Chapter 2 - Health Insurance

Question 1

Accident Cover

Answer 1

The event must arise from an identifiable cause, and must be fortuitous.
There is a time limit from the date of the accident to the specified event.
The bodily injury must result in death or disablement, independently of any other cause.

Question 2

Sickness Cover

Answer 2

There is a weekly benefit of up to 104 weeks for TTD due to sickness or disease.
There is a deferment period (time franchise) of generally 7 days.
It excludes sickness contracted during the first 21 days of the policy period to ensure the insurer is only liable for sickness or disease contracted after commencement.

Question 3

Policy Benefits

Answer 3

• Death
• Total loss of sight in one or both eyes
• Total loss of one or both limbs
• PTD, PPD, TTD, TPD
• Medical expenses
• Payment benefits - maximum amount of any claim is limited to the capital sum or annuity benefit provided

Question 4

Limitations

Answer 4

PA cover is usually worldwide. Sickness is restricted to UK, Europe, USA, Canada, Australia and New Zealand. It can be extended for an AP.
Common age range for PA is 16-70 and 16-60 for sickness. Renewal terms can be offered to insureds up to 5 or 10 years beyond the age ranges and will ask to see evidence of continuing good health, like a report from the policyholder’s usual GP.
Family PA can also include children from 6 months to 16 years but benefits are significantly less than for adults. Policies will increase the age to 23 if the child is dependant on the main policyholder when in full time education.

Question 5

Exclusions

Answer 5

• The insured being under the influence of alcohol or dugs, unless under medical supervision.
• Self-inflicted injury or disease.
• Physical defects or infirmity which existed prior to an accident.
• Engaging in certain sports or pastimes, but can be covered for an AP.
• Childbirth, pregnancy, venereal disease or AIDS.
• War risks.

Question 6

Medical Expenses Insurance

Answer 6

Provides cover for individuals who seek private medical treatment, often arranged on a group basis by an employer.
Premiums tend to increase as age increases.

Question 7

Medical Expenses Insurance - Standard Policy Cover

Answer 7

Inpatients’ cover provides:
• Hospital charges
• Specialist fees
• Ambulance and nursing fees
Rather than optional extensions, there are a range of standalone policies offering different levels of cover.
Policies usually exclude payments that relate to medical conditions that the insured has received treatment within 5 years before applying.
Policies also don’t provide cover for long-term residential care.