Ch.6 health Flashcards
(39 cards)
The Entire Contract provision
the insurance policy itself, any riders and endorsements/amendments, and the application comprise the entire contract between all parties
The time limit on certain defense provision
the policy is incontestable after it has been in force a certain period of time, usually two years
The notice of claim policy provision
describes the policy owner’s obligation to provide notification of a claim to the insurer within a reasonable period of time. Typically, the period is 20 days after the occurrence or commencement of the loss, or as soon thereafter as is reasonably possible
Claim forms provision
the formal request to an insurance company asking for a payment based on the terms of the insurance policy. It is the company’s responsibility to supply a claim form to an insured within 15 days after receiving notice of claim
Proof of loss provision
a mandatory health insurance provision stating that the insured must provide a completed claim form to the insurer within days of the date of loss
Time of payment claims provision
a provision that requires claims be paid immediately or within a stated number of days. If the claim involves disability income payments, they must be paid at least monthly if not at more frequent intervals specified in the policy
Payment of claims provision
states that the insured and insurance company will share the cost of covered losses
The physical exam and autopsy provision
a standard health insurance policy provision allowing the insurer to examine the insured when a claim is pending, and in the event of death perform an autopsy where not prohibited by law
Legal actions provison
states the insured cannot take legal action against the company in a claim dispute until after 60 days from the time the insured submits proof of loss. At least give us 2 months before you take us to court
The change of beneficiary provision
permits the insured to change the beneficiary as often as he or she wishes, except in policies where the beneficiary is irrevocable
The change of occupation provision
allows the insurer to reduce the maximum benefit payable under the policy if the insured switches to a more hazardous occupation or to reduce the premium rate charged if the insured changes to a less hazardous occupation
The misstatement of age or sex provision
allows the insurer to adjust the policy benefits if the insured’s age or sex is misstated on the policy application
The other insurance in this insurer provision
states that the total amount of coverage to be underwritten by a company for one person is restricted to a specified maximum amount, regardless of the number of policies issued
The insurance with other insurer provision
The “insurance with other insurer” provision in an insurance policy outlines how claims are handled when multiple policies cover the same loss. It determines how insurers will share the payment for the claim, which can be based on primary and secondary coverage, pro-rata distribution, or equal sharing among insurers. This provision ensures fair distribution of payment and avoids duplication
The relation of earnings provision
states that the insurer is liable only for that proportionate amount of benefits as the insured’s earnings bear to the total benefits under all such coverage
The unpaid premiums provision
a provision that permits unpaid premiums to be taken from claim payments. If there is an unpaid premium at the time a claim becomes payable, the amount of the premium is to be deducted from the sum payable to the insured or beneficiary
The conformity with state statutes provision
designed to ensure that the policy complies with state laws and regulations
The illegal occupation clause
states the insured is not covered for losses that arise if he or she tries to commit a felony. Coverage is also voided if the insured is working at an illegal occupation
The intoxicants and narcotics provision
states the policy is not liable for losses that occur as a result of the policyholder being intoxicated or taking a narcotic without a physician’s supervision and recommendation
Cancellable Policies
insurance contracts that may be terminated by the company or that is renewable at its option
Policy loan or cash value provisions
found in whole life policies and some long-term care policies. These policies must begin to build cash value after a certain number of years. In most states, this is 3 years. These loans, with interest, cannot exceed the guaranteed cash value or the policy is no longer in force. The policyowner has the right to the policy’s cash value. Policy loans are not taxable. Any loans with interest due at the time of death will be deducted from the insured’s policy proceeds
Automatic premium loans
allow the insurer to automatically use the policy cash value to pay an overdue premium
The Social Security rider
provides for the payment of additional income when the insured is eligible for social insurance benefits but those benefits have not yet begun, have been denied, or have begun in an amount less than the benefit amount of the rider
The right of assignment
built into most commercial health policies lets policyowners assign benefit payments from the insurer directly to the health care provider, thus relieving the policyowner of first having to pay the medical care provider
