Chapter 2 - Health Insurance Flashcards
What is a benefit policy?
A benefit policy does not provide an indemnity, instead it pays a sum of money in the event of a certain contingency, regardless of weather or not the insured suffers a direct financial loss
Why are the first 21 days excluded?
Ensures that the insured is only liable for sickness or disease contracted after the commencement of the policy.
Under which circumstances will the benefits from a medical expenses policy become payable? A on diagnosis of a critical condition B on undergoing a minor surgery C when unable to work due to illness D when unable to work due to an accident
B on undergoing a minor surgery
Why are personal accident insurance contracts not contracts of indemnity?
Personal accident contracts are benefit policies rather than contracts of indemnity because they seek to provide a sum which is fixed in advance
Age for sickness cover
16 to 60
What are the main benefits available under the personal accident policy?
Death Total loss of sight in one or both eyes Total loss of one or both limbs Permanent total disablement Permanent partial disablement Temporary total disablement The portable partial disablement Medical expenses
When must death occur if the death benefit is to become payable under a personal accident policy?
Death must occur within 12 months of the accident
What is the usual geographical scope of
A accident cover
B sickness cover
A worldwide
B uk, USA, Europe, Canada, Australia, New Zealand
What are three hazardous activities that are usually excluded from an accident and sickness policy
Motorcycling Polo Racing on horseback or wheels Winter sports or mountaineering using ropes Aviation
What cover is available to in-patients under medical expenses insurance?
In-patients cover provides for hospital charges, specialist fees and additional costs
What do low cost policies limit on medical treatment?
Limit the level of hospital accommodation available
Use NHS treatment within 6 weeks of diagnosis
When is a child up to the age of 23 allowed on family personal accident policies?
Only if the ‘child’ is living with, or is dependent on, the main policyholder whilst in full time education
Age for accident cover?
16 to 70
What is meant by the term ‘accidental’ for personal accident cover
Must be a fortuitous event from an identifiable cause
Under accident policy what is the length for usual weekly benefits in weeks
104 weeks or 10 years annuity
How long is the sickness policy providing cover for up to for temporarily and total disablement
104 weeks
What happens if the insured is sick for less than 7 days
No payment is made and it’s a time franchise but of sickness is over 7 days the first initial 7 days are included
How long is excluded for sickness at the beginning of the contract
21 days
How much is paid out for death
Must occur within 12 months of the event giving rise to a claim and its £10,000
How much is paid out for total loss or sight in one or both eyes
£10,000 regardless of whether one or both eyes
How much is paid out for total loss of one or both limbs
Has to occur within a max of 24 months after the accident. Fixed sum of £20,000
How much is paid out for permanent total disablement
Not payable to 12 or 24 months after the accident £20,000 or £2,000 for a year for 10 years
How much is paid out for permanent partial disablement
Percentage of the capital sum paid is on a sliding scale and represent s a smaller percentage
How much is paid for temporary total disablement
Must be engaging in usual occupation usually paid in a form of a weekly benefit for example £100 a week for a max of 104 weeks
How much is paid for temporary partial disablement
Usually 40% of the temporary total disablement amount. But can be £100 per week
What is the definition of medical expenses
Cost of medical, surgical or other remedial attention, treatment or appliances given or prescribed, all hospital, nursing, home as ambulance charges
What happens of death following permanent total disablement
Benefits aren’t cumulative which means one capital benefit
What is an optional extension or personal accident policies
Legal expenses but only relates to incidents following bodily injury
What are the geographical limits for accidents
Worldwide
What is the geographical limit for sickness
UK, Europe, USA, Canada, Australia and New Zealand
What is the age limit for accident cover
16-70 years
What is the age limit for accident cover
16-60 years
Can a health policy exceed the age ranges
Yes, as long as they can provide proof they are in good health usually from a GP
What is the age limit for family personal accident policies
Children can be covered from 6 months to 16 years. But if they are in full time education it can be 23 years
What are the 7 exclusions for personal accident and sickness
- Under the influence of alcohol or drugs
- Self inflicted injury or disease
- Anything that occurred prior to the accident
- Involving in sports such as aviation, motor cycling, polo, racing on horseback, winter sports or mountaineering, involving use of ropes
- Childbirth, pregnancy, veneral disease or aids
- War risks
- Sickness occurring within 21 days of the commencement
What does it mean by the fact that personal accident and sickness only cover fortuitous losses
Must be unlikely and uninevitsble. That’s why pre existing conditions are not payable
What does medical expenses insurance do
Provide cover for individuals who seek private medical treatment outside the NHS when they are ill
What happens to medical expenses insurance when the insured age increases
The premium increases
What are the 3 standard policy covers for medical expenses insurance
Hospital charges- theatre fees, surgical dressings and consultations
Specialist fees- surgeons and anaesthetics fees
Additional costs- ambulance fee and nursing fees
Do medical expenses cover long term residential care
No
What is excluded under medical expenses insurance
Any medical conditions the insured has received treatment for in the past 5 years
