Provisions, Riders, & Clauses Flashcards
Within how many days of a loss is the insured required to give notice to the insurer?
20 days
What must the insurer provide to the insured when notice of a claim is filed?
Claim form
Within how many days must proof of loss be submitted?
90 days or as soon as reasonably possible
Not to exceed 1 year
Disability income benefits must not be paid less frequently than how often?
Monthly
What is the Physical Examination and Autopsy Provision?
Insurer has right to examine insured at own expense as often as reasonably necessary while claim is pending.
If not forbidden by state, can conduct autopsy.
How long must an insured wait to take legal action after proof of loss?
Must wait 60 days
No longer than 3 years
What are uniform mandatory provisions?
Required standard provisions
What is a probationary period?
Period of time must lapse before coverage goes into effect
Who is effected by the probationary period?
Those receiving disability income
New employees who must wait before enrolling in a group plan
What is an integrated deductible?
Amount of deductible may be satisfied by the amount paid under basic medical expense coverage.
What is a carry-over provision?
If insured didn’t incur enough expenses during the year to meet the deductible, any expenses in last 3 months can be carried over to satisfy the new annual deductible.
What is a Usual, Reasonable, and Customary (URC) Charge?
Insurance company pays an amount for a given procedure based upon the average charge for that procedure in the specific geographic area.
What happens through subrogation?
The insured cannot collect twice on a claim.
What provision allows the insurer to nonrenew coverage if certain events occur?
Conditionally renewable
What provision prevents the insured from suing the insurance company for at least 60 days after proof of loss is provided?
Legal actions
When can an insurer contest fraudulent misstatements on an application?
Any time while the policy is in force
Once a lapsed policy is reinstated, how long before the policy will cover any accidents?
Immediately
What policy renewability provision allows the insurer to terminate coverage for any reason and to increase premiums for any class of insureds?
Optionally renewable
What provision describes the insured’s right to cancel the policy?
Renewal provision
What provision will most likely appear on a travel accident policy?
Period of time
What provision states to whom the claims must be paid?
Payment of claims
Main difference between coinsurance and copay?
Copay is a set amount while coinsurance is a percentage.
What is the main purpose of coinsurance?
Prevent overutilization of policy benefits
What happens if the premium isn’t paid by the end of the grace period?
It’s cancelled
Who decides which optional provisions are included in a health policy?
the insurance company
