(6 )- Health Insurance Policy Provisions

8 May 2023
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question
J purchased a Disability Income Policy that ONLY J can terminate and on which the rates will never increase above those illustrated in the policy. Which of the following types of policies did J purchase?
answer
Noncancelable . ( A Disability Income Policy that only the policyowner can terminate and on which the rates will never increase is a Noncancelable policy.
question
Which of the following health policy provisions states that the producer does NOT have the authority to change the policy or waive any of its provisions?
answer
Entire Contract. (The Entire Contract provision states that the producer does NOT have the authority to change the policy or waive any of its provisions.)
question
Which health policy clause specifies the amount of benefits to be paid?
answer
Insuring. (In an Accident & Health policy, the insuring clause states the amount of benefits to be paid.)
question
When does a Probationary Period provision become effective in a health insurance contract?
answer
At the policy's inception (The probationary period begins when a policy goes into effect. During this period, no benefits will be paid under the policy.)
question
A Disability Income policyowner recently submitted a claim for a chronic neck problem that has now resulted in total disability. The original neck injury occurred before the application was taken 5 years prior. The neck injury was never disclosed to the insurer at the time of application. How will the insurer handle this claim?
answer
Claim will be paid and coverage will remain in force (After a policy has been in force for 2 (sometimes 3) years, it enters the incontestable period, in which the insurer may not deny a claim based on information not disclosed at the time of application.)
question
An insurer must provide an insured with claim forms within __ days after receiving notice of a loss.?
answer
"15". (Under the Claims Forms provision, an insurer must provide an insured with claim forms within a MAXIMUM of 15 days after receiving notice of a loss.)
question
Which of these statements accurately describes the Waiver of Premium provision in an Accident and Health policy?
answer
Premiums are waived after the insured has been totally disabled for a specified time period.
question
T owns an Accident & Health policy and notifies her insurance company that she has chosen a less hazardous occupation. Under the Change of Occupation provision, which of the following actions may her insurance company take?
answer
Increase her policy's coverage amount. (Under the Change of Occupation provision in an Accident & Health policy, if the insured notifies the insurance company of a less hazardous occupation, the insurance company may increase the policy's coverage.)
question
The clause identifying which losses resulting from an accident or sickness are insured by the policy is called the?
answer
Insuring clause (The Insuring clause identifies which losses resulting from an accident or sickness are insured by the policy.)
question
In health insurance policies, a waiver of premium provision keeps the coverage in force without premium payments?
answer
After an insured has become totally disabled as defined in the policy (The waiver of premium provision keeps the coverage in force without premium payments if the insured has become totally disabled as defined in the policy.)
question
The policy provision that entitles the insurer to establish conditions the insured must meet while a claim is pending is?
answer
Time Limit on Certain Defenses . ( This provision limits the period during which an insurer can deny a claim based on a misstatement made by the insured.)
question
T files a claim on his Accident and Health policy after being treated for an illness. The insurance company believes that T misrepresented his actual health on the initial insurance application and is, therefore, disputing the claim's validity. The provision that limits the time period during which the company may dispute a claim's validity is called?
answer
Time Limit on Certain Defenses (The Time Limit on Certain Defenses (Incontestability) provision limits the time during which the insurance company may challenge the validity of an insurance claim on the basis of a misstatement made on the insured's application.)
question
With Optionally Renewable Health policies, the insurer may?
answer
Review the policy annually and determine whether or not to renew it.
question
The insuring clause?
answer
"States the scope and limits of the coverage". ( The purpose of the insuring clause is to specify the scope and limits of the coverage provided.)
question
According to the Time Payment of Claims provision, the insurer must pay Disability Income benefits no less frequently than which of the following options?.
answer
Monthly. (The time of payment for claims is usually specified in different policies as 60 days, 45 days, or 30 days. However, if the claim involves disability income benefits, the benefits must be paid not less frequently than monthly)
question
Which Accident and Health policy provision addresses preexisting conditions?
answer
"Time Limit on Certain Defenses". (The Time Limit on Certain Defenses provision limits the period during which an insurer can deny a claim on the basis of a preexisting condition).
question
When an insurance company sends a policy to the insured with an attached application, the element that makes the application part of the contract between the insured and the insurer is called the?
answer
Entire Contract provision (The Entire Contract provision states that the application and policy contain all provisions and constitute the entire contract.)
question
What is considered to be a characteristic of a Conditionally Renewable Health Insurance policy?
answer
Premiums may increase at time of renewal. (A Conditionally Renewable Health Insurance policy can increase premiums at time of renewal.)
question
Which type of renewability best describes a Disability Income policy that covers an individual until the age of 65, but the insurer has the right to change the premium rate for the overall risk class?
answer
Guaranteed Renewable. (The renewal provision in a guaranteed renewable policy specifies that the policy must be renewed (as long as premiums are paid) until the insured reaches a specified age. These usually have increasing premiums.)
question
Which of the following provisions specifies how long a policyowner's health coverage will remain in effect if the policyowner does not pay the premium when it is due?
answer
The grace period ( is the additional period of time after a premium payment is due that will allow the policy to remain in force in the event of nonpayment.)
question
An insurance company receives E's application for an individual health policy. E did not complete all of the medical history questions because she could not remember the exact dates. E signed the policy and submitted it to the insurance company anyway. A few weeks later, E suffers a heart attack and is hospitalized without completing the medical history questions and paying the initial premium. E is not insured. Which of the following clauses details the conditions that E did not meet?
answer
Consideration clause (A health insurance contract is valid only if the insured provides consideration in the form of the full minimum premium and the statements made in the application.)
question
Health insurance benefits NOT covered due to an act of war are?
answer
Excluded by the insurer in the contract provisions.
