Unit 14 Health Insurance Policy Provisions Flashcards
Name the 12 provisions that are mandatory in every health insurance contract:
- Entire Contract; Changes
- Time Limit on Certain Defenses (Incontestability Clause)
- Grace Period
- Reinstatement
- Notice of Claim
- Claim Forms
- Proof of Loss
- Time of Payment of Claims
- Payment of Claims
- Physical Exam and Autopsy
- Legal Actions
- Change of Beneficiary
The ____ Policy Provision requires 12 standard provisions in every insurance contract. Insurance companies are not required to use the exact wording of these provisions, they are allowed to reword them as long as the wording is not ____ to the insured.
Uniform Health Insurance Policy Provision
Less favorable
Entire Contract; Changes: This provision states that the insurance policy represents a contract between the insurer and the insured and consists of:
1. ____ if attached to the policy
2. ____ - the actual insurance contract itself
3. ____ - (endorsements), any other papers or amendments attached to the policy.
In order for something to be included in the contract, it must be in ____, and it must be ____ to the policy.
An agent or producer may NOT change a policy or waive any of its provisions. For a change to be made, it must be approved in writing by an ____ of the insurance company and attached to the policy in the form of an amendment.
- Application
- Insurance Policy
- Riders
Writing
Attached
Executive Officer
Time Limit on Certain Defenses (Incontestability Clause): This provision states that after ____ years from the date of the policy issue, no misstatement, except for ____ misstatements made by the applicant in the application for the policy, shall be used to void the policy or deny a claim for loss after this time period. Fraudulent statements are ground to contest a policy at any time. In addition, the policy cannot deny a claim or reduce benefits on the ground that an illness or a condition was pre-existing after the policy has been in force for ____ years.
2 Years
Fraudulent
2 Years
Pre-existing condition exclusions are still allowed for: (4)
- Disability policies
- Long-term care insurance
- Medicare supplements
- Limited-benefit policies
Grace Period: this is a specified time following the due date of a premium payment in which the premium has not been paid. A loss that occurs during the grace period would be covered minus the premium that was due. Grace periods:
____ - if premiums are paid weekly
____ - if premiums are paid monthly
____ - if premiums are paid annually
7 Days
10 Days
31 Days
Reinstatement: If the premium on the health policy is not paid by the end of the grace period, the policy will lapse and coverage will terminate. The policy is reinstated when the delinquent payment is accepted by the ____ or ____. If the insurer requires a reinstatement application to be submitted, a conditional receipt will be issued for the premium and reinstatement is effective on approval of the application. Coverage is automatically reinstated ____ days after the application is submitted if the insurer has not disapproved the application and notified the applicant by that time. The premium may be applied to a previous period of unpaid coverage, but that unpaid period may not be more than ____ days before the date of reinstatement.
Once a policy is reinstated, there is a ____-day probationary period for sickness coverage. There is no probabtion period for accident coverage.
Insurer or its Agent
45 Days
60 Days
10-Day
Notice of Claim: Written notice of claim must be given to the insurer within ____ days after the occurrence or commencement of any loss covered by the policy or as soon thereafter as is reasonably possible.
If the insured suffers a loss of time on account of disability for which indemnity may be payable for at least ____ years, the insured shall give notice to the insurer once every ____ months of the continuance of the disability except in the case of legal incapacity. (Translation, if continuing disability, the insured is only required to provide proof every ____ months)
20 Days
2 Years
6 Months
Claim Forms: Insurers must provide a claim form within ____ days upon receipt of the insured’s notice of a claim. If the forms are not furnished with ____ days, the insured shall be deemed to have complied with the proof of loss requirement upon submitting written proof that describes the occurrence and the character and extent of the loss
15 Days
15 Days
Proof of Loss: Written proof of loss must be provided to the insurer within ____ days of the date of loss. If it is not reasonably possible to furnish proof within ____ days, it does not invalidate nor reduce any claim. Proof of loss may be filed up to ____ year(s) after the date of loss unless the insured has a legal incapacity.
90 Days
90 Days
1 Year
Time of Payment of Claims: Insurers must pay lump sum claims ____ after receiving proof of loss. For claims involving periodic payments such as disability income, payments must be made at least ____.
Immediately
Monthly
Payment of Claims: This provision states how and to whom payments are to be made. All benefits are payable to the insured while they are alive unless the policy designates a different payee. Death benefits will be paid to either: the ____ or the insured’s ____ if no beneficiary is named or the beneficiary is deceased. If the insured was receiving monthly benefits and some accrued benefits remain after the insured’s death, they will be paid to the beneficiary or the insured’s estate.
Policies may also include an optional provision allowing payment of up to $____ in benefits to any relative of the insured or beneficiary by blood or marriage that appears to be entitled to them. A second optional provision can allow the payment of benefits directly to a medical provider.
Beneficiary or Estate
$1000
Physical Examination and Autopsy: Insurers may require insureds to submit to a physical examination. Insurers may also require an autopsy to be performed on a deceased insured. The ____ pays the cost of the physical exam and autopsy.
Insurer
Legal Actions: No action at law can be brought to recover on the policy:
- Prior to ____ days after filing a written proof of loss, or
- After the expiration of ____ years after filing a written proof of loss
60 Days (the earliest you can take action against the insurer)
3 Years (time is up!)
Change of Beneficiary: The right to change beneficiaries is up to the policyowner. If the beneficiary is designated as ____, changes may not be made to the policy without the beneficiary’s permission.
Irrevocable
