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Life & Health Insurance - General & Texas Specific > Chapter 7: Health Policy Provisions, Clauses, and Riders > Flashcards

Chapter 7: Health Policy Provisions, Clauses, and Riders Flashcards

1
Q

The ______, which was developed by the National Association of Insurance Commissioners (NAIC), has been adopted in all states and established standard provisions that are to be included in all individual health insurance policies.

A

Uniform Individual Accident and Sickness Policy Provisions Law

UIAS-PPL

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2
Q

The ______ provision states that the health insurance policy, together with a copy of the signed application and attached riders and amendments, constitutes the ______.

A

Entire Contract

Health Policy Provision - Entire Contract

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3
Q

The ______ is the period of time after the premium due date in which premiums may still be paid before the health policy lapses for nonpayment of the premium.

A

Grace Period

Health Policy Provision - Grace Period

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4
Q

In most cases the grace period cannot be shorter than ______ for weekly premium policies (industrial policies), ______ for monthly premium policies, and ______ for all other modes.

A
  1. 7 Days
  2. 10 Days
  3. 31 Days

Health Policy Provision - Grace Period

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5
Q

If the premium has not been paid by the end of the health policy’s grace period, the policy will lapse (terminate). The ______ provision stipulates under what conditions the insured may ______ coverage.

A
  1. Reinstatement
  2. Reinstate

Health Policy Provision - Reinstatement

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6
Q

Coverage is automatically reinstated if not refused within ______ from the date the conditional receipt was issued. Accidents will be covered ______ following the reinstatement; however, sickness is covered only after ______.

A
  1. 45 Days
  2. Immediately
  3. 10 Days

Health Policy Provision - Reinstatement

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7
Q

The ______ provision stipulates that the policyowner may change the beneficiary at any time by providing a written request to the insurer, unless the beneficiary is designated as ______.

A
  1. Change of Beneficiary
  2. Irrevocable

Health Policy Provision - Change of Beneficiary

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8
Q

The ______ provision spells out the insured’s duty to provide the insurer with reasonable notice in the event of a loss. Notice is required within ______ of the loss, or as soon as reasonably possible.

A
  1. Notice of Claim
  2. 20 Days

Health Policy Provision - Claims Procedures

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9
Q

Upon receipt of a notice of claim, the company must supply ______ to the insured within a specified number of days (usually ______, but may vary from state to state).

A
  1. Claims Forms
  2. 15 Days

Health Policy Provision - Claims Procedures

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10
Q

After a loss occurs, the claimant must submit ______ within ______ of the loss or as soon as reasonably possible, but not to exceed ______.

A
  1. Proof of Loss
  2. 90 Days
  3. 1 Year

Health Policy Provision - Claims Procedures

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11
Q

The ______ provision specifies that claims are to be paid immediately upon written proof of loss. The time of payment for claims is usually specified in different policies as ______, ______, or ______. However, if the claim involves disability income benefits, the benefits must be paid not less frequently than ______.

A
  1. Time of Payment of Claims
  2. 60 Days, 45 Days, or 30 Days
  3. Monthly

Health Policy Provision - Claims Procedures

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12
Q

The ______ provision specifies to whom claims payments are to be made, typically to insured, then beneficiary, then estate.

A

Payment of Claims

Health Policy Provision - Claims Procedures

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13
Q

The ______ provision gives the insurer the right to examine the insured, at its own expense, as often as may be reasonably necessary while a claim is pending. The insurer also usually has the right to conduct an autopsy, if not forbidden by a state law.

A

Physical Exam and Autopsy

Health Policy Provision - Physical Examination and Autopsy

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14
Q

The ______ provision states that no statement or misstatement (except fraudulent misstatements) made in the application at the time of issue will be used to deny a claim after the policy has been in force for ______.

A
  1. Time Limit on Certain Defenses
  2. 2 Years

Health Policy Provision - Time Limit on Certain Defenses (Incontestable)

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15
Q

The ______ provision limits the time in which a claimant may seek recovery from an insurer under a policy. The insured must wait ______, but not later than ______ (in most states) after proof of loss, before legal action can be brought against the company.

