Chapter 3 - Individual Health Insurance Policy General Provisions Flashcards
Termination of an in-force insurance policy, by either the insured or the insurer, prior to the expiration date shown in the policy
cancellation
a request filed with an insurance company asking for payment according to the terms of an insurance policy
claim
policy pays health policy benefits as a reimbursement of actual expenses
expense-incurred basis
a plicy that is written on a non cancancellable basis with the right to renew guaranteed
guaranteed renewable
a beneficiary who has a vested interest in the policy and therefore, the policy owner may not exercise ceratain rights without the consent of the beneficiary
irrevocable beneficiary
policy termination due to nonpayment of premium
lapse
a legal clause in an insurance contract spelling out mandatory or optional duties and rights of the insured and the insurer
provision
returning a lapsed policy to active status
reinstatement
a formal written law enacted by legislature; ;insurance _____ can be found in the state insurance code.
statute
define the rights and duties of insurers and policyowners
general provisions
copy of application plus policy
entire contract
section near front of policy including names of parties to the contract, length of coverage, premium to be paid, types of loss (peril) covered.
insuring clause
2 parties to the contract
insurer and insured
time limit on certain defenses, insurer can deny a claim due to material misrepresentation on the application
2 years
After _____ a claim cannot be denied even due to misstatement of facts or concealment.
2 years
mistatement of gender, age, or identity _____ fall under the time limit on certain defenses.
does not
How does the insurer address mistatement of age or gender
adjust benefit to be paid base of what premiums should have been
when you deliver policy and they typically have 10 days to review period and have access to 100% refund of premium for any reason
free-look period
every party to an insurance policy must have something of value insurers promise to pay.. owners statement on the app. and premium payment
consideration clause
Claims procedures
notice of claims claim forms proof of loss time payment of claims payment of claims
insured must notify the insurere of loss within how many days
20 days
insurer must PROMPTLY send what to the insured when a claim is made
claim forms
insured must submit proof of loss within how many days of the loss
90
completed proof of loss submitted then typically how many days required thru time of payment of claims
60 day most states
you cant file a suit against insurer until time of payment of claims has passed so typically how many days?
60
provision that specifies to whom the benefits are paid
payment of claims
especially important in dissability of income policies.. where insured promptly notifies insurer of job changes to they can change your premium
change of occupation
when there is a mistatement age the insurerer will usually adjust the benefit down
mistatement of age
pricipal of indemnity; means you cannot make money by filing claims. puts you back to where you were financially before the accident.
overinsurance
with multiply policies one will always be paid before the other.. primary and ____ to avoid overpayment of claims
secondary
If you terminate a policy before end of year and you paid a full 12 month premium and you only used 6 months what will they do with additional premium
return plus fee if you cancel; return all if they cancel (prorata)
your policy has to follow your states own statutes… your policy will cover you as is if you are in another state at the time of accident
conformity of state statutes
filing claims while doing something illegal you wont be covered
illegal occupation
not covered while under the influence
intoxicants and narcotics
allows the insured to purchase additional amounts of disability income coverage without evidence of insurability
guaranteed insurability rider
also referred to as future increase options or guaranteed purchase options
guaranteed insurability rider
allows the insurance company to limit the insured’s benefits to insured’s earnings at the time of disability or average income over the last 2 years (whichever is greater) ONLY used on health products
relation of earning to insurance
benefits may be ____ in response to a more hazardous occupation
reduced
rates may be ____ in response to a less hazardous occupation
reduced
protects insured against inflation. monthly benefit automatically increased to match consumer price index.
cost of living adjustment (cola)
best option… renewability featuring no cancellation, no increase, and for the life of the contract (usually age of 65)
noncancellable
2nd best option regarding renewability - features no cancellation, increases on renewal date (class basis only), and for the life of the contract
guaranteed renewable
least favorable option regarding renewability - features cancellation at any time with notice, increses - based on policy, no renewals (insured must purchase new policy)
nonrenewable
physical examination and autopsy is _______ for health insurance policies
mandatory
How soon following the occurence of a covered loss must an insured submit written proof of such loss to the insurance company?
90 days, or as soon as reasonably possible but not to exceed 1 year
Includes:
Types of losses covered
identities of the insurance co. and the insured
that insurance against loss is provided
insuring clause
legal action time period =
3 years
type of deductible that is commonly found in disability income policies. period of days which must expire after the onset of an illness or accident before benefits will be payable. The longer the wait the lower the cost of coverage
elimination period
recovable change of beneficiary can be changed. ____
any time
irrevocable change of beneficiary can be changed ____
with beneficiarys consent
give the insurer the right to examine the insures as often as necessary while a claim is pending
physical examination and autopsy
rights of renewability: insurer cannot cancel or raise premiums beyond amount stated in the policy
noncancellable
rights of renewability: Insuer may cancel the policy at any time or at end of policy period with proper written notice and a refund of any unearned premium paid
cancellable
rights of renewability: insure may increase the policy premium (on class basis only) on the policy anniversary date; insured has the unilateral right to renew the policy for the life of the contract
guaranteed renewable
