Accident & Health Insurance Provisions Flashcards Preview

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Flashcards in Accident & Health Insurance Provisions Deck (22):
0

Grace Period

cannot be less than
7 days for a weekly premium
10 days for a monthly premium
31 for all other modes

1

Reinstatement

reinstatement is automatic if the policy premium is accepted.
an application may be required along with conditional receipt which can be approved or disapproved.
coverage is automatically reinstated if not refused within 45 days from the date of the conditional receipt.

2

Change of Beneficiary

beneficiary may be changed at any time with written request to the insurer. however if the designation is irrevocable written consent is required from the beneficiary.

3

Notice of claim

notice is required within 20 days of the loss or as soon as reasonably possible. Notice to the agent is the same as notice to the insurer.

4

Claim Forms

the company must supply claim forms within a specified number of days (generally 15)

5

Proof of Loss

Claimant must submit proof of loss within 90 days or as soon as possible within reason not to exceed one year

6

time of payment of claims

must be paid immediately upon written proof of loss. 60, 45, 30 days

if disability income they must be paid not less frequently than monthly.

7

Payment of claims

all benefits are paid to the insured if living. if deceased claims that are pending are paid to the beneficiary or the estate unless assigned to a hospital or doctor who has rendered services

8

facility of payment clause

some policies allow the insurer to expedite payments of urgently needed claim and pay a specified limit in benefits to a relative or individual who is considered to be equitably entitled to payment

9

Physical Examination and Autopsy

gives the insurer the right to examine the insured while a claim is pending

10

TIme limit on certain defenses

no statement or misstatement will be used to deny a claim after the policy has been in force for 2 years

11

Legal Actions

insured must wait 60 days but not longer than 3 years to commence legal action against insurer

12

Change of occupation (optional)

if the insured makes a change to a more hazardous occupation benefits will be adjusted to the amount he premiums would have purchased.
if the change is to a less hazardous job the insured can apply for a premium deduction

13

Other insurance with this insurer

the provision provides for a pro rata benefit reduction and a return of premiums when there are multiple policies with the same company when the benefits exceed a stated maximum

14

Insurance with other insurers

expense incurred basis - each insurer will pay a proportionate share of any claim

15

Relation of earnings to insurance

if the total amount of benefits for a single loss under all policies exceeds the monthly earnings of the insured or average monthly earnings for the immediate prior 2 years the insurer will be liable for the proportionate amount of the benefit. if premiums returns are required in no event may the benefit amount be reduced to less than 200 monthly

16

Unpaid premium

upon payment of a claim any past due premiums will be deducted

17

Insuring clause

first page of the policy - identifies the basic agreement lists
the insured, insurer, states what kid of loss or peril is covered

18

consideration clause

makes it clear that both parties to the contract must give some valuable consideration; the insured pays the premium and the insurer promises to pay in accordance with the contract

19

policy continuation

optional renewable - the insurer may cancel the policy for any reason
conditionally renewable - insurer may terminate the contract only at renewal for certain conditions stipulated in the contract
guaranteed renewable - the insured has unilateral right to renew the policy, however the insurer may still increase the premium

20

noncancellable

the insurer cannot cancel the policy nor can the premium be increased beyond what is stated in the policy

21

pre existing conditions

coverage usually does not apply to prior conditions for which the insured received medical advice or treatment within a certain amount of time before the date of application