A
  1. Legal Action
  2. 60 Days
  3. 3 Years

Health Policy Provision - Legal Actions

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16
Q

If the insured misstated his or her ______ or ______ at the time of the application, the benefits paid under the policy would be adjusted to what the premium paid would have purchased with the correct information.

A
  1. Age
  2. Gender

Health Policy Provision - Misstatement of Age or Sex

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17
Q

Because the occupation of the insured is an important underwriting consideration, particularly for disability income insurance, health insurance policies usually include a provision that allows the insurer to adjust ______ if the insured changes ______.

A
  1. Benefits
  2. Occupations

Health Policy Provision - Change of Occupation

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18
Q

The ______ provision states that liability will be denied if the insured is injured while committing a(n) ______ act or is engaged in a(n) ______ occupation.

A
  1. Illegal Occupation
  2. Illegal
  3. Illegal

Health Policy Provision - Illegal Occupation

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19
Q

The ______ provision allows the insurance company to limit the insured’s benefits to his/her average income over the last ______.

A
  1. Relation of Earnings to Insurance
  2. 24 Months

Health Policy Provision - Relation of Earnings to Insurance

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20
Q

The ______ or ______ identifies the insured and the insurance company and states what kind of loss (peril) is covered.

A
  1. Insuring Agreement

2. Insuring Clause

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21
Q

The ______ or ______ provision allows the insured a period of several days to look over the policy, and if dissatisfied for any reason, return it for a full refund. It is commonly ______ from the date the policy is delivered, but may vary.

A
  1. Free-Look
  2. Right To Examine
  3. 10 Days
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22
Q

The ______ clause makes it clear that both parties to the contract must give some valuable consideration.

A

Consideration

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23
Q

The ______ provision states that a period of time must lapse before coverage for specified conditions goes into effect.

A

Probationary Period

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24
Q

The ______ states that a period of days must expire after the onset of an illness or occurrence of an accident before benefits will be payable.

A

Elimination Period

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25
Q

The ______ provision provides that in the event of permanent and total disability, premiums will be waived for the duration of the disability.

A

Waiver of Premium

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26
Q

______ are conditions for which the insured has received diagnosis, advice, care, or treatment during a specific time period prior to the application for health coverage.

A

Pre-Existing Conditions

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27
Q

Most major medical policies include a(n) ______ provision that provides for the sharing of expenses between the insured and the insurance company. After the insured satisfies the policy deductible, the insurance company will usually pay the majority of expenses, typically ______, with the insured paying the remaining ______.

A
  1. Coinsurance

2. 80% / 20%

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28
Q

Most ______ policies also limit the amount of out-of-pocket expenses the insured can incur during a policy year. A(n) ______ is a specified dollar amount beyond which the insured no longer participates in the sharing of expenses.

A
  1. Coinsurance

2. Stop-Loss Limit

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29
Q

A(n) ______ provision is similar to the coinsurance feature in that the insured shares part of the cost for services with the insurer. Unlike coinsurance, a(n) ______ has a set dollar amount that the insured will pay each time certain medical services are used.

A

Copayment

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30
Q

A(n) ______ is a specified dollar amount that the insured must pay first before the insurance company will pay the policy benefits. The purpose is to have the insured absorb the smaller claims, while the coverage provided under the policy will absorb the larger claims.

A

Deductible

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31
Q

Most major medical policies feature a(n) ______ that is paid once in any year, regardless of the amount of claims in that year.

A

Annual Deductible (Calendar Year Deductible)

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32
Q

Some policies may contain a(n) ______, in which each insured is personally responsible for a specified deductible amount each year.

A

Individual Deductible

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33
Q

Some policies may contain a(n) ______ whereby the annual deductible is satisfied if two or more family members pay a deductible in a given year, regardless of the amount of claims incurred by additional family members.

A

Family Deductible

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34
Q

Some policies contain what is known as a(n) ______ or ______ which the insured is required to pay for each claim, possibly resulting in more than one deductible being paid in a given year.

A
  1. Per Occurrence Deductible

2. Flat Deductible

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35
Q

The policy may contain a provision which applies when more than one family member is injured in a single accident, also called the ______ provision. In this case, only one deductible applies for all family members involved in the same accident.

