Ch. 2 - Accident and Health Insurance Basics Flashcards
An unforseen and unintended injury that resulted from an accident rather than a sickness.
accidental bodily injury
an agreement between an insurer and insured in which both parties are expected to pay a certain portion of the potential loss and other expenses
coinsurance
health insurance that provides coverage for most types of medical expenses
comprehensive coverage
an arrangement in which an insured must pay a specified amount for services “up front” and the provider pays the remainder of the cost
copayment
the portion of the loss that is to be paid by the insured before any claim may be paid by the insurer
deductible
someone relying on the insured for support
dependent
a person enrolled in a health insurance plan, an insured (doesn’t include dependents of the insured)
enrollee
unable to meet financial obligations
insolvent
NAIC
national assoc. of insurrance commissioners
an organizations composed of ins. commissioners from all 50 states, the distric of columbia and the US territories, formed to resolve insurance regulatory issues
NAIC
conditions for which the insured has received diagnosis, advice, care, or treatment during a specific time period prior to the application for health coverage
pre-existing conditions
added to the basic insurance policy to add, modify or delete policy provisions
riders
an attempt to persuade a person to buy an insurance policy; it can be done orally or in writing
solicitation
a period of time that mus pass after a loss occurs before the insurer starts paying policy benefits
waiting period
an illness that first manifests itself while the policy is in force
sickness
not premeditated, or intentional. unforseen unintended injury resulting from an accident vs illness
accident
unequal exchange of values. you pay a small premium in exchange for possible a large claim. nature of health ins. contract
aleatory
between insurer and insured; nature of health ins. contract
personal
take it or leave it nature of health ins. contract. not negotiable
adhesion
one - sided promise nature of health ins. contract
one-sided promise
nature of health ins. contract where certain conditions must be met; all neccessry info must be obtained. typically through underwriting process.
conditional
Most health policies will pay the accidental death benefits if the death is caused by an accident and occurs within how many days?
90 days
In insurance, what is the term used for cause of loss?
Peril
During the application process for health insurance, a producer is trying to obtain creditable information about the applicand that would help underwriters determine if the risk is insurable. In what role is the producer acting?
Field underwriter
Under a credit disability policy, payments to the creditor will be made for the insurer until what point in time?
Until the period of disability ends or until the debt is repaid
What are the two types of expenses that are covered by health insurance?
Expenses related to health care, and expenses that compensate for loss of ncome.
What type of hospital policy pays a fixed amount each day that the insured is in the hospital?
Hospital indemnity
Whose responsibility is it to inform an applicat for health insurance about the insurer’s information gathering practices
The Agent
people who are more likely to submit insurance claims are seeking insurance more often than preferred risks.
Adverse Selection
In health insurance, the policy itself and the insurance application form what?
The entire contract
If an insurer decides to obtain medical info from different sources in order to determine the insurability of an applicant, who must be notified of the investigation.
The applicant
If an agent makes a correction on the application for health insurance, who must initial the correct answer?
The applicant
If an applicant does not receive his or her insurance policy, who would be held responsible?
The Agent
When should an agent obtain a statement of good health from the insured?
When the premium was paid upon policy delivery and not at the time of application
Who is a field underwriter
the agent/producer
An illness that first arises while the policy is in force
Sickness
What is the capital sum in accidental death and dismemberment (AD&D) coverage?
A percentage of the principal sum
Who must sign a health insurance application?
The policy owner; the insured (if different), and the agent
In medical expense contracts, what is the term that describes the payment method when the insured is responsible for paying the medical expenses, and the the insurer pays directly to the insured?
Reimbursement
What is the entire contract in health insurance underwriting?
The application and the policy issued
whose responsibility is it to determine that all the questions on an insurance application are answered?
The agents
During which stage in the insurance process do insurers evaluate info that identifies adverse selection risks?
underwriting
What is the term used for a written request for an insurer to issue an insurance contract based on the provided information?
Application
Who is responsible for paying the cost of a medical exam required in the process of underwriting?
Insurer
Under a credit disability policy, payments to the creditor will be made for the insurer until what point in time?
Until the period of disablity ends or until the debt is repaid.
To comply with fair credit reporting act, when must a producer notify an applicant that a credit report may be requested?
At the time of application
What type of hospital policy pays a fixed amount each day that the insured is in the hospital?
Indemnity
An insurer wishes to compare the info given in an ins. app. with previous ins. app.s by the same applicant but for diff. companies. What organization will help the insurer accomplish this?
The Medical information Bureau (MIB)
When is the insurability conditional receipt given?
When the premium is paid at the time of application
a risk that is below the insurers standard of avg. risk guidelines for a number of reasons… poor health, dangerous occupation, dangerous avocations. Some are rejectted outright, while others will be accepted for coverage at a higher premium.
substandard risk
Which benefits would a disabllity plan most likely pay?
income lost by insured’s inability to work
A percentage of the principal amount
capital amount
AD&D pay a _____ amount in a lump sum for the loss of sight in one eye or the loss of one limb.
Capital
AD&D pays out the ____ amount in a lump sum for death or often the loss of both limbs or loss of sight in both eyes.
Prinicipal
What is an important feature of a dental expense insurance plan that is NOT typically found in a medical expense insurance plan?
Diagnostic and preventive care
Can a person with HIV be declined for medical coverage solely base on HIV status?
No
The HIV ______ form provides the insurance company with authorization to test for the presence of the HIV virus
consent
Under an AD&D policy, the death benefit will be paid if the accidental death occurs within ____ days of the accident.
90
Who has the authority to make changes to an insurance policy?
insurers executive officer
The provision in a health insurance policy that ensures that the insurer cannot refer to any document that is not contained in the contract
entire contract clause
If an accident happens within the grace period will insurance pay?
yes
defines the rights and duties of both the insurer and policy holder. Although wording may change from one insurer to another the provisions are essentially the same and are required by law to be included in all health policies. wording may be altered, provided the changes wouldn’t be detrimental to policy holder or beneficiary.
uniform individual accident and sickness provisions
a mandatory provision of life insurance policies. The period of time after the premium date in which premiums may still be paid before the policy lapses for nonpayment of the premium.
31 day grace period
under uniform required provisions, proof of loss under a health insurance policy normally should be filed within ___ days
90
specifies that claims are to be paid immediately upon written proof of loss
time of payment claims
Spells out the insured’s duty to provide the insurer with reasonale notice in the event of a loss
notice of claim
upon receipt of a notice of claim, the company must supply what to the insured within a specified number of days?
claims forms
Insurance code requires that each policy must include what be given to the insurer within 20 days after the occurrence or commencement of any loss covered by the policy or as soon thereafter as is reasonably possible
written notice of claim
Which provision states that the insurance company must pay medical expense claims immediately
Time of payment claims
Which provision concerns the insured’s duty to provide the insurer with reasonable notice in the event of a loss?
Notice of claim
how soon, under the “proof of loss” provision, must the claimant submit a proof of loss
90 days
If it is not possibly for a claimant to comply with the 90 day rule on providing proof of loss the time parameter may be extended to.. unless claimant is not legally competent to comply
1 year
Payments for loss of life benefits are paid to the …
designated beneficiary
If there is no designated beneficiary payment proceeds are to be paid to the deceased insured’s ___
estate
Claims other than death benefits are to be paid to the _____ or the _____ estate, unless otherwise assigned.
Insured, insured’s
The payment of claims provision states that the claims must be paid to _______ unless the death proceeds need to be paid to a beneficiary
the policy owner
Under the physical exam and autopsy provision how many times can an insurer have the insured examined, at its own expense, while a claim is pending?
unlimited
under an individual disability policy the minimum schedule of time in which claim payments must be made to an insured is
Monthly
A policy that covers medical costs for a particular medical condition such as cancer or heart disease
dread disease policy
a health insurance policy that pays a lump sum if the insured suffers a heart attack or stroke is known as
critical illness
hospital policy pays a fixed amount each day that the insured is in a hospital?
indemnity
Health coverage becomes effective when
first premium has been paid and application has been approved
with a conditional receipt, insurance coverage is effective the date of the receipt, so long as…
the application is approved
What phase begins after a new policy is delivered
free-look period
an underwrite may or may not reject an application based off genetic characteristics, marital status, or sexual orientation
may not
temporary insuring agreements
conditional receipts
The 3 rating classifications that denote the risk of the insured
standard
substandard
preferred
True or false: MIB reports come from docs and hospitals
false
agents observations about the applicant that can assist in underwriting
producer/agents report
includes info on an applicant’s character, general reputation, personal habits, and mode of living that is obtained through investigation.
investigative consumer report
Temporarily Covers members of a particular group
Blanket policy
Limits coverage to one I’ll see or one limiting group of coverings; written as stand alone policies or as a part of major med.
Specified policy
