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MY HEALTH PROVISIONS
health insurance provisions
| Question | Answer |
|---|---|
| Is an insurance company required to return unearned premiums on a policy cancellation? | In all cases where the insured has paid for coverage beyond the cancellation date |
| Matilda goes motocross racing over the Memorial Day weekend and suffers a broken leg. She contacts her agent to purchase a major medical policy and files a claim when the policy is issued. The company declines the claim. The grounds for declination is: | The broken leg was a preexisting condition |
| John has been in the hospital for five days. How long does he have to file a claim form and show proof of loss with his insurance company? | 90 days |
| Which of the following may be an optional provision under the Uniform Provisions Law? Physical Exam Change in occupation Entire Contract Time limit to file claims | change in occupation |
| What provision of a health policy may cover preexisting conditions? | entire contract |
| Joan asked her agent when she will have benefits if she reinstates a lapsed health policy. Her agent would be correct if he told her: | Immediately for accidents and 10 days for sickness |
| Michael was laid off accepted a new position with a substantial reduction in pay. Due to an accident, Michael was disabled. The benefit paid was more than Michael's current salary. What is the company that issued the policy obligated to do? | under a relation of earnings to insurance optional provision, pay a reduced benefit based on Michael's current earnings |
| Co-insurance is designed to control what? | Make the insured responsible for some of the charges to hold down claims payments |
| Which of the following is one of the ownership rights of an insurance contract? Pay a claim Change a beneficiary Consideration provision Insuring provision | Change a beneficiary |
| Fred has purchased a cancellable policy. He should understand that: | The insurance company may cancel the policy at any time with proper notice and refund all unearned premium. |
| A grace period allows a certain number of days by contract for the insured to submit a premium. Except for weekly and monthly premium contracts, what is the usual grace period? | 31 days |
| Old Reliable issues a policy that may not be cancelled by the insurance company, except for non-payment of premium. The company does have the right to adjust premiums for an entire class of business. This type of policy is called: | guaranteed renewable |
| Fred has purchased a health policy with a Waiver of Premium rider. When can Fred expect to receive benefits from this rider? | If Fred becomes totally and permanently disabled, the insurance will waive all premiums during the period of disability. |
| The incontestable clause will provide what protection? | After two years, the claim may not be contested by the insurance company except for fraud. |
| The policy requires her to notify the insurance company if she changes occupations. When the policy was issued, Julia was a bank employee. At the time of disability, she had changed occupations to become a welder. What kind of benefit should she expect? | A lower benefit since she had changed to a more hazardous occupation |
| A company may use a rider or an endorsement to do any of the following EXCEPT: Add benefits Change the insuring clause Increase premiums Restrict benefits | change the insuring clause |
| Zack was involved in a serious accident that required him to be hospitalized. His blood alcohol level was well above the allowable limit. Zack's insurance policy will most likely pay his benefit at what level? | Nothing, as alcohol related accidents are usually policy exclusion. |
| Mr. Jones wants a health policy that can never be cancelled by the insurance company. He also wants one that will guarantee the premiums for the life of the policy (no premium increases). He should look for a policy that is: | noncancelable |
| Normally, proof of loss for a medical claim must be submitted to the insurance company for consideration within 90 days UNLESS: | the insured is not of legal capacity |
| Using the facility of payment clause in a policy, the insurance company may pay an amount up to the maximum limit to: | the insured's estate |
| Martha decides she does not want the new policy she purchased. She is within her free look period, so she returns the policy. She should receive: | a full refund of all premiums paid |
| The application and the premium is which part of the contract? | consideration |
| The grace period for a health insurance policy may vary according to: | frequency of premium payments |
| Mary has been admitted to the hospital for testing. How long does she have to give notice of claim to the insurance company? | 20 days |
| Seth has notified his insurance company that he has a claim. The insurance company must furnish a claim form within how many days to comply with the governing provisions? | 15 days |
