Other Provisions and Clauses Flashcards
What does the insuring clause in a health insurance policy specify?
The insuring clause identifies the basic agreement between the insurer and the insured, stating the type of losses covered and under what circumstances the insurer is obligated to pay.
What is the purpose of the free look period in health insurance policies?
The free look period allows the insured to review the policy and return it for a full refund if dissatisfied, typically within 10 days from the policy delivery date.
What does the consideration clause in a health insurance policy state?
It specifies that the policyholder’s consideration includes the premium payments and statements in the application, while the insurer’s consideration is the promise to pay claims in accordance with the policy terms.
What is the function of the probationary period in health insurance?
The probationary period delays coverage for certain conditions for a specified time, often found in disability policies, and also refers to the waiting period for new employees to enroll in a group plan.
How does the elimination period function in disability insurance?
It is a waiting period from the onset of a disability before benefits begin, acting as a deductible in time rather than in amount, typically influencing the cost of the policy.
What does the waiver of premium provision entail for a disabled insured?
This provision waives the premium payments while the insured is totally disabled after a specified period, often 3-6 months, with a refund of premiums paid during the waiting period if the disability is confirmed.
How are pre-existing conditions handled in health insurance policies under the Affordable Care Act?
The ACA eliminated pre-existing condition exclusions in individual and group health plans, though limitations may still apply in other types of insurance like disability and long-term care.
What is coinsurance and how does it affect the insured’s costs?
Coinsurance is a cost-sharing arrangement where the insured pays a set percentage of the medical costs after the deductible has been met, typically affecting out-of-pocket expenses.
How do copayments work in health insurance?
Copayments are set dollar amounts the insured pays at the time of service, which help manage utilization and out-of-pocket costs.
How do deductibles influence insurance coverage and out-of-pocket costs?
Deductibles are amounts the insured must pay before the insurer begins to pay their share, influencing premiums and out-of-pocket costs; higher deductibles generally lower premiums.
What are eligible expenses in the context of a health insurance policy?
These are medical expenses that are covered under the health insurance plan as specified in the policy.
What is the purpose of pre-authorization and prior approval requirements in health insurance?
These requirements ensure that certain medical services are medically necessary and covered under the policy before they are provided, helping manage costs.
What are usual, reasonable, and customary charges, and how are they determined?
URC charges are based on the average cost of services in a geographic area, used by insurers to determine the amount they will pay for services.
What is the Uniform Individual Accident and Sickness Policy Provision Law?
Defines the rights and duties of the insurer and insured. Wording can be altered as long as it is not detrimental to the policyholder or beneficiary.
What is the requirement for submitting proof of loss?
Proof of loss must be submitted to the policy holder within 90 days. Can extend up to one year.
