Policy Provisions, Clauses, and Riders Flashcards
what are the provisions of the entire contract?
health insurance policy, copy of the signed application, attached riders and amendments
Grace period
time after the premium due date where payments can be made prior to lapse of premium
after reinstatement how long till accidents are covered?
immediately
how long after reinstatement is coverage returned?
45 days after conditional receipt is issued
when is sickness covered after reinstatement?
10 days
claims procedures
notice of claim, claims forms, after loss, payment of claims
what are the insured’s and the insurer’s duties during claims prodecures?
insured: Notice of claim and proof of loss
insurer: claims forms and the time of payment of claim
legal actions
must wait 60 days, but no longer than 3 years after proof of loss
insuring clause
defines the scope of coverage, identifies the rights and duties of each party of the contract
free-look
allow the insured time to look over the policy and the ability to return policy for a full refund
consideration clause
both parties give some valuable consideration
applicant: payment of premium, statements on the application
Insurer: promise to pay according to contract
probationary period
time must lapse before coverage begins
elimination period
the longer the elimination period the lower the cost of coverage
waiver of premium
premiums waive for the duration of disability, premiums paid during waiting period refunded
a stop loss limit
dollar amount which the insured is no longer sharing the expenses
coinsurance
after deductible is paid the insurer will take the majority of the expenses
copayments
the insured shares a part of the cost, set dollar amount
deductible
dollar amount the insured has to pay prior to insurer policy benefits kick in
per occurrence or flat deductible
insured pays for each claim, possibility of more than one deductible being paid in one year
common accident provision
more than one family member injured in an accident, only one deductible applies
integrated deductible
the amount of the deductible is satisfied with the basic medical expense coverage
carry over provision
not enough expenses incurred the the expenses incurred over the last 3 months will be carried over to satisfy the new annual deductible
time deductible
elimination period
exclusions
specify what the insurer won’t pay
common exclusions
war, self inflicted injury, dental expense, cosmetic medical expense
preauthorizations and prior approval requirements
insured requests authorizations for some medical procedures, tests, or hospital stays. needs approval prior to receiving them
usual, reasonable, and customary (URC) charges
the insurer will pay an amount based on the average cost of the procedure in the specific geographic area
impairment or exclusions rider
attached to the contract to eliminate coverage for specific pre-existing conditions. adds some form of additional coverage. extra cost on premium
Guaranteed insurability rider
ability for the insured to purchase additional disability income coverage without evidence of insurability
rights to renewability
face page must clearly state the condition required for the individual health policy to be renewed
noncancellable
insurer cannot cancel or increase premium not stated within the policy; insured can cancel anytime
cancellable
insurer can cancel at anytime or at the end of the policy period
guaranteed renewable
required the insurer to continue coverage as long as premiums are paid
revocable beneficiary
can be changed at any time
irrevocable beneficiary
can only be changed with the beneficiaries consent
notice of claim
insured provides insurer with reasonable notice of loss within 20 days of loss
claim form
insured must be supplied with a claims form within a specified number of days
proof of loss
submission of proof of loss within 90 days of loss
time of payment of claims
must be paid upon written proof of loss
payment of claims
who claims payment will be made to
physical examination and autopsy
insurer has the right to examine the insured as often as needed while claim is pending
time limit on certain defenses
misstatements on application can’t be used to deny a claim after 2 years the policy has been in force
misstatement of age
benefits adjusted according to what the premium paid would be at the correct age
illegal occupation
liability will be denied if insured is injured while committing an illegal act or the insured holds an illegal occupation
pre-existing conditions
specifies the coverage doesn’t apply to prior conditions
recurrent disability
specifies the time that must lapse between to illnesses for a new set of benefits to be available
eligible expenses
medical expenses covered by plan (specific)
lifetime, annual, per cause max benefit limits
specifies the largest benefit amount a policy will pay per lifetime, year, or cause
change of occupation
allows the insurer to adjust benefits if the insured changes occupation