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The Notice of Claims provision requires a policyowner to?
answer
Spells out the insured's duty to provide the insurer with reasonable notice in the event of a loss.
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The provision that defines to whom the insurer will pay benefits to is called?
answer
The Payment of Claims provision in a Health Insurance policy states to whom claims will be paid.
question
With Accidental Death and Dismemberment policies, what is the purpose of the Grace Period?
answer
The purpose of the Grace Period is to give the policyowner additional time to pay overdue premiums.
question
What is considered to be a characteristic of a Conditionally Renewable Health Insurance policy?
answer
A Conditionally Renewable Health Insurance policy can increase premiums at time of renewal.
question
What is the purpose of the Time of Payment of Claims provision?
answer
Is to prevent the insurance company from delaying claim payments.
question
The Notice of Claims provision requires a policyowner to?
answer
Notify an insurer of a claim within a specified time.
question
The policy provision that entitles the insurer to establish conditions the insured must meet while a claim is pending is?
answer
Time Limit on Certain Defenses.
question
Which of the following statements describes the purpose of the Insuring clause in Health and Accident policies?
answer
States the scope and limits of the coverage.
question
If an individual has an Accidental Death and Dismemberment policy and dies, an autopsy can be performed in all these situations EXCEPT?
answer
When the state prohibits this by law.
question
What type of renewability guarantees premium rates and renewability?
answer
Guaranteed renewable.
question
Which of the following BEST describes a short-term medical expense policy?
answer
Nonrenewable.
question
If an insurance company issues a Disability Income policy that it cannot cancel or for which it cannot increase premiums, the type of renewability that best describes this policy is called?
answer
Noncancellable.
question
K failed to pay a renewal premium within the time granted by the insurer. K then sends in a payment which the insurer subsequently accepts. Which policy provision specifies that coverage may be restored in this situation?
answer
Reinstatement.
question
G is involved in an automobile accident as a result of driving while intoxicated and suffers numerous injuries. According to the Intoxicants and Narcotics exclusion in G's policy, who is responsible for paying the medical bills?
answer
The insured.
question
Which Accident and Health policy provision addresses preexisting conditions?
answer
Time Limit on Certain Defenses.
question
Which of these is considered a mandatory provision?
answer
Payment of Claims.
question
What is considered to be a characteristic of a Conditionally Renewable Health Insurance policy?
answer
Premiums may increase at time of renewal.
question
Which of the following statements about a Guaranteed Renewable Health Insurance policy is CORRECT?
answer
Premiums normally increase at time of renewal.
question
Which of the following statements BEST describes what the Legal Actions provision of an Accident and Health policy requires?
answer
An insured must wait at least 60 days after Proof of Loss has been submitted before a lawsuit can be filed.
question
Which of these statements accurately describes the Waiver of Premium provision in an Accident and Health policy?
answer
Premiums are waived after the insured has been totally disabled for a specified time period.
question
Periodic health claim payments MUST be made at least?
answer
Monthly.
question
What should an insured do if the insurer does not send claims forms within the time period set forth in a health policy's Claims Forms provision?
answer
Submit the claim in any form.
question
Which of the following provisions specifies how long a policyowner's health coverage will remain in effect if the policyowner does not pay the premium when it is due?
answer
Grace Period.
question
Which Accident and Health policy provision addresses preexisting conditions?
answer
Time Limit on Certain Defenses.
question
When an insured changes to a more hazardous occupation, which disability policy provision allows an insurer to adjust policy benefits and rates?
answer
Change of occupation provision.
question
An insurance company receives E's application for an individual health policy. E did not complete all of the medical history questions because she could not remember the exact dates. E signed the policy and submitted it to the insurance company anyway. A few weeks later, E suffers a heart attack and is hospitalized without completing the medical history questions and paying the initial premium. E is not insured. Which of the following clauses details the conditions that E did not meet?
answer
Consideration clause.
question
Which health policy clause specifies the amount of benefits to be paid?
answer
Insuring.
question
After an insured gives notice of loss, what must he/she do if the insurer does not furnish forms?
answer
File written proof of loss.
question
When does a Probationary Period provision become effective in a health insurance contract?
answer
At the policy's inception.
question
Which of these statements accurately describes the Waiver of Premium provision in an Accident and Health policy?
answer
Premiums are waived after the insured has been totally disabled for a specified time period.
question
When an insurance company sends a policy to the insured with an attached application, the element that makes the application part of the contract between the insured and the insurer is called the?
answer
Entire Contract provision.
question
An insured must notify an insurer of a medical claim within how many days after an accident?
answer
20.
question
Which of the following statements describes what an Accident and Health policyowner may NOT do?
answer
Adjust the premium payments.
question
According to the Time Payment of Claims provision, the insurer must pay Disability Income benefits no less frequently than which of the following options?
answer
Monthly. (The time of payment for claims is usually specified in different policies as 60 days, 45 days, or 30 days. However, if the claim involves disability income benefits, the benefits must be paid not less frequently than monthly.)
question
Which of the following health insurance policy provisions specifies the health care services a policy will provide?
answer
Insuring clause.
question
What must the policyowner provide to the insurer for validation that a loss has occurred?
answer
Proof of Loss.