Chapter 3 - Individual Health Insurance Policy General Provisions

Question 1

Termination of an in-force insurance policy, by either the insured or the insurer, prior to the expiration date shown in the policy

Answer 1

cancellation

Question 2

a request filed with an insurance company asking for payment according to the terms of an insurance policy

Answer 2

claim

Question 3

policy pays health policy benefits as a reimbursement of actual expenses

Answer 3

expense-incurred basis

Question 4

a plicy that is written on a non cancancellable basis with the right to renew guaranteed

Answer 4

guaranteed renewable

Question 5

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

Answer 5

irrevocable beneficiary

Question 6

policy termination due to nonpayment of premium

Answer 6

lapse

Question 7

a legal clause in an insurance contract spelling out mandatory or optional duties and rights of the insured and the insurer

Answer 7

provision

Question 8

returning a lapsed policy to active status

Answer 8

reinstatement

Question 9

a formal written law enacted by legislature; ;insurance _____ can be found in the state insurance code.

Answer 9

statute

Question 10

define the rights and duties of insurers and policyowners

Answer 10

general provisions

Question 11

copy of application plus policy

Answer 11

entire contract

Question 12

section near front of policy including names of parties to the contract, length of coverage, premium to be paid, types of loss (peril) covered.

Answer 12

insuring clause

Question 13

2 parties to the contract

Answer 13

insurer and insured

Question 14

time limit on certain defenses, insurer can deny a claim due to material misrepresentation on the application

Answer 14

2 years

Question 15

After _____ a claim cannot be denied even due to misstatement of facts or concealment.

Answer 15

2 years

Question 16

mistatement of gender, age, or identity _____ fall under the time limit on certain defenses.

Answer 16

does not

Question 17

How does the insurer address mistatement of age or gender

Answer 17

adjust benefit to be paid base of what premiums should have been

Question 18

when you deliver policy and they typically have 10 days to review period and have access to 100% refund of premium for any reason

Answer 18

free-look period

Question 19

every party to an insurance policy must have something of value insurers promise to pay.. owners statement on the app. and premium payment

Answer 19

consideration clause

Question 20

Claims procedures

Answer 20

notice of claims
claim forms
proof of loss
time payment of claims
payment of claims

Question 21

insured must notify the insurere of loss within how many days

Answer 21

20 days

Question 22

insurer must PROMPTLY send what to the insured when a claim is made

Answer 22

claim forms

Question 23

insured must submit proof of loss within how many days of the loss

Answer 23

90

Question 24

completed proof of loss submitted then typically how many days required thru time of payment of claims

Answer 24

60 day most states

Question 25

you cant file a suit against insurer until time of payment of claims has passed so typically how many days?

Answer 25

60

Question 26

provision that specifies to whom the benefits are paid

Answer 26

payment of claims

Question 27

especially important in dissability of income policies.. where insured promptly notifies insurer of job changes to they can change your premium

Answer 27

change of occupation

Question 28

when there is a mistatement age the insurerer will usually adjust the benefit down

Answer 28

mistatement of age

Question 29

pricipal of indemnity; means you cannot make money by filing claims. puts you back to where you were financially before the accident.

Answer 29

overinsurance

Question 30

with multiply policies one will always be paid before the other.. primary and ____ to avoid overpayment of claims

Answer 30

secondary

Question 31

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

Answer 31

return plus fee if you cancel; return all if they cancel (prorata)

Question 32

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

Answer 32

conformity of state statutes

Question 33

filing claims while doing something illegal you wont be covered

Answer 33

illegal occupation

Question 34

not covered while under the influence

Answer 34

intoxicants and narcotics

Question 35

allows the insured to purchase additional amounts of disability income coverage without evidence of insurability

Answer 35

guaranteed insurability rider

Question 36

also referred to as future increase options or guaranteed purchase options

Answer 36

guaranteed insurability rider

Question 37

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

Answer 37

relation of earning to insurance

Question 38

benefits may be ____ in response to a more hazardous occupation

Answer 38

reduced

Question 39

rates may be ____ in response to a less hazardous occupation

Answer 39

reduced

Question 40

protects insured against inflation. monthly benefit automatically increased to match consumer price index.

Answer 40

cost of living adjustment (cola)

Question 41

best option… renewability featuring no cancellation, no increase, and for the life of the contract (usually age of 65)

Answer 41

noncancellable

Question 42

2nd best option regarding renewability - features no cancellation, increases on renewal date (class basis only), and for the life of the contract

Answer 42

guaranteed renewable

Question 43

least favorable option regarding renewability - features cancellation at any time with notice, increses - based on policy, no renewals (insured must purchase new policy)

Answer 43

nonrenewable

Question 44

physical examination and autopsy is _______ for health insurance policies

Answer 44

mandatory

Question 45

How soon following the occurence of a covered loss must an insured submit written proof of such loss to the insurance company?

Answer 45

90 days, or as soon as reasonably possible but not to exceed 1 year

Question 46

Includes:
Types of losses covered
identities of the insurance co. and the insured
that insurance against loss is provided

Answer 46

insuring clause

Question 47

legal action time period =

Answer 47

3 years

Question 48

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

Answer 48

elimination period

Question 49

recovable change of beneficiary can be changed. ____

Answer 49

any time

Question 50

irrevocable change of beneficiary can be changed ____

Answer 50

with beneficiarys consent

Question 51

give the insurer the right to examine the insures as often as necessary while a claim is pending

Answer 51

physical examination and autopsy

Question 52

rights of renewability: insurer cannot cancel or raise premiums beyond amount stated in the policy

Answer 52

noncancellable

Question 53

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

Answer 53

cancellable

Question 54

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

Answer 54

guaranteed renewable