Chapter 10 - Individual Health Insurance Policy General Provisions

Question 1

The section of the health policy that states the causes of eligible loss under which an insured is assumed to be disabled is the what?

Answer 1

The Insuring Clause - Privison on the 1st page of the policy that states the coverage and when it applies.

Question 2

What is the free-look provision in health insurance?

How long is it in NY?

Answer 2

• A provision that allows a policy owner to review a new health policy after it has been delivered. If the policyowner decides to return in with a certain time period, the full premium will be refunded.
• In New York, a free-look period cannot be longer than 20 days (as little as 10 days).

Question 3

An insurer can cancel a policy when?

Answer 3

Within 90 days of the effective coverage date and must be done by written notice.

Question 4

What can an insurer not cancel coverage based upon?

Answer 4

A claim that was made prior to cancelation.

Question 5

How are claims covered when covered by multiple insurers when they are not informed about other sources of coverage before the loss?

Answer 5

In the event that an insured is covered on an expense-incurred basis for the same expenses under multiple insurers and the insurers are not informed about the other sources of coverage before the loss, proportionate shares of the claims should be paid. Same principal applies when the policy pays specific benefits.

Question 6

What is the Uniform Individual Accident and Sickness Policy Provisions Law? (5)

Answer 6

• Developed by the NAIC
• Adopted in all states
• It defines the rights and duties of both the insurer and the policyholder.
• Although the wording of the provisions may change from insurer to insurer, the provisions are essentially the same and are required by law to be included in all health insurance policies.
• The wording may be altered, provided that the changes would not be detrimental to the policyholder or beneficiary.

Question 7

A policy with a 31-day grace period implies what?

Answer 7

The policy will not lapse for 31 days if the premium is not paid when due.

Question 8

If a health insurance policy lapses but is reinstated within an acceptable timeframe, how soon from the reinstatement date will coverage become effective?

Answer 8

For Accidents - Immediately

For Sickness - May have a waiting period of about 10 days

Question 9

In a guaranteed renewable policy, an insurer agrees to renew the policy until when?

Answer 9

The insured has reached age 65.

Question 10

What is the difference in what is allowed for premiums between a guaranteed renewable policy and a noncancellable policy?

Answer 10

In the guaranteed renewable policy, the insurer can increase the policy premium on the policy anniversary date.