Policy Provisions, Clauses and Riders [Health]

Question 1

Entire contract

Answer 1

Health insurance policy, together with a copy of the signed application and attached riders and amendments.

Question 2

Time limit on certain defenses

Answer 2

no statement or misstatement on the application can be used to deny a claim if the policy has been in effect for 2 years

Question 3

Grace period

Answer 3

period of time after the premium due date, that the policy owner has to pay the premium before the policy lapses.; 7 days - weekly premium, 10 days - monthly premium, 31 days - all other premium modes (quarterly, bi-annually, annually)

Question 4

Reinstatement

Answer 4

A policy can be restored within a specified period of time with proof of insurability; if the insurer does not reject the late payment within 45 days, the policy automatically goes back into effect

Question 5

Notice of claim

Answer 5

the insured must notify the insurer within 20 days of a loss

Question 6

Claim forms

Answer 6

Company must supply insured with claims forms within 15 days

Question 7

Proof of loss

Answer 7

insured must submit proof of loss within 90 days of loss

Question 8

Time of payment of claims

Answer 8

the insurer must pay the insured immediately after proof of loss is provided

Question 9

Payment of claims

Answer 9

Specifies to whom claims payments will be made

Question 10

Physical examination and autopsy

Answer 10

Gives the insurer the right to examine the insured as often as necessary while a claim is pending

Question 11

Legal actions

Answer 11

the insured must wait 60 days and no longer than 3 years after proof of loss before bringing legal action against the company

Question 12

Change of beneficiary

Answer 12

consent is not required unless the beneficiary is irrevocable; if the beneficiary is irrevocable, their signature is required

Question 13

Insuring clause

Answer 13

on the first page of the policy; names the insured, insurer, the amount and time period of coverage, and covered perils/losses

Question 14

Free look

Answer 14

a specific number of days to look over a policy and return it for a full refund; 10 days for health plans, 30 days for senior (medicare) plans

Question 15

Consideration clause

Answer 15

A part of the insurance contract that states that both parties must give something of value for the transfer of risk, and specifies the conditions of the exchange.

Question 16

Probationary period

Answer 16

time period before coverage goes into effect for pre-existing conditions

Question 17

Elimination period

Answer 17

time period the insured has to have the disability or sickness before benefits are paid

Question 18

Waiver of premium

Answer 18

In the event of permanent and total disability, premiums will be waived for the duration of the disability

Question 19

Preexisting conditions

Answer 19

Specifies that coverage does not apply to prior conditions

Question 20

Coinsurance

Answer 20

cost-sharing between the insured and the insurer after the deductible is met where the insurer pays the higher amount;

Question 21

Deductibles

Answer 21

the amount that must be paid before the insurer contributes to the claim; can be individual or family

Question 22

Copayments

Answer 22

the set amount paid for each service visit; usually covers administrative fees

Question 23

Guaranteed insurability

Answer 23

also known as the future insurability option; allows the insured to purchase additional benefits without proof of insurability; requires an additional premium

Question 24

Noncancelable

Answer 24

benefits and premiums can not be changed; the insurer can not cancel the plan; most favorable for the insured

Question 25

Cancelable

Answer 25

the insurer can cancel the policy at any time after providing notice to the insured; least favorable

Question 26

Guaranteed Renewable

Answer 26

Insurer can increase the policy premium (on a class basis only) on the policy anniversary date; insured has the unilateral right to renew the policy for the life of the contract

Question 27

Guaranteed Insurability Rider

Answer 27

Allows insured to purchase additional amounts of disability income insurance without evidence of insurability.