Chapter 24 - Individual Health Required Provisions Flashcards
Provisions (differ slightly for Health and Life)
Free Look Clause - 10 days for Health as well. No free look for Group. 30 days for long term care and Medicare. You get a full refund of premium if you return the policy within the 10 days.
Incontestable Clause - Time Limit on Certain Defenses Provision - gives the company 2 years to find mistakes in the application. After two years, honest mistakes are covered no matter what. DIFFERENT FROM LIFE, fraud (misrepresentation or concealment) is always contestable with Health Insurance.
Grace Period - rather than the 31 days, it depends on the frequency of your premiums. Not from your paycheck but when the premiums are paid to the health insurance company.
- weekly premium - 7 days
- monthly premium - 10 days
- Quarterly, semi annual or annual - 31 days.
Reinstatement Provision - unlike life with the 3 year reinstatement the insurance company can choose not to reinstate upon laps of the policy. The insured can submit a reinstatement application and pay the late premium. If the company fails to complete underwriting on the reinstatement application within 45 days, the insured is automatically reinstated. The insurer cannot collect more than 60 days of past due premiums. Reinstatement will also start another 2 year contestable period.
Notice of Claim Provision - policy owner must notify the company in writing within 20 days of a loss.
Claim Form Provision - The insurer must send a claim form within 15 days. If they fail to do this, the insured can submit the claim in their own words and hand written.
Proof of Loss Provision - requires that the claim form (being submitted by the insured) be returned to the insurance company within 90 days of the loss, not when the claim was submitted.
Time of Payment of Claims - the company has 30 days to pay claims on an individual claim. It has 60 days on Group claims.
Payment of Claims Provision - determines whose name will go on the check. Usually the policy owner.
Physical Exam and Autopsy Provision - the insurer may examine the insured as often as is reasonable at its own expense to verify illness and disability. The insurer may only perform one autopsy unless that is prohibited by state law.
