Policy Provisions and Clauses Flashcards
Define uniform provisions
Provisions that have captions and wording that are the same as the captions and wordings in the state statutes or they have been approved by the commissioner because their wording is at least as favorable
What does the entire contract changes provision state
It requires that any policy changes have to have the approval of an executive officer of the insurer endorsed on or attached to the policy.
Under the entire contract changes provision, can the producer make changes
No the producer has no authority to make changes, all changes must be approved by the executive officer
Define the time limit on certain defenses provision
After 2 years from the issue date, only fraudulent statements may be used to void the policy or deny any claims (for example - if someone didn’t disclose that they had a pre-existing condition, then you cannot deny their claims after 2 years from the effective date, however, if someone lied about their SSN, then you could deny coverage after 2 years from the effective date.
How does the two year rule work to void a policy
Say you have someone that didn’t disclose a pre-existing heart condition on their application and then suffered a heart attack six months later, the insurance company would be able to deny their coverage
Define incontestable provision
That if you have a policy that is guaranteed renewable to at least age 50 or if it is issued to a person after age 44 with a guaranteed renewability for at least 5 years, that if the policy has been in force for two years then it is incontestable (you can’t deny coverage for a disease or condition that was excluded)
Are claims still paid during a grace period?
Yes, they are still covered, however, the claims payment may be reduced by the amount that the member still owes in premium
If a policy is reinstated, would it still cover a loss from injury and a loss due to sickness?
It would cover the injury immediately, however, it would not cover a sickness that occurred within 10 days after the reinstatement (waiting period - won’t pay for sickness right away)
Within how many days shoulda claim or notice of a claim be submitted to the producer or the insurer
Within 20 days after the occurrence
Define the claim forms provision
States that if the insurer does not send proof of loss forms within 15 days after the receipt of notice of the claim then the insured can submit some other written proof of the loss
The proof of loss provision gives the insured time to file proof of loss: (4)
- Within 90 days from the date of loss
- Before the 91st day from the date of loss for a continuing loss
- Within one year if the person is physically unable
- No time limit if the person is legally incapacitated
Define the physical examinations and autopsy provision
The insurer at their own expense can examine the dead member as often as reasonably required while a claim is pending
Define a time payment of claims provision
States when benefit payments are going to be made (ie monthly)
Define payment of claims provision
States that benefits will be paid to the insured, or their beneficiary or to the insured’s estate
Define facility of payments clause
States how benefits are paid out (like how much all of your relatives get)
Define assignment of payment scluase
Allows the insurer to pay providers
Define legal actions provision
The member cannot sue the insurance company within 60 days after showing proof of loss or after 3 years if they didn’t show proof of loss when it was required (missed their window)
