Individual health insurance policy provisions Flashcards
The NAIC developed how many provisions that MUST appear in all health insurance policies?
12
These mandatory provisions exist primarily for the protection of whom?
The policyowner
Name of the provision that states, if any guarantees, promises, exclusions, or anything else are not included in the policy…then they are not apart of the contract.
Entire contract provision
Provision that limits the time an insurer can void a policy or deny a claim for material misrepresentations on the application.
Time limit on certain defenses provision
Most states limit the time limit on a contestability period to how long?
two years
Provision that gives the policy owner some time after the due date to pay the premium
Grace Period provision
The grace period provision usually depends on how often the premium is due. 3 most common ?
7,10, or 31 day depending on the type of policy
Provision that lets a policyowner reinstate a lapsed policy within a certain time period?
Reinstatement provision
How long is the normal reinstatement period? What are the conditions?
policyowner has 3 years to reinstate. They must pay past premiums with interest and provide proof of insurability.
How long does the insurer have to reject the application for reinstatement of a lapsed policy?
45 days
If the insurer doesn’t respond to a reinstatement application within their given time period, what happens?
The reinstatement is automatic.
Provision that allows the insurer to require a physical exam (for a disability claim), or an autopsy (for a death claim) at the insurers expense?
Physical examination and autopsy provision
Provision that sets a period for the policyowner to take legal action against the insurer to dispute a decision on a claim?
Legal action provision
What is the time period given, after proof off loss is provided,for the legal action provision?
the policyowner must wait at least 60 days and cannot exceed 3 years after proof off loss.
Provision that gives the policyowner the right to change the beneficiary?
Change of beneficiary provision
In this provision the policyowner can only exercise the right to change beneficiary if the designation is what?
revocable.
What is it called when the beneficiary designation can only be changed with the written consent of current beneficiary?
Irrevocable
Provision that explains how claims are paid.
Payment of claims provision
If the insured dies, the insurer pays the beneficiary. If the insured did not specify a beneficiary, the insurer pays who?
The insurer will pay the insured’s estate.
Provision that is step 1 in the claims process, and requires the insured to notify the insurer within how many days of a covered loss?
Notice of claim provision. must notify within 20 days after loss
Provision that is step 2 in claims process, and requires the insurer to provide the claim forms to the insured within how many days from the notice of a claim?
Claim forms provision. Insurer has 15 days to provide the forms.
Provison that is step 3 in the claims process, and requires the insured to provide written proof of loss to the insurer within how many days of the loss?
Proof of loss provision. The insured has 90 days to provide written proof of loss.
Provision that compels the insurer to pay the claims ‘immediately’ after receiving the written proof of loss?
Time of payment of claims provision
States differ on how they define ‘immediate’ payment after proof of loss. Most sates require ____days and some other states ___ days?
most states 60 days and some others 45 days.