Health Insurance Policy Provisions

Question 1

Entire contract

Answer 1

Application
Insurance policy
Riders

Required health policy provision

Question 2

Time Limit on certain defenses (incontestability clause)

Answer 2

Two years after application
Fraud in the application can void policy when discovered

Required health policy provision

Question 3

Grace period

Answer 3

If missed payment due date

7 days if paid weekly
10 days if paid monthly
31 days if paid annually, semi-annually, and quarterly
Insurance still in force during grace period
Unpaid premiums deducted from claim

Required health policy provision

Question 4

Reinstatement

Answer 4

Application and receipt
Must deny within 45 days after application or policy is in effect
Accident claims covers immediately
Sickness claims covered 10 days after reinstatement

Required health policy provision

Question 5

Notice of claim

Answer 5

Claim must be given 20 days after loss
If continuing disability can only be required to show proof every 6 months

Required

Question 6

Claim forms

Answer 6

Insurers provide the claim form to the insured
Must be furnished to insured within 15 days notice of loss

Required

Question 7

Proof of loss

Answer 7

Written proof of loss must be provided to the insurer within 90 days

Required

Question 8

Time payment of claims

Answer 8

Insurer to pay immediately

At least monthly if a periodic claim such as long term disability policy or long term care policy

Required

Question 9

Payment of claims

Answer 9

Any death benefits go to Beneficiary or Insureds estate

Facility of payment
- 1000$ to a family member if entitled

Question 10

Medical exams and autopsy

Answer 10

Insurer pays all costs if either of these are necessary

Required

Question 11

Legal action against insurer

Answer 11

Earliest 60 days after proof of loss

Maximum 3 years after proof of loss

Required

Question 12

Change of beneficiary

Answer 12

Revocable (anytime)
Irrevocable (permission needed)

Required

Question 13

Change of occupation

Answer 13

If switch to more hazardous reduction of benefits

If switch to less hazardous refund of excess premiums

Optional

Question 14

Misstatement of age

Answer 14

Younger than stated in application
-benefits increase

Older than stated
-benefits reduced

Optional

Question 15

Other insurance with this insurer

Answer 15

Total of all policies exceeds maximum

• benefits reduced
• excess premiums refunded

Optional

Question 16

Insurance with other insurer

Answer 16

Each company pays a proportionate share

Excess premiums are refunded

Optional

Question 17

Relation of earnings to insurance

Answer 17

Benefit cannot exceed earnings

If benefit exceeds earnings benefit is reduced and excess premiums are refunded

Optional

Question 18

Unpaid premiums

Answer 18

Can be deducted from claim

Optional

Question 19

Cancellation

Answer 19

Company must give at least 5 day notice but can cancel at any time

Unearned premium must be refunded pro rata

Insured cancels short rate penalty will apply

Optional

Question 20

Conformity with state statutes

Answer 20

Minimum requirements of the insureds state laws must be met. Otherwise automatically Amended

Optional.

Question 21

Illegal occupation

Answer 21

No benefits if committing a felony, or engaged in an illegal occupation

Optional

Question 22

Narcotics

Answer 22

No benefits if loss is caused by alcohol or narcotics unless doctor’s orders

Optional

Question 23

Right to examination (free look)

Answer 23

Right to examine policy for a specified period of time with the option to return

10 days from receipt (30 days for senior products- Medicare supplements, long term care)

Begins date received by policy holder

If policy is returned- complete refund of money

Other

Question 24

Insuring clause

Answer 24

Promise to pay
Conditions of payment

Other

Question 25

Consideration clause

Answer 25

Company promises to pay
Applicant provides information and pays premium

Other

Question 26

Renewability

Answer 26

Cancelable (insurer at any time)
Optionally renewable (company can’t review)
Conditionally renewable (non renewal can happen under certain conditions like reaching age 65)
Guaranteed renewability (insurer must renew, premiums can be raised by classes)
Noncancelable (insurer must renew and premiums can’t be raised)

Question 27

Military suspense provision

Answer 27

Temporary suspension while in military
Reactivated after leaving military

Other