Health Insurance Policy Provisions

Question 1

What is the purpose of the NAIC law?

Answer 1

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

Question 2

• 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

Answer 2

1. Entire Contract

Question 3

2. Time Limit on Certain Defenses

Answer 3

• 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

Question 4

• 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

Answer 4

3. Grace Period

Question 5

4. Reinstatement

Answer 5

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

Question 6

5. Notice of Claim

Answer 6

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

Question 7

6. Claim Forms

Answer 7

-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

Question 8

The claimant has 90 days in which to submit what?

Answer 8

7. Proof of Loss

Question 9

• 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

Answer 9

8. Time of Payment of Claims

Question 10

9. Payment of Claims

Answer 10

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

Question 11

10. Physical Exam and Autopsy

Answer 11

unless it’s forbidden by state

law

Question 12

11. Legal Actions

Answer 12

• 60 days from the time the insured submits proof of loss to file lawsuit
• limited to no more than 5 years

Question 13

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

Answer 13

12. Change of Beneficiary

Question 14

Change of Occupation

Answer 14

-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