A

Common Accident Provision

36
Q

Some supplemental major medical plans also include a(n) ______ in which case the amount of the deductible may be satisfied by the amount paid under basic medical expense coverage.

A

Integrated Deductible

37
Q

Some policies also include a(n) ______ provision that states that if the insured did not incur enough expenses during the year to meet the deductible, any expenses incurred during the last 3 months may be carried over to the next policy year to satisfy the new annual deductible.

A

Carry-Over

38
Q

Disability and long-term care policies usually have a(n) ______ in the form of elimination period.

A

Time Deductible

39
Q

______ specify for what the insurer will not pay. ______ are a decrease in benefits because of certain specified conditions.

A
  1. Exclusions

2. Reductions

40
Q

The most common ______ in health insurance policies are injury or loss that results from:

  1. War or military duty
  2. Self-inflicted injury
  3. Dental expense
  4. Cosmetic medical expenses
  5. Eye refractions
  6. Care in government facilities
A

Exclusions

41
Q

Most policies will temporarily suspend coverage while an insured resides in a(n) ______ or while serving in the ______.

A
  1. Foreign Country

2. Military

42
Q

Usually the lifetime benefit for major medical coverage limits the amount payable for ______ or ______ disorders as well as outpatient treatment of ______.

A
  1. Mental
  2. Emotional
  3. Substance Abuse
43
Q

______ are those medical expenses covered by a health insurance plan and are specified in the policy.

A

Eligible Expenses

44
Q

Some health insurance policies will require the ______ or ______ of certain medical procedures, tests, or hospital stays before expenses will be covered.

A
  1. Pre-Authorization

2. Prior Approval

45
Q

Some medical expense insurance plans contain a(n) ______, which very specifically states exactly what is covered in the plan and for how much.

A

Benefit Schedule

46
Q

Some medical expense insurance plans may incorporate the term ______/______/______, meaning that the insurance company will pay an amount for a given procedure based upon the average charge for that procedure in that specific geographic area.

A

Usual/Reasonable/Customary

47
Q

The maximum benefit is the largest benefit amount a policy will pay and may be expressed as:

______: Specifies a benefit amount that is the most a policy will pay during the lifetime of the insured.
______: Specifies the most a policy will pay each year that policy is in force.
______: Specifies the most a policy will pay for expenses incurred from the same or related causes.

A
  1. Lifetime Limit
  2. Annual Limit
  3. Per-Cause Limit
48
Q

The ______ (______) rider may be attached to a contract for the purpose of eliminating coverage for a specifically defined pre-existing condition, such as back injuries.

A

Impairment (Exclusion)

49
Q

Most riders in both life and health insurance add some form of additional coverage; the ______ (______) rider is an exception in that it takes something away from standard coverage.

A

Impairment (Exclusion)

50
Q

The ______ or the ______, which is also available on life insurance policies, will allow the insured to purchase additional amounts of disability income coverage without evidence of insurability, usually up to age ______.

A
  1. Future Increase Option
  2. Guaranteed Purchase Option
  3. 50
51
Q

The insurance company cannot cancel a(n) ______ policy, nor can the premium be increased beyond what is stated in the policy (note that the policy may call for an increase in a certain year, such as “age 65”, but that must be stated in the original contract).

A

Noncancelable

52
Q

The ______ provision allows the insurer to cancel the policy at any time, or at the end of the policy period.

A

Cancellable

53
Q

The ______ provision is similar to the noncancelable provision, with the exception that the insurer can increase the policy premium on the policy anniversary date. The insurer may increase premiums on a(n) ______ only and not on an individual policy.

A
  1. Guaranteed Renewable

2. Class Basis

54
Q

Medicare Supplements and long-term care policies must be written as ______ contracts, and cannot be cancelled by the company at the insured’s age 65.

A

Guaranteed Renewable

55
Q

______ provisions, such as the grace period, protect the insured. ______ provisions, such as probationary periods, protect the insurance company.

A
  1. Mandatory

2. Optional

56
Q

An insurance company may contest a claim after 2 years, if they prove ______. Companies are usually reluctant to charge ______, since it requires proof of intent to deceive and is usually difficult to prove.

A

Fraud

57
Q

The ______ clause’s primary purpose is to protect the insurance company.

A

Incontestability

58
Q

The ______ clause is another name for the incontestability clause.

A

Time Limit on Certain Defenses

59
Q

______ is the longest grace period.

A

31 Days

60
Q

If a reinstatement application is required, the insured is reinstated when the ______ says so or after ______, whichever comes first. When the insured is reinstated, a(n) ______ probationary period begins on sickness only.

A
  1. Company
  2. 45 Days
  3. 10-Day
61
Q

If no reinstatement application is required, the insured is reinstated effective upon ______ of their ______ to either the company or the producer.

A
  1. Payment

2. Late Premium

62
Q

______ may be denied if they occur after policy expiration.

A

Claims

63
Q

Under the ______ provision, claims must be paid immediately. ______ claims must be paid at least on a monthly basis.

A
  1. Time Payment of Claims

2. Disability Income

64
Q

The ______ provision allows the claims department time to investigate (maximum of ______).

A
  1. Time Payment of Claims

2. 60 Days

65
Q

Under the ______ provision, if a claim is not paid immediately, the claimant must wait at least ______ before filing a lawsuit for failure to pay. Such suits must be filed within ______ of the original loss.

A
  1. Legal Actions
  2. 60 Days
  3. 3 Years
66
Q

In the ______ clause the insurer promises to pay.

A

Insuring Clause

67
Q

The maximum ______ on a policy varies by state.

A

Probationary Period

68
Q

The ______ is different from the time limit on certain defenses provision (incontestability), which is a maximum of ______.

A
  1. Probationary Period

2. 2 Years

69
Q

On ______ policies, to reduce the premium, an insured may choose a longer waiting period.

A

Disability Income

70
Q

On ______ insurance, the waiting period is just another name for the ______.

A
  1. Disability Income

2. Elimination Period

71
Q

The waiting period is waived on a disability income policy if the same recurrence happens within ______.

A

90 Days

72
Q

______ does not pay money to the insured; it pays the premium to the insurer on behalf of the insured.

A

Waiver of Premium

73
Q

A(n) ______ limits the total amount the family must pay during the year, no matter how many family members become sick or injured.

A

Family Deductible

74
Q

If an insurer wants to stress preventive care, they should waive the ______ for office visits.

A

Deductible

75
Q

To find what is covered on a health insurance policy, the insured would want to look at the area of the policy entitled ______.

A

Eligible Expenses

76
Q

URC stands for ______, ______, and ______.

A
  1. Usual
  2. Reasonable
  3. Customary
77
Q

The ______ is a rider which allows the insured to purchase additional coverage at certain intervals without a physical exam. This rider is also known as the ______.

A
  1. Guaranteed Purchase Option

2. Guaranteed Insurability Rider (GIR)

78
Q

A(n) ______ policy must be renewed if certain specified conditions are met.

A

Conditionally Renewable

79
Q

______ policies provide the biggest disadvantage for the insured.

A

Optionally Renewable

80
Q

On a(n) ______ policy, the insurance company cannot change the coverage or the rates, but can decline to offer renewal.

A

Noncancelable

81
Q

______ policies are usually written as cancellable, which means the company can cancel at any time as long as it gives advance notice.

A

Medical Expense

82
Q

A(n) ______ policy may be canceled at any time by either party, with proper advance notice.

A

Cancellable

83
Q

______ will have no effect on a pending claim, only on future claims.

A

Cancellation

84
Q

On a(n) ______ policy, the insurance company cannot change the coverage; however, it can change the rates by class, although not individually.

A

Guaranteed Renewable

85
Q

If a policy is ______ and ______ (the best kind), the company cannot change the coverage or rates, AND must offer renewal.

A
  1. Noncancelable

2. Guaranteed Renewable

86
Q

At the option of the insured, a(n) ______ policy is renewable by paying the premium up to a certain, specified age (usually age ______).

A
  1. Guaranteed Renewable

2. 65

Life & Health Insurance - General & Texas Specific (15 decks)

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