| Bill has a policy that will always be the same premium. He has a: | noncancelable policy |
| A pre-existing condition clause protects the insurance company against: | adverse selection |
| A health insurance policy will generally exclude Injuries sustained while falling off a ladder | no |
| A health insurance policy will generally exclude Losses sustained as a result of drug abuse | yes |
| A health insurance policy will generally exclude Hurting oneself intentionally | yes |
| A health insurance policy will generally exclude Injuries incurred while robbing a bank | yes |
| Winston applied for a health ins policy stating that he had never had heart trouble, even though he had suffered a heart attack one year prior to making the application. Winston has a heart attack 2 months after the policy is issued. What will insurer do? | The insurance company cancelled the policy and refunded his premiums under Pre-existing condition exclusion |
| Warren has followed the procedure to initiate a claim for a hospital stay. His insurance company has requested information from him that documents his loss. How long does Warren have to produce this proof of loss? | 90 days |
| The "time limit on certain defenses" provision allows the insurance company to defend against: | The time limit for which the insurance company may cancel the policy and refund premiums for material misrepresentation in the application |
| Nick is reading his policy to determine any exclusions that he should know about. If he suffers a loss as a result of using intoxicants or narcotics, he should expect which of the following from most policies? | Losses from the use of intoxicants or narcotics will only be covered if prescribed by a licensed physician |
| Samantha has not paid her premium on her health insurance policy. It has not lapsed, but the premium is due. On her pending claim, Samantha can expect: | The insurance company will pay the claim minus the premium due |
| Joan was robbing a bank when she was severely injured in a car accident as she tried to make her escape. Joan can expect her health insurance policy to: | pay nothing because she was engaged in illegal activity |
| The legal action provision states that a policyholder must wait for how long after presenting proof of loss before bringing legal action against the insurer? | 60 days |
| The free look period for an insurance policy begins: | when the agent delivers the policy |
| The company will renew the policy to a certain age and never increase premiums is an example of a | guaranteed renewable policy |
| The policy clause that states, "benefits are subject to all the provisions, conditions, and exclusions of the policy" is: | insuring clause |
| The insured and the insurance company are each responsible for a percentage of a medical claim. This feature is called a: | co insurance |
| Which of the following types of policies might have a Guaranteed Insurability Clause attached? Major Medical PPO HMO Disability Income | disability income |
| A policyholder is injured while robbing a home. He has to be hospitalized as a result of his injury. When the insurance company discovers that a felony is involved with the claim, the insurance company may do what? | Deny the claim based on no liability |
| Roland has been on a trip and has failed to pay the premium due on his health insurance policy. His agent explains to him that he still has coverage because his policy has what? | a grace period |
| Regina is insured under a guaranteed renewable health contract. The insurance company may increase rates as follows: | Only when an entire class of insured's has a premium increase |
| What is the time limit for an insured to notify the insurance company of a loss? | 20 days |
| Kathy has a cancellable health policy. Her insurance company may Raise premiums for her class of insured's | yes |
| Kathy has a cancellable health policy. Her insurance company may Cancel the policy with notice | yes |
| Kathy has a cancellable health policy. Her insurance company may Change the state required provisions of the policy | no |
| Kathy has a cancellable health policy. Her insurance company may Give a 30-day notice of cancellation | yes |
| How many mandatory provisions for health insurance contracts are there? | 12 mandatory 11 optional |
| There are two parties mentioned in the insuring clause. Who are they? | the insurance company and the insured |
| Joe has named his wife, Sarah, primary beneficiary to his Accidental Death and Dismemberment Policy. Joe is not able to change the beneficiary without Sarah's consent. This type of arrangement is called | irrevocable |
| An insured has reported the wrong age and the wrong occupation on his application. What is the insurance company allowed to do when the error is discovered? | Pay a benefit that the premium paid would have purchased at the correct age or occupation |
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