Individual Policy Provisions Flashcards
The “time limit on certain defenses” generally terminates the insurance company’s right to void a claim that is not based on a fraudulent statement for more than _________ years from the date of policy issue.
A
1
B
5
C
10
D
2
D
2
Under the legal actions provision, the insured cannot take legal action against the insurer for at least:
A
6 months after the Notice of Claim is filed
B
3 years after the proof of loss was submitted
C
90 days after the loss occurs
D
60 days after providing proof of loss
D
60 days after providing proof of loss
A policy is issued based on an insured’s age of 40. After a disability occurs, the insurer discovers that the age was understated and the insured was actually 45 years old at the time of application. The insurer will most likely:
A
Reduce the benefit based on what the premiums paid would have purchased at the correct age
B
Refund the excess premiums since the insured overpaid premiums
C
Cancel the policy if the discovery is made within 2 years of policy issue
D
Pay the benefit as stated in the policy with no adjustment to the policy
A
Reduce the benefit based on what the premiums paid would have purchased at the correct age
If the age is stated younger than the actual age (understated) on the application, benefits paid will be reduced based on what the premium paid would have purchased at the correct age.
The insurer’s promise to pay benefits is expressly stated in the:
A
Insuring clause
B
Entire contract clause
C
Consideration clause
D
Legal actions provision
A
Insuring clause
The time period that must elapse after a loss before benefits are payable under a policy is the:
A
Probationary period
B
Free look
C
Grace period
D
Elimination or waiting period
D
Elimination or waiting period
An individual is covered under an individual disability income policy with a 90-day waiver of premium provision and a $100 monthly premium. If the insured becomes disabled due to a serious illness and is unable to work for 6 months, which of the following statements will apply?
A
The insured is responsible for paying the premiums for 3 months and will then receive a $300 refund and premiums are no longer payable for the remainder of the disability
B
Premiums do not have to be paid during the entire 6 months
C
The insured does not qualify for the waiver of premium since the disability is due to sickness
D
The premiums must be paid by the insured for the entire 6 months and upon returning back to work the insurer will reimburse the insured for the premiums paid for the first 90 days
A
The insured is responsible for paying the premiums for 3 months and will then receive a $300 refund and premiums are no longer payable for the remainder of the disability
In a guaranteed renewable policy, the premiums may:
A
Be increased only in relation to the number of claims paid in the past year
B
Only be increased according to the increased risk of an individual insured’s health status
C
Be increased for all similarly classified insureds based on age
D
Not be changed at all from the original premium at the time the policy was issued
C
Be increased for all similarly classified insureds based on age
The guaranteed renewable provision allows for premiums to be increased but only if all insureds in the same classification, such as age group, have the same increase.
Which of the following is not an example of a cost containment measure specific to managed health care plans?
A
Replacement
B
Preventive care
C
Utilization review
D
Mandatory second opinion
A
Replacement
An insurance company would most likely use an impairment rider in which of the following situations?
A
G is looking to obtain a health insurance policy, but is concerned about a current heart condition
B
S is looking to buy a disability income policy, but is unemployed
C
F has cancer and is looking to buy a cancer only policy to help with the cost of treatment
D
T, age 70, wants to buy a long-term care policy but is receiving skilled care in a nursing home
A
G is looking to obtain a health insurance policy, but is concerned about a current heart condition
Kirk has just reinstated an individual A&H policy that had lapsed and wants to know how soon coverage will be in effect for any accident or sickness. You, the agent, would say:
A
Sickness immediately, accidents after 30 days
B
Sickness immediately, accidents after 10 days
C
Accidents immediately, sickness after 30 days
D
Accidents immediately, sickness after 10 days
D
Accidents immediately, sickness after 10 days
Harry was hospitalized and in a coma for 6 months. When does proof of loss for this claim have to be submitted?
A
Within 1 year, unless he suffers legal incapacity
B
An executor would be appointed by the courts to handle the necessary paperwork
C
Anytime, since he was in a coma and obviously could not submit a claim
D
Within 2 years, covered under the contestable period
A
Within 1 year, unless he suffers legal incapacity
The Proof of Loss Provision (a Mandatory Uniform Provision) stipulates that the insured must provide proof of the loss within 90 days of the loss, or within in the shortest time possible, but not to exceed 1 year unless the insured suffers legal incapacity. Since Harry was in a coma for 6 months, it would not have been possible for him to file a claim within the 90-day time period.
Case managers do all of the following, except:
A
Requiring a referral or second opinion prior to approving a procedure
B
Determining the appropriate course of action for the insured
C
Managing the utilization review of a hospital stay
D
Providing the necessary care
D
Providing the necessary care
Does the insured have the right to change the beneficiary designation of a health insurance policy?
A
Yes, the beneficiary designation is always revocable in health policies
B
Yes, unless the beneficiary is designated as irrevocable
C
No, the beneficiary designation in health policies is always irrevocable
D
No, only the insurer has that right in health policies
B
Yes, unless the beneficiary is designated as irrevocable
An insured should receive necessary claim forms within _____ days after notice of claim.
A
20
B
15
C
5
D
10
B
15
Which of the following is not a Mandatory Uniform Provision of an Accident and Health policy?
A
Time Limit on Certain Defenses
B
Payment of Claims
C
Proof of Loss
D
Waiver of Premium
D
Waiver of Premium
The other choices are Mandatory Uniform Provisions. Waiver of Premium is a provision that may or may not be included.
