Flashcards in Health Insurance Policy Provisions Prep Deck (22):
What's the entire contract clause
It assures the policyowners that no changes will be made to the contract or waive any of the provisions after it has been issued
Time limit on certain defenses clause?
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 insureds application....
Grace period provision?
It's in accidental death and dismemberment policies, its to give the policyowners additional time to pay overdue premiums.. 10 days weekly premiums and 31 days to policies payable on annual.
Specified that if an insured fails to pay a renewal premium within the time granted but the insurer subsequently accepts the premium, coverage may be restored...
Notice of claim provision
Describes the policyowners publication to notify the insurance company of a claim in a reasonable period of time, typically the period is 20 days after the occurrence
It's the company's responsibility to supply a claim for to an insured within 15 days after receiving notice of claim, if the company fails to send out claim forms, insured should submit the claim in any form.
Proof of loss
The claimant has 90 days in which to submit proof of loss.
Time payment of claims
Provides for immediate payment of the claim after the insurer receives notification and proof of loss... the purpose of this shit is to prevent the insurance company from delaying claim payments, also insurer establishes certain conditions insured must meet while claim is pending
Payment of claims
Specified how and to whom claim payments are to be made.
Physical exam autopsy
Unless it's forbidden by state law
Insured cannot take legal action agains company over claims dispute until after 60 days from the time the insured submits proof of loss
Change of beneficiary
Insured can change beneficiary
Change of occupation
Reduces maximum benefit payable under the policy of the insured switches to a more hazardous occupation, or to reduce the premium rate charged if the insured changes to a less hazardous job
Misstatement of age
The insurer can adjust the benefit to what the premiums paid would have purchased at the insureds actual age
Is to specify the scope and limits of the coverage provided. It's the part of the health insurance policy that identifies the specific type of health care services that are covered by that policy and the circumstances under which they will be paid
States the amount and frequency of the premium payments
Becomes effective at the inception of the policy
Allows the insurer to cancel or terminate the policy at anytime
Optionally renewable policies
Gives the insurer the option to terminate the policy on a date specified in the contract
Conditionally renewable policies
Allows an insurer to terminate the coverage but only in the event of one or more conditions stated in the contract (reaching a certain age or loosing employment)
Guaranteed renewable policies
Specifies that the policy must be renewed as along as the premiums are being paid, until the insured reaches a specified age (60-65)