IV. Individual Health Insurance Policy General Provisions

Question 1

Ind. Health:

What is included in the entire contact?

Answer 1

Health insurance policy,
copy of signed application and
attached riders and amendments.

Question 2

Ind. Health:

Who has the authority to change a policy provision?

Answer 2

The executive officer of the company, not an agent.

Question 3

Ind. Health:

What are the grace periods for an individual policy?

Answer 3

7 days for weekly premium policies (industrial policies)
10 days for monthly
31 days for all other modes

Question 4

Ind. Health:

Coverage is automatically reinstated if not refused within ___ days from the date of the conditional receipt was issued.

Answer 4

45

Question 5

Ind. Health:

How long after reinstatement will accidents be covered?

Answer 5

Immediately

Question 6

Ind. Health:

How long after reinstatement will sickness be covered?

Answer 6

Only after 10 days to prevent adverse selection

Question 7

Ind. Health:

Which provision states to whom the claims are to be paid?

Answer 7

Payment of Claims

Question 8

Ind. Health:

Who decides which optional provisions are included in a policy?

Answer 8

The insurance company

Question 9

Ind. Health:

In what specific way could changing to a more dangerous occupation affect a person’s insurance policy?

Answer 9

Reduction in benefits to match what the premiums paid would have purchased assuming the more hazardous occupation.

Question 10

Ind. Health:

If the insured misstates his/her age, how will benefits be paid?

Answer 10

Policy would be adjusted to what the premium paid would have purchased if done correctly.

Question 11

Ind. Health:

What does the ‘other insurance with this insurer’ provision try to protect against?

Answer 11

Multiple policies with the same company:
provides for a pro rata benefit reduction and return of premium in the event of multiple policies with the same company when the benefits exceed a stated maximum.

Question 12

Ind. Health:

What does the Insurance With Other Insurers provision protect against?

Answer 12

If the insured as 2 or more policies from different companies that provide benefits on an expense-incurred basis, and the policies cover the same expenses, and if hte insurance companies were not notified of the other coverage existed, then each insurer will pay a proportionate share of any claim.

Question 13

Ind. Health:

What is identified in the insuring clause?

Answer 13

Identifies the insured and the insruance company and states what kind of loss (peril) is covered.

Question 14

Ind. Health:
Where is the consideration clause usually located in the policy?

What is consideration for both parties?

Answer 14

First page

Applicant: Payment of premium and the sattements in the application.
Insurer: Promise to pay in accordance with the contract terms.

Question 15

Ind. Health:

What is the difference between a guaranteed renewable and noncancellable policy?

Answer 15

They are similar, except that the insurer can increase the policy premium on the policy anniversary date in guaranteed renewable.

Question 16

Ind. Health:
Which renewal provision gives the insured the right to renew the policy for the life of the contract but allows the insurer to alter premiums?

Answer 16

Guaranteed Renewable

Question 17

Ind. Health:

What is the difference between a conditionally renewable policy and one whose renewability is optional?

Answer 17

Optional renewability allows the insurer to cancel the policy for any reason whatsoever.

Question 18

Ind. Health:

When is notice required for a claim?

Answer 18

Within 20 days of the loss, or as soon as reasonably possible. Notice to the agent equals notice to the insurer.

Question 19

Ind. Health:

When must the company supply claims forms to the insured after receipt of the notice of claim?

Answer 19

Within a specified number of days, usually 15. If forms are not furnished, the claimant is deem?ed to have complied with the requirements of the policy if he or she submits written proof of the occurrence, nature of the loss, and extent of loss to the insurer.

Question 20

Ind. Health:

How long after a loss occurs must the claimant submit proof of loss

Answer 20

Within 90 days or as soon as reasonably possible, but not to exceed one year. (unless not legally competent to comply)

Question 21

Ind. Health:
Time of payment of claims specifies?
and regarding disability income benefits?

Answer 21

Claims are to be paid immediately upon written proof of loss. Usually specified as 60, 45, or 30 days. If claim involves disability income benefits, the benefits must be paid not less frequently than monthly.

Question 22

Elimination Period?

Answer 22

type of deductible commonly found in disability income policies. Period of days which must expire after the onset of an illness or occurrence of an accident before benefits will be payable.