Chapter 7. Health Insurance Policy Provisions, Clauses, and Riders

Question 1

What health policy provision describes the insured’s right to cancel coverage?

Answer 1

Renewability provision

Question 2

A waiver of premium provision may be included with what type of health insurance policies?

Answer 2

Disability Income

Question 3

What is a probationary period in group health insurance?

Answer 3

The period of time that must lapse before an employee is eligible for group health coverage

Question 4

What does the free-look period allow the insured to do?

Answer 4

Return the policy for a full refund of premium within a specified time period (usually 10 days)

Question 5

What health policy provision defines the insured’s duty to provide the insurer with reasonable notice in the event of a loss?

Answer 5

Notice of claim

Question 6

According to the Time Limit on Certain Defenses provision in health insurance policies, when can an insurer contest fraudulent misstatements on a health insurance application?

Answer 6

Any time while the policy is in force

Question 7

Which health insurance provision describes the insured’s right to cancel coverage?

Answer 7

Renewal provision

Question 8

If a health insurance policy has a 31-day grace period, what does that mean?

Answer 8

The policy remains in effect for 31 days after the premium is due and not paid

Question 9

What is the main difference between coinsurance and copay?

Answer 9

Copay is a set dollar amount; coinsurance is a percentage of the expenses

Question 10

What will happen to a health insurance policy if the premium has not been paid by the end of the grace period?

Answer 10

The policy will be cancelled

Question 11

What will determine the length of the grace period in a health insurance policy?

Answer 11

The mode of the premium payment

Question 12

What section of a health insurance policy lists the services for which the insurer will not provide coverage?

Answer 12

Exclusions

Question 13

Who pays the expense for an autopsy under the physical examination and autopsy provision?

Answer 13

The insurer

Question 14

The insured on a health policy misstated his age on the insurance application. If this misrepresentation is discovered, what will happen to the policy?

Answer 14

The benefit amount payable under the policy will be adjusted to the insured’s correct age.

Question 15

According to the Reinstatement provision, once a lapsed policy is reinstated, how soon will coverage be available for accidents?

Answer 15

Immediately

Question 16

How can an irrevocable beneficiary be changed?

Answer 16

With the written consent of the beneficiary

Question 17

Under an individual disability income policy, the benefits must be paid on at least what schedule?

Answer 17

Monthly

Question 18

What is the purpose of the coinsurance provision in health insurance policies?

Answer 18

To prevent overutilization of the policy benefits

Question 19

If the insured pays a monthly premium for health insurance, how long would the grace period be on the policy?

Answer 19

10 days

Question 20

After the elimination period, a totally disabled insured qualified for benefits from a disability income policy that has a waiver of premium rider. What will happen to the premium that was paid into the policy during the elimination period?

Answer 20

Premium will be refunded

Question 21

What is the name of the act by the insured to voluntarily give up insurance?

Answer 21

Cancellation

Question 22

What health policy provision prevents the insured from bringing a lawsuit against the insurance company for at least 60 days after proof of loss is provided?

Answer 22

Legal actions

Question 23

What provision provides for the sharing of expenses between the insured and the insurance company?

Answer 23

Coinsurance

Question 24

Who decides which optional provisions would be included in a health policy?

Answer 24

The insurance company

Question 25

What health policy provision allows the insured a period of time to examine the policy and determine whether keep it?

Answer 25

Free-look period

Question 26

How will changing one’s occupation to be more hazardous affect the health insurance policy in force?

Answer 26

Claim benefits will be reduced to what the premium would have bought for a more hazardous occupation

Question 27

What health policy provision states to whom the claim benefits must be paid?

Answer 27

Payment of claims

Question 28

What is a deductible in a health insurance policy?

Answer 28

A specified dollar amount that the insured must pay before the insurer will pay the policy benefits

Question 29

What are usual/reasonable and customary charges based on?

Answer 29

Average charge for a given procedure in the specific geographic area