Policy Provisions, Clauses, and Riders

Question 1

what are the provisions of the entire contract?

Answer 1

health insurance policy, copy of the signed application, attached riders and amendments

Question 2

Grace period

Answer 2

time after the premium due date where payments can be made prior to lapse of premium

Question 3

after reinstatement how long till accidents are covered?

Answer 3

immediately

Question 4

how long after reinstatement is coverage returned?

Answer 4

45 days after conditional receipt is issued

Question 5

when is sickness covered after reinstatement?

Answer 5

10 days

Question 6

claims procedures

Answer 6

notice of claim, claims forms, after loss, payment of claims

Question 7

what are the insured’s and the insurer’s duties during claims prodecures?

Answer 7

insured: Notice of claim and proof of loss
insurer: claims forms and the time of payment of claim

Question 8

legal actions

Answer 8

must wait 60 days, but no longer than 3 years after proof of loss

Question 9

insuring clause

Answer 9

defines the scope of coverage, identifies the rights and duties of each party of the contract

Question 10

free-look

Answer 10

allow the insured time to look over the policy and the ability to return policy for a full refund

Question 11

consideration clause

Answer 11

both parties give some valuable consideration
applicant: payment of premium, statements on the application
Insurer: promise to pay according to contract

Question 12

probationary period

Answer 12

time must lapse before coverage begins

Question 13

elimination period

Answer 13

the longer the elimination period the lower the cost of coverage

Question 14

waiver of premium

Answer 14

premiums waive for the duration of disability, premiums paid during waiting period refunded

Question 15

a stop loss limit

Answer 15

dollar amount which the insured is no longer sharing the expenses

Question 16

coinsurance

Answer 16

after deductible is paid the insurer will take the majority of the expenses

Question 17

copayments

Answer 17

the insured shares a part of the cost, set dollar amount

Question 18

deductible

Answer 18

dollar amount the insured has to pay prior to insurer policy benefits kick in

Question 19

per occurrence or flat deductible

Answer 19

insured pays for each claim, possibility of more than one deductible being paid in one year

Question 20

common accident provision

Answer 20

more than one family member injured in an accident, only one deductible applies

Question 21

integrated deductible

Answer 21

the amount of the deductible is satisfied with the basic medical expense coverage

Question 22

carry over provision

Answer 22

not enough expenses incurred the the expenses incurred over the last 3 months will be carried over to satisfy the new annual deductible

Question 23

time deductible

Answer 23

elimination period

Question 24

exclusions

Answer 24

specify what the insurer won’t pay

Question 25

common exclusions

Answer 25

war, self inflicted injury, dental expense, cosmetic medical expense

Question 26

preauthorizations and prior approval requirements

Answer 26

insured requests authorizations for some medical procedures, tests, or hospital stays. needs approval prior to receiving them

Question 27

usual, reasonable, and customary (URC) charges

Answer 27

the insurer will pay an amount based on the average cost of the procedure in the specific geographic area

Question 28

impairment or exclusions rider

Answer 28

attached to the contract to eliminate coverage for specific pre-existing conditions. adds some form of additional coverage. extra cost on premium

Question 29

Guaranteed insurability rider

Answer 29

ability for the insured to purchase additional disability income coverage without evidence of insurability

Question 30

rights to renewability

Answer 30

face page must clearly state the condition required for the individual health policy to be renewed

Question 31

noncancellable

Answer 31

insurer cannot cancel or increase premium not stated within the policy; insured can cancel anytime

Question 32

cancellable

Answer 32

insurer can cancel at anytime or at the end of the policy period

Question 33

guaranteed renewable

Answer 33

required the insurer to continue coverage as long as premiums are paid

Question 34

revocable beneficiary

Answer 34

can be changed at any time

Question 35

irrevocable beneficiary

Answer 35

can only be changed with the beneficiaries consent

Question 36

notice of claim

Answer 36

insured provides insurer with reasonable notice of loss within 20 days of loss

Question 37

claim form

Answer 37

insured must be supplied with a claims form within a specified number of days

Question 38

proof of loss

Answer 38

submission of proof of loss within 90 days of loss

Question 39

time of payment of claims

Answer 39

must be paid upon written proof of loss

Question 40

payment of claims

Answer 40

who claims payment will be made to

Question 41

physical examination and autopsy

Answer 41

insurer has the right to examine the insured as often as needed while claim is pending

Question 42

time limit on certain defenses

Answer 42

misstatements on application can’t be used to deny a claim after 2 years the policy has been in force

Question 43

misstatement of age

Answer 43

benefits adjusted according to what the premium paid would be at the correct age

Question 44

illegal occupation

Answer 44

liability will be denied if insured is injured while committing an illegal act or the insured holds an illegal occupation

Question 45

pre-existing conditions

Answer 45

specifies the coverage doesn’t apply to prior conditions

Question 46

recurrent disability

Answer 46

specifies the time that must lapse between to illnesses for a new set of benefits to be available

Question 47

eligible expenses

Answer 47

medical expenses covered by plan (specific)

Question 48

lifetime, annual, per cause max benefit limits

Answer 48

specifies the largest benefit amount a policy will pay per lifetime, year, or cause

Question 49

change of occupation

Answer 49

allows the insurer to adjust benefits if the insured changes occupation