Individual Health Policy Provisions

Question 1

Time Limit on Certain Defenses

Answer 1

Part of NAIC Uniform Policy Provisions Model Law: Limited period of time is provided for an insurer to challenge a contract or deny a claim. In PA, this limit is 3 years (2 in most states).

Question 2

Grace Period

Answer 2

Part of NAIC Uniform Policy Provisions Model Law: Policy holder has additional days to pay a premium based on payment schedule. 7 for weekly premium, 10 days for monthly premium, 31 days for others.

Question 3

Reinstatement

Answer 3

Part of NAIC Uniform Policy Provisions Model Law: Acceptance of overdue premium by insurance company will reinstate the policy. If an application is required and not approved, insurer must notify within 45 days or policy is reinstated. Will not cover loss due to due to sickness at all that begins ten days or less after reinstatement, but WILL cover accident immediately upon reinstatement.

Question 4

Notice of Claim Provision, Claim Forms Provision, Proof of Loss Provision

Answer 4

Part of NAIC Uniform Policy Provisions Model Law: Policy holder must give insurer or rep. notice of claim within 20 days. Insurer must furnish claim forms to the claimant within 15 days. Proof of loss must be filed within 90 days of loss. If claim forms are not furnished within 15 days under the Claims Form provision, the proof of loss requirement is fulfilled.

Question 5

Insurance with Other Insurance Provision

Answer 5

Optional Provision that says that if member has coverage through multiple insurers, insurers pay cost share based on the proportion of the coverage that their benefits pay based on the benefit.

Question 6

Illegal Occupation Provision

Answer 6

Insurance doesn’t pay for loss when person is being dumb (illegal)

Question 7

Noncancelable Contracts

Answer 7

Guarantee the premium on a contract will never go up at renewal