Health 2 Flashcards
What is the main principle of an HMO plan?
Preventive care
why: HMO’s stress preventive care to reduce the cost of health care and duplication of services. Preventive care includes annual checkups, immunization, early detection and diagnosis.
Who determines the eligibility and contribution limits of a Health Reimbursement Account (HRA)?
The employer
Why: HRAs consist of funds set aside by employers to reimburse employees for qualified medical expenses. The employer determines eligibility and contribution limits of an HRA.
Who are the parties in a group health contract?
The employer and the insurer
Why: In a group insurance, the contract is between the insurance company and the group sponsor (employer, union, trust, or other organization). The group sponsor receives the master policy and the insureds receive certificates of insurance.
Most health policies will pay the accidental death benefit if the death is caused by an accident and occurs within how many days?
90 Days
Why: Most accidental death and dismemberment (AD&D) policies will pay the accidental death benefit as long as the death is caused by the accident and occurs within 90 days.
Under an individual disability income policy, the benefits must be paid on at least what schedule?
Monthly
Why: If a claim involves disability benefits, the policy must pay those benefits not less frequently than monthly.
What do individual insureds receive as proof of their group health coverage?
Certificate of insurance
Why: The individuals covered under a group insurance contract are issued certificates of insurance. The policy itself, called the master policy, is issued to the group sponsor (usually the employer).
The insured on a health policy misstated his age on the insurance application. If this misrepresentation is discovered, what will happen to the policy?
The benefit amount payable under the policy will be adjusted to the insureds correct age.
Why: If an insured misstates his or her age on the policy application, the misstatement of age provision will change the payable benefit to that which would have been purchased at the insured’s actual age.
In health insurance, when would an excess plan pay benefits?
After the primary plan has paid its full promised benefit, the excess plan will pay the balance
Why: According to the coordination of benefits provision, once the primary plan has paid its full promised benefit, the insured submits the claim to the secondary, or excess, provider for any additional benefits payable.
When an individual is covered under two health plans that have duplicate benefits, the benefit will be prorated to avoid what?
Overinsurance
Why: Overinsurance exists when an individual purchases duplicating coverage with the intent to collect from each policy for a single loss. The coordination of benefits provision limits the total amount of claims paid from all insurers covering the insured to no more than the total allowable medical expenses.
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?
Anytime while the policy is in force
Why: Fraudulent misstatements made in the application for insurance may be contested by the insurer any time the policy is in force and may be used to deny a claim.
