Health Insurance Policy Provisions Flashcards
Entire contract
Application
Insurance policy
Riders
Required health policy provision
Time Limit on certain defenses (incontestability clause)
Two years after application
Fraud in the application can void policy when discovered
Required health policy provision
Grace period
If missed payment due date
7 days if paid weekly
10 days if paid monthly
31 days if paid annually, semi-annually, and quarterly
Insurance still in force during grace period
Unpaid premiums deducted from claim
Required health policy provision
Reinstatement
Application and receipt
Must deny within 45 days after application or policy is in effect
Accident claims covers immediately
Sickness claims covered 10 days after reinstatement
Required health policy provision
Notice of claim
Claim must be given 20 days after loss
If continuing disability can only be required to show proof every 6 months
Required
Claim forms
Insurers provide the claim form to the insured
Must be furnished to insured within 15 days notice of loss
Required
Proof of loss
Written proof of loss must be provided to the insurer within 90 days
Required
Time payment of claims
Insurer to pay immediately
At least monthly if a periodic claim such as long term disability policy or long term care policy
Required
Payment of claims
Any death benefits go to Beneficiary or Insureds estate
Facility of payment
- 1000$ to a family member if entitled
Medical exams and autopsy
Insurer pays all costs if either of these are necessary
Required
Legal action against insurer
Earliest 60 days after proof of loss
Maximum 3 years after proof of loss
Required
Change of beneficiary
Revocable (anytime)
Irrevocable (permission needed)
Required
Change of occupation
If switch to more hazardous reduction of benefits
If switch to less hazardous refund of excess premiums
Optional
Misstatement of age
Younger than stated in application
-benefits increase
Older than stated
-benefits reduced
Optional
Other insurance with this insurer
Total of all policies exceeds maximum
- benefits reduced
- excess premiums refunded
Optional
Insurance with other insurer
Each company pays a proportionate share
Excess premiums are refunded
Optional
Relation of earnings to insurance
Benefit cannot exceed earnings
If benefit exceeds earnings benefit is reduced and excess premiums are refunded
Optional
Unpaid premiums
Can be deducted from claim
Optional
Cancellation
Company must give at least 5 day notice but can cancel at any time
Unearned premium must be refunded pro rata
Insured cancels short rate penalty will apply
Optional
Conformity with state statutes
Minimum requirements of the insureds state laws must be met. Otherwise automatically Amended
Optional.
Illegal occupation
No benefits if committing a felony, or engaged in an illegal occupation
Optional
Narcotics
No benefits if loss is caused by alcohol or narcotics unless doctor’s orders
Optional
Right to examination (free look)
Right to examine policy for a specified period of time with the option to return
10 days from receipt (30 days for senior products- Medicare supplements, long term care)
Begins date received by policy holder
If policy is returned- complete refund of money
Other
Insuring clause
Promise to pay
Conditions of payment
Other
Consideration clause
Company promises to pay
Applicant provides information and pays premium
Other
Renewability
Cancelable (insurer at any time) Optionally renewable (company can’t review) Conditionally renewable (non renewal can happen under certain conditions like reaching age 65) Guaranteed renewability (insurer must renew, premiums can be raised by classes) Noncancelable (insurer must renew and premiums can’t be raised)
Military suspense provision
Temporary suspension while in military
Reactivated after leaving military
Other
