the policy nor can the premium be increased beyond what is stated in the policy.

Question 22

Pre-existing Conditions

Answer 22

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.