When an individual needs to file a health ins. claim, what are his responsibilities?
-notice is required within 20 days
-proof of loss must be submitted within 90 days, no later than a yr.
What are the grace periods for an individual policy?
-7 days for weekly pay
-10 days for monthly pay
-31 days for all others
In what specific way would changing to a more dangerous occupation affect a person's insurance policy?
Benefits would be reduced to that which the premium would have purchased assuming the more hazardous occupation
Who has the authority to change a policy provision?
Only an executive officer of the company (not an agent)
Included in the entire contract:
_Health Insurance policy
-Copy of signed application
-Any attached endorsements
Accidental Bodily Injury
Unforeseen and unintended injury that resulted from an accident rather than a sickness
Hospital Indemnity
-Specific Amount
-BAsed only on the # of days confined in a hopsital
Travel Accident
Coverage for death or injury occuring whil a fare-paying passenger on a common carrier
How might an insurance co. offcer a sub-standard policy?
-Applicant has poor health history or dangerous a/vocation
-Higher rates
-Rider that excludes p.e.c.
2 types of insurance included in the term "heatl insurance"
-Accidental Injury
-Sickness
Difference b/t limited and comprehensive policies
Limited: Only covers specific accidents or disesases
Comprehensive: All sickness or accidents that are not specifically excluded
What is the basic purpose of field underwriting for health insurance?
Gather info from an applicant and select risks
Outline of coverage
must be delivered at the time of application or upon delivery of policy
Sub-standard vs. standard policy
Sub-standard as a higher premium and a rider excluding p.e.c.
Credit Disability:
In debt to a specific creditor
Application Procedures
-form provided by insurance co.
-questions asked of the applicant
-hs/her responses recorded
-completed by agent
comvin exclusions from coverage (5)
-p.e.c.
-intentional, self inflicted
-elective cosmetic surgery
-covