Ch 3 Individual Accident and Health Insurance Policy Provisions Flashcards
Policy pays health policy benefits as a reimbursement of actual expenses
Expense incurred basis
A policy that is written on a non-cancelable basis with the right to renew guaranteed
Guaranteed renewable
A legal clause in an insurance contract spelling out duties and rights of the insured and the insurer
Provision
A formal written law enacted by legislature; insurance _______ can be found in the state insurance code
Statute
KT
Insurers must include an individual health insurance policies the standard provision status under NAIC’s uniform individual accident and sickness policy provision
True
KT
An insurer is prohibited from making changes to a health insurance policy without an insured’s consent
True
KT
A notice of claim and proof of loss are the ________ duties; claims forms in the time of payment of claims are the responsibilities of the ________.
Insured’s / Insurer
KT
In response to a misstatement of age on an insurance application, benefits are adjusted per the current premium.
True
KT
The ______________ defines the scope of coverage as well as identifies the rights and duties of his party of the contract.
insuring clause
KT
Can the insured cancel the insurance policy at any time?
Yes
KT
A guaranteed renewable policy requires the issuer to continue coverage, as long as premiums are paid.
True
Name the mandatory provisions required in all health insurance policies?
Entire contract, Grace period, Reinstatement, change of beneficiary, claims, legal action…
What provision allows the insured a period of time to review the policy and return it for a full refund if dissatisfied?
Free look (or right to examine)
What renewability options apply to individual health insurance policies?
Non-cancelable, cancelable, guaranteed renewable
What health policy provision allows the insurer to non-renew health coverage if certain events occur?
Conditionally renewable
What is the name of the act by the insured to voluntarily give up insurance?
Cancellation
What health policy provision describes the insured’s right to cancel coverage?
Renewability provision
If the insured pays a monthly premium for health insurance, how long would the grace period be on the policy?
10 days
Under an individual disability income policy, the benefits must be paid on at least what schedule?
Monthly
What health policy provision allows the insured a period of time to examine the policy and determine whether or not to keep it?
Free look period
What health policy provision prevents the insured from bringing a lawsuit against the insurance company for at least 60 days after proof of loss is provided?
Legal actions
What health policy provision defines the insured’s duty to provide the insurer with reasonable notice in the event of a loss?
Notice of claim
When can an irrevocable beneficiary be change?
With the written consent of the beneficiary
What does the free look period allow the insured to do?
Return the policy for a full refund of premium within a specified time period (Usually 10 days)
What will determine the length of the grace period in a health insurance policy?
The mode of the premium payment
According to the time limit on certain defenses provision on health insurance policies, when can an insurer contest fraudulent misstatements on a health insurance application?
Any time while the policy is in force
The insured on a health policy misstated his age on the insurance application. If this misrepresentation is discovered, what will happen to the policy?
The benefit amount payable under the policy will be adjusted to the insured’s correct age.
Who pays the expense for an autopsy under the physical examination and autopsy provision?
the insurer
Who decides which optional provision would be included in a health policy?
The insurance company
What health policy provision states to whom the claim benefits must be paid?
Payment of claims
How will changing one’s occupation to be more hazardous affect the health insurance policy in force?
Claim benefits will be reduced to what the premium would have bought for a more hazardous occupation
According to the reinstatement provision, once a lapsed policy is reinstated, how soon will coverage be available for accidents?
Immediately
If a health insurance policy has a 31 day grace period, what does that mean?
The policy remains in effect for 31 days after the premium is due and not paid
What will happen to a health insurance policy if the premium has not been paid by the end of the grace period?
The policy will be canceled
What renewability provision will most likely appear on a travel accident policy?
Period of time
What health policy renewability provision allows the insurer to terminate coverage for any reason, and to increase the premiums for any class of insureds?
Optionally renewable
