Standard Policy Provisions and Clauses Flashcards
How do minimum benefit standards differ between grandfathered and non-grandfathered health plans in Florida?
In Florida, grandfathered plans provide creditable coverage towards pre-existing condition exclusions, whereas non-grandfathered plans do not offer this provision, aligning instead with newer regulations that prohibit pre-existing condition exclusions.
What are some key required provisions in Florida health insurance policies?
Key required provisions in Florida health insurance policies include entire contract/changes, time limit on certain defenses, grace period, reinstatement, notice of claim, claim forms, proofs of loss, time of payment of claims, denial of claims, legal actions, and change of beneficiary. These provisions establish the rules and procedures for the administration of the policy.
What is the role of the “Entire Contract/Changes” provision in Florida health insurance policies?
The “Entire Contract/Changes” provision ensures that the insurance policy, along with any endorsements or amendments, constitutes the full agreement between the insurer and the insured. Changes to the policy must be in writing and agreed upon by both parties, safeguarding transparency and agreement.
How does Florida law specify the rules for the “Time Limit on Certain Defenses” provision in health insurance policies?
Under Florida law, except in cases of fraud, no misstatements made by the applicant in the policy application can be used to void the policy or deny a claim for loss or disability after the policy has been in effect for two years.
What are the grace period durations specified by Florida law for health insurance policies, and what does it entail?
Florida law specifies a grace period of 7 days for weekly premium payments, 10 days for monthly premiums, and 31 days for all other payment modes. The policy remains in force during this grace period, providing continued coverage despite payment delays.
What is the process for reinstating a lapsed health insurance policy in Florida according to your textbook?
In Florida, if a renewal premium is not paid within the time granted for payment, the policy can still be reinstated if the insurer or its producer accepts a subsequent premium without requiring a reinstatement application. Coverage is automatically reinstated if the insurer does not refuse it within 45 days from the date the conditional receipt was issued.
What is the timeframe of notice of claims and claim forms?
The insured must provide notice of claim within 20 days after loss; the insurer must provide claim forms within 15 days from receiving notice of claims.
What is the timeframe for proof of loss?
The proof of loss must be sumbitted to the insurer within 90 days.
How does Florida law specify the timeframe within which claims must be paid after receiving sufficient proof of loss?
Indemnities payable will be paid immediately after receipt of proof of loss.
How does Florida law handle the denial of claims in health insurance policies, and what are the requirements for appealing such denials?
Under Florida law, if a claim is denied, the insured has the right to an appeal. The insurer’s licensed physician must review and respond to the appeal within a reasonable time frame, not exceeding 15 business days, ensuring a prompt and equitable resolution process.
What are the timeframes for initiating legal action against an insurer in Florida following a claim denial?
In Florida, legal action can be initiated 60 days after proof of loss has been provided if the loss has not been paid within 120 days. The statute of limitations for filing a lawsuit is 5 years after the proof of loss is furnished to the insurance company.
Under what conditions may individual and group health insurance policies and HMO contracts not be renewed in Florida?
Non-Payment of Premiums: Policies may not be renewed due to failure to pay or untimely payment of premiums.
Fraud or Misrepresentation: If there is fraud or intentional misrepresentation of a material fact by the policyholder.
Group Policy Requirements: Failure to meet minimum participation or contribution requirements of a group policy.
Withdrawal from Market: The insurer ceases offering coverage in a market segment.
Discontinuation of Plan Forms: If a policy form is no longer issued, insurers may terminate coverage under current forms with 90 days notice, provided they offer any other available coverage.
Market Exit: If all coverages in a market are discontinued, insurers must give 180 days notice and are barred from issuing any coverage in that market in Florida for 5 years.
Service Area Requirements: For network plans or associations, if no enrollee resides or works in the service area, provided this is uniformly applied.
What are the key provisions regarding coverage for newborn children in Florida health insurance policies?
Coverage Duration: Coverage must be provided for newborns from birth up to $1000.
Termination: Coverage terminates after 18 months from birth.
Notice Requirement: The insured member must notify the insurer of the birth within 30 days after birth.
Premium Adjustment: If timely notice is given, the insurer may not charge an additional premium for coverage. If timely notice is not given, the insurer may charge an additional premium
What is one of the prohibited provisions in health insurance policies in Florida?
It is illegal to discriminate between individuals of the same class or risk exposure in the amount of premiums, policy fees, or rates charged for any policy.
