Health Insurance Policy Provisions Flashcards

1
Q

What is the purpose of the NAIC law?

A

-to establish uniform of model terms, provisions, amd wording standards for inclusion in all individual health insurance contracts

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2
Q
  • actual policy and the application
  • It also assures the policyowner that no changes will be made to the contract or waive any of the provisions after it has been issued
A
  1. Entire Contract
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3
Q
  1. Time Limit on Certain Defenses
A
  • limits the time during which the insurance company may
    challenge the validity of an insurance claim based on a misstatement made on the insured’s application.
  • a fraudulent statement
    on a health insurance application is grounds for contest at any time, unless the policy is guaranteed renewable
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4
Q

• the minimum grace periods typically specified are 7 days/weekly
premium payments, 10 days/monthly basis, and 31 days/annual basis.
• If an insurer pays an individual accident and health insurance claim during a policy’s grace period, the amount of unpaid premium may be subtracted from the reimbursement

A
  1. Grace Period
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5
Q
  1. Reinstatement
A

•if an insured fails to pay a renewal premium within the time granted but the insurer subsequently accepts the premium, coverage may be restored.

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6
Q
  1. Notice of Claim
A

•describes the policyowner’s obligation to notify the insurance company of a
claim in a reasonable period of time
• 20 days after the occurrence

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7
Q
  1. Claim Forms
A

-within 15 days after receiving notice of
claim
• If the insurance company fails to send out the claim forms within the time period required by the provision, the insured should submit the claim in any form, which must be accepted by the company as adequate proof
of loss

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8
Q

The claimant has 90 days in which to submit what?

A
  1. Proof of Loss
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9
Q
  • provides for immediate payment of the claim after the insurer receives notification and proof of loss.
  • If the claim involves disability income payments, they must be paid at least monthly if not at more frequent intervals specified in the policy
  • prevents the insurance company from delaying claim payments
A
  1. Time of Payment of Claims
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10
Q
  1. Payment of Claims
A

• The payment of claims provision in a health insurance contract specifies how and to whom claim payments are to be made.

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11
Q
  1. Physical Exam and Autopsy
A

unless it’s forbidden by state

law

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12
Q
  1. Legal Actions
A
  • 60 days from the time the insured submits proof of loss to file lawsuit
  • limited to no more than 5 years
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13
Q

The insured, as policyowner, may change the beneficiary designation at any time unless a beneficiary has been named irrevocably.

A
  1. Change of Beneficiary
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14
Q

Change of Occupation

A

-reduce the max benefit payable if the insured switches to a more hazardous occupation or to reduce the premium rate charged if the insured changes to a less hazardous occupation

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