Unit 5: Health Insurance Intro Flashcards
Health insurance policy renewability provisions and cancellations
- Optionally Renewable
- Conditionally Renewable
- Guaranteed Renewable
- Non-Cancellable
- Cancellation Clause
_________ – non-renewal at expiration; policy is not cancellable during the term.
Optionally Renewable
_______ – non-renewal for policy stated reasons only; no other reasons can apply.
Conditionally Renewable
_______ – renewable to a stated attained age of the insured (i.e. 65) – premiums can be increased by age or class.
Guaranteed Renewable
– renewable to a stated attained age of the insured (i.e. 65) – premiums cannot be increased by age or class.
Non-Cancellable
- A 20 day written notice to the insured required by Florida Law
Cancellation Clause
______ - provision waives the required payment of premiums if the insured becomes totally disabled AND the policy remains in force.
Waiver of Premium
____________ – this provision places a two year limitation to defenses an insurer may raise to deny a claim or void a policy.
Limitations on Insurer Defense
_____________ provision – simply states the time period after a policy has gone into effect before benefits begin.
Waiting or Elimination Period provision
_______ – this provision increases the policy benefit to double the death benefit for a stated number of incidents.
Double Indemnity
There is a ___ year limitation to defenses or reservations an insurer may raise to deny a claim or void a policy.
2
____________ policies protect against catastrophic losses; most policies have –
deductibles (the portion the insured is responsible for in a policy year).
maximum limits (normally quite high).
coinsurance up to a maximum stop loss limit.
Coverages Include -
Hospital room and board.
Physicians and surgeons fees.
Operating room and Medical expenses including lab work.
Transfusions, drugs, and other medicines.
X-rays, anesthetics, nursing services.
Major medical insurance
Common exclusions in a __________ policy include –
Injury or disease payable under Workers Compensation.
Childbirth and pregnancy.
Treatment in a VA or government hospital.
Intentionally self-inflicted injury.
Dental expenses (except resulting from an accident).
Mental illness.
War.
Cosmetic surgery (except as required following an accident).
Major Medical policy Exclusions
Medicare Supplement Insurance covers the gaps, deductibles, exclusions, and coinsurance of __________ Medicare.
Federal
____________ (HMO) provide the insured with comprehensive health services with a focus on preventative activity –
HMOs employ medical care providers as direct employees. have small if any deductibles. include coinsurance provisions. have minimal exclusions. include broad coverage.
Health Maintenance Organizations (HMO)
________ (____) provide the insured with comprehensive health services with a focus on managed care, cost containment, and flexibility.
PPOs are organized by physicians and hospitals that contract with an insurance company; services are provided via a negotiated scheduled contract.
Preferred Provider Organizations (PPO)
Insurance providing payment if the insured’s death results from an accident, if the insured accidentally severs a limb above the wrist or ankle joints, or totally and irreversibly loses eyesight.
Accidental Death and Dismemberment Insurance
Number of days Florida Statutes (F.S. 627.67 1-675) requires Medicare Supplement Insurance to be returnable within for full premium refund.
30 days
Health insurance provision which states how a lapsed policy may be reactivated.
Reinstatement Provision
Type of service provider which employs medical care providers as direct employees; has small if any deductibles; coinsurance provisions; minimal exclusions; and offers broad coverage.
HMO- Health Maintenance Organizations
Provides coverage for gaps, deductibles, and exclusions in Federal Medicare.
Medicare Supplement Insurance
The Health insurance continuation provision in which the insurer reserves the right to terminate the coverage at any anniversary or, in some cases, at any premium due date, but does not have the right to terminate coverage between such dates.
Optionally Renewable
The Health insurance continuation provision which permits the insured may renew the contract from period to period, or continue it to a stated date or an advanced age, subject to the right of the insurer to decline renewal only under conditions defined in the contract.
Conditionally Renewable
Pays benefits for nonsurgical doctors’ fees commonly rendered in a hospital; sometimes pays for home and office calls.
Medical Expense Insurance
Which Health insurance provision waives premiums if the insured becomes totally disabled but the policy remains in force?
Waiver of Premium
Which Health insurance provision provides a period of time after a premium is due and not paid that an insurer must keep the policy in force and accept a late payment?
Grace Period
This Health insurance provision increases policy payout to double the death benefit for a stated number of fortuitous events.
Double Indemnity
Health insurance policies may contain any one of a wide range of renewability provisions, which define the rights of the insurer to cancel the policy at different points during the life of the policy. There are five principal renewability classifications: cancellable, optionally renewable, conditionally renewable, guaranteed renewable, and non-cancellable.
Renewability Provisions
This joint federal-state program provides medical care for the needy.
Medicaid
This Federally sponsored health insurance and medical program covers persons age 65 or older; and is administered under provisions of the Social Security Act.
Medicare
Health insurance policies that provide daily indemnity benefits for extended care confinement.
Long-Term Care Policies
An illness or medical condition that existed before a policy’s effective date; usually excluded from coverage, through the policy’s standard provisions or by waiver.
Pre-Existing Conditions
Health insurance contract that the insured has the right to continue in force by payment of premiums set forth in the contract for a substantial period of time, during which the insurer has no right to make unilaterally any change in any contract provision.
Non-Cancellable Renewability Provision
The Health insurance continuation provision which states the insured has the right to continue in force by payment of premiums for a substantial period of time during which the insurer has no right to make unilaterally any change in any provision, other than a change in premium rate for classes of insureds.
Guaranteed Renewable Provision
Policy covers fees of physicians for performing surgery by listing covered surgical procedures in a schedule with applicable dollar amounts of coverage.
Surgical Expense Policy
Major Medical Insurance
A type of Health insurance intended to provide protection against catastrophic losses. These policies cover hospital room and board; operating room expenses; and nursing services.
Major Medical Insurance
Health insurance designed to indemnify the insured for basic hospitalization expenses of room and board in the hospital, nursing care, lab fees, operating room, medical supplies, and related items.
Hospitalization Expense Insurance Policy
This type of service provider is organized by physicians and hospitals who contract with an insurance company who offers their services via a negotiated scheduled contract?
PPO- Preferred Provider Organizations
Health insurance that pays a flat amount per day of hospitalization, regardless of expenses or other insurance. Its primary purpose is to supplement other coverage that may be inadequate due to rising costs.
Hospital Indemnity Insurance Policy
A type of Health insurance that reimburses the insured for non-surgical care provided by a physician.
Physicians Coverage Policy
Insurance policy that includes coverages that are designed to protect the insured against a loss of income resulting from injury or sickness.
Disability Income Insurance Policy
The ‘limitations on insurer defense’ provision limits an insurer’s defenses or reservations by which an insurer may deny a claim or void a policy.
What is the time limit for the ‘limitations on insurer defense provision?
2 years
Major Medical Insurance policies typically have all of the following EXCEPT:
death benefit
Major Medical Health Insurance policies typically cover:
- hospital room and board
- physicians and surgeon’s fees
- operating room expenses
- all of the above
all of the above;
Major Medical Health Insurance policies typically cover: hospital room and board; physicians and surgeon’s fees; operating room expenses; medical expenses including lab work, drugs, medicines and anesthetics; and transfusions, X-rays, and nursing services.
Florida Statutes require Medicare Supplement Insurance to:
A) have easy read policy language
B) be returnable within 90 days of purchase for full
premium refund
C) both A and B
D) neither A or B
Florida Statutes require Medicare Supplement Insurance to: have easy read policy language; be returnable within 30 days of purchase for full premium refund; provide an outline of coverage with a Medical Supplement Buyers’ Guide; and limit coverage limitations for pre-existing conditions to six months.
All of the following statements are correct concerning Hospitalization Indemnity Insurance EXCEPT:
- payments are made directly to the hospital
- benefits are paid on a maximum daily room rate
- benefits are paid on a maximum daily room rate
- Hospitalization Indemnity Insurance is used as
supplement to other coverage
payments are made directly to the hospital
The Hospitalization Indemnity Insurance policy features include: payments made directly to the insured; benefits paid on a maximum daily room rate; benefits limited to a maximum number of days; and the policy is used as a supplement to other insurance coverage. Hospitalization Indemnity Insurance narrowly cover only room and board at a hospital.
Florida law requires a Florida health insurance company to provide ___ days written notice of cancellation of a Florida health insurance policy.
not less than 20 (days)
The most stringent ‘total disability’ definition in a Disability Income Insurance policy is:
complete inability to do any work
