Unit 14 - Health Insurance Policy Provisions Flashcards
12 mandatory and 11 optional uniform provisions, renewability types, free-look, consideration, and how benefits adjust for age/occupation changes (25 cards)
List
12 Mandatory Uniform Provisions
Unit 14 – Health Insurance Policy Provisions, p.294
Entire Contract, Time Limit on Defenses, Grace Period, Reinstatement, Notice of Claim, Claim Forms, Proof of Loss, Time Payment of Claims, Payment of Claims, Physical Exam & Autopsy, Legal Actions, Change of Beneficiary
Mnemonic “E T G R N C P T P P L C”.
Unit 14 – Health Insurance Policy Provisions, p.294
Define
Entire Contract Clause
Unit 14 – Health Insurance Policy Provisions, p.295
Policy + application + riders constitute full agreement; only exec officer can modify.
Prevents post‑issue changes.
Unit 14 – Health Insurance Policy Provisions, p.295
Define
Time Limit on Defenses
Incontestable
Unit 14 – Health Insurance Policy Provisions, p.296
After 2 years (fraud indefinite) insurer cannot void policy for misstatements.
Protects insured after contest period.
Unit 14 – Health Insurance Policy Provisions, p.296
Define
Grace Period
Unit 14 – Health Insurance Policy Provisions, p.297
Premium can be paid after due date without lapse—7days weekly, 10 monthly, 31 other.
Keeps coverage in force briefly.
Unit 14 – Health Insurance Policy Provisions, p.297
Define
Reinstatement Provision
Unit 14 – Health Insurance Policy Provisions, p.298
Allows lapsed policy to be restored within 3 yrs with back premiums & proof of insurability.
Accident coverage immediate; sickness 10‑day waiting.
Unit 14 – Health Insurance Policy Provisions, p.298
Define
Notice of Claim
Unit 14 – Health Insurance Policy Provisions, p.299
Insured must notify insurer within 20 days of loss (or ASAP).
Triggers claim process.
Unit 14 – Health Insurance Policy Provisions, p.299
Define
Claim Forms
Unit 14 – Health Insurance Policy Provisions, p.300
Insurer must send forms within 15 days of notice.
If not, claimant may submit written proof.
Unit 14 – Health Insurance Policy Provisions, p.300
Define
Proof of Loss
Unit 14 – Health Insurance Policy Provisions, p.301
Claimant submits within 90 days of loss (but no later than 1 year).
Documents losses.
Unit 14 – Health Insurance Policy Provisions, p.301
Define
Time Payment of Claims
Unit 14 – Health Insurance Policy Provisions, p.302
Insurer must pay within 60 days of proof (at least monthly for periodic benefits).
Ensures timely payment.
Unit 14 – Health Insurance Policy Provisions, p.302
Define
Payment of Claims
Unit 14 – Health Insurance Policy Provisions, p.303
Specifies claims paid to insured or medical provider; death benefits to beneficiary/estate.
Allows facility-of-payment clause up to $1,000.
Unit 14 – Health Insurance Policy Provisions, p.303
Define
Physical Exam & Autopsy
Unit 14 – Health Insurance Policy Provisions, p.304
Insurer may exam insured or autopsy where legal; insurer pays cost.
Helps verify claim validity.
Unit 14 – Health Insurance Policy Provisions, p.304
Define
Legal Actions
Unit 14 – Health Insurance Policy Provisions, p.305
No lawsuit until 60 days after proof, within 3 years.
Limits litigation period.
Unit 14 – Health Insurance Policy Provisions, p.305
Define
Change of Beneficiary
Unit 14 – Health Insurance Policy Provisions, p.306
Owner may change revocable beneficiary; irrevocable requires consent.
Provision mandatory.
Unit 14 – Health Insurance Policy Provisions, p.306
List
11 Optional Provisions
Unit 14 – Health Insurance Policy Provisions, p.307
Change of Occupation, Misstatement of Age, Other Insurance with this Insurer, Other Insurance with Other Insurers, Relation of Earnings, Unpaid Premium, Cancellation, Conformity with State Law, Illegal Occupation, Intoxicants/Narcotics.
Insurer may include for risk control.
Unit 14 – Health Insurance Policy Provisions, p.307
Define
Change of Occupation
Unit 14 – Health Insurance Policy Provisions, p.308
Insurer adjusts benefits/premium if insured changes to more/less hazardous job.
Prevents adverse occupation change.
Unit 14 – Health Insurance Policy Provisions, p.308
Define
Misstatement of Age/Sex
Unit 14 – Health Insurance Policy Provisions, p.309
Benefit adjusted to amount premium would have purchased at correct age/sex.
Similar to life adjustment.
Unit 14 – Health Insurance Policy Provisions, p.309
Define
Other Insurance With This Insurer
Unit 14 – Health Insurance Policy Provisions, p.310
Prevents over‑insurance by prorating benefits.
Duplicates recovered premiums refunded.
Unit 14 – Health Insurance Policy Provisions, p.310
Define
Relation of Earnings to Insurance
Unit 14 – Health Insurance Policy Provisions, p.311
Disability benefits limited to earnings level.
Avoids profit from disability.
Unit 14 – Health Insurance Policy Provisions, p.311
Define
Unpaid Premium Provision
Unit 14 – Health Insurance Policy Provisions, p.312
Allows insurer to deduct unpaid premium from claim.
Keeps account current.
Unit 14 – Health Insurance Policy Provisions, p.312
Define
Cancellation Provision
Unit 14 – Health Insurance Policy Provisions, p.313
Insurer may cancel with 5 days written notice; pro‑rata refund to insured.
Insured may cancel any time short‑rate refund.
Unit 14 – Health Insurance Policy Provisions, p.313
List
Renewability Types
Unit 14 – Health Insurance Policy Provisions, p.314
Cancellable, Optionally Renewable, Conditionally Renewable, Guaranteed Renewable, Non‑Cancelable.
Stronger guarantees lower insurer flexibility.
Unit 14 – Health Insurance Policy Provisions, p.314
Define
Guaranteed Renewable
Unit 14 – Health Insurance Policy Provisions, p.315
Insurer must renew; can raise class premium.
Policyowner controls renewal.
Unit 14 – Health Insurance Policy Provisions, p.315
Define
Non‑Cancelable
Unit 14 – Health Insurance Policy Provisions, p.316
Insurer must renew & cannot raise premium beyond stated age.
Strongest guarantee, typically DI/LTC.
Unit 14 – Health Insurance Policy Provisions, p.316
Define
Free‑Look Period – Health
Unit 14 – Health Insurance Policy Provisions, p.317
10 days standard; 30 days for LTC/Medigap.
Full refund if returned.
Unit 14 – Health Insurance Policy Provisions, p.317
