HI Provisions Flashcards
Uniform Individual Accident & Sickness Policy Provisions Law
standardized contract language in individual accident and health policies
Reinstatement
Application and receipt. Must deny within 45 days after application/policy is in effect (Accident claims covered immediately. Sickness claims covered 10 days after reinstatement)
Notice of Claim
20 days after loss (If continuing disability can only be required to provide proof every six months)
Claim Forms
must be furnished to insured within 15 days of notice of loss
Proof of Loss
Within 90 days
Time of Payment Claims
At least monthly if a periodic claim such as a long term disability policy or long term care policy. (Insurer pays immediately)
Payment of Claims
Any death benefits (Beneficiary, Insured’s Estate). Facility of Payment ($1k to a family member)
Physical Exam & Autopsy
If company requires and state law allows (Insurer pays all costs)
Legal Actions
Earliest - 60 days after proof of loss. Max - three years after proof of loss
Change of Beneficiary
can be done at any time by policy owner if recovable. Permission of beneficiary needed if irrevocable
Change of Occupation
More hazardous = reduction of benefits. Less hazardous = refund of excess premiums
Misstatement of Age
Younger than stated in application = benefits increased. Older than stated in application = benefits reduced
Other Insurance with This Insurer
Total of all policies exceeds maximum (benefits reduced, excess premiums refunded)
Insurance with Other Insurers
Each company pays a proportionate share. Excess premiums are refunded
Relation of Earnings to Insurance (Average Earnings)
Disability benefits exceeds earnings. (Benefit reduced, excess premiums refunded)
Unpaid Premium
can be deducted from the claim
Cancellation
Company must give at least a five day notice. Unearned premium must be refunded pro rata. Insured cancels short rate penalty will apply
Conformity with State Statutes
makes policy comply with laws of the insured’s state of residence
Illegal Occupation
No benefits (if committing a felony or engaged in an illegal occupation
Narcotics
No benefits (loss caused by alcohol or narcotics unless doctor’s orders)
Right to Examine (Free Look)
10 days from receipt (30 days for senior products/medicare/LTC). Begins on the date received by policyholder. If policy returned - complete refund of money.
Insuring Clause (First provision)
states the insurer’s promise to pay and conditions of payment
Consideration Clause
company promises to pay. applicant provides information and pays premium
Renewability
whether an insurer may refuse to renew a policy depends upon this provision in the policy
Cancelable
the insurer can cancel the policy at any time
Optionally Renewable
the insurer has the option to renew or not for any reason on a premium due or anniversary date (premiums may be increased on policy anni.)
Conditionally Renewable
the insurer may terminate coverage but only for reasons not based on the insured’s health such as reaching a certain age. (premiums may be increased on policy anni.)
Guaranteed Renewable
the policy cannot be canceled except for non-payment of premium, and premiums may increase on a renewal date if the insurer has raised premiums for all insureds in that coverage class
Military Suspense Provision
temporary suspension while in military (reactivated after leaving military)
