Chapter 18 : Health Insurance Policy Provisions

Question 1

Entire Contract

Answer 1

Policy + App

Question 2

Time Limit

Answer 2

Usually 2 years
Fraudulent statement is always contestable

Question 3

Grace Period

Answer 3

7- more than once per month payments

10- once per month payment

31- less than monthly; quarterly, semi-annual payments

Question 4

Reinstatements

Answer 4

Allow reinstatement up to 3 years after a policy has lapsed. Some states are 5-7 years.

Reinstatement app
Statement of good health
Back premiums

Question 5

Notice of claim

Answer 5

20 days

Question 6

Claims Forms Provision

Answer 6

Insurer must provide to insured within 15 days after receiving notice of claim.

Question 7

Legal Actions Provisions

Answer 7

Insured cannot take legal action against the company in a claim dispute until after 60 days/2 months from the time the insure submits proof of loss.

Question 8

12 Mandatory Policy Provisions:

Answer 8

1. Entire contract; policy and app
2. Time limit on certain defenses-
   2-3 years
3. Grace Period
   10 days (monthly)/ 31 days
4. Reinstatement
   -45 days / 10 days
5. Notice of claim
   -20 days
6. Claim Forms
   -15 days
7. Proof of Loss-
   90 days
8. Time of Payment of Claims
9. Payment of Claims
10. Physical Exam and Autopsy
11. Legal Actions-
    No more than 5 years. 60 days from claim submitted.
12. Change of beneficiary

Question 9

11 Optional Provisions

Answer 9

1. Change of Occupation
2. Misstatement of age
3. Other Insurance with This Insurer
4. Other Insurance with Other Insurer
5. Insurance with other insurers
6. Relations of Earnings to Insurance
7. Unpaid Premiums
8. Cancellation- 45 days written to insured
9. Conformity with State Statutes
10. Illegal Occupation
11. Intoxicants and Narcotics

Question 10

Common Policy Exclusions:

Answer 10

1. War
2. Military
3. Foreign travel
4. Noncommerical air travel
5. Suicide
6. Felony
7. Occupational injury
8. Cosmetic surgery
   Medical necessity

Question 11

Impairment Rider

Answer 11

AKA Exclusion Rider / Coverage Waiver / Waiver of Disability

Restrict coverage for the illness or injury in questions for a period of years

Question 12

Nonrenewable policies

Answer 12

Short-term health insurance; year or less

Question 13

Conditionally Optional Renewable

Answer 13

Insurer can increase premiums at time of renewal

Question 14

Guaranteed Renewable

Answer 14

Insurer can increase premiums over time

Question 15

Noncancellable Policies

Answer 15

Premium rates remain level

Usually found in disability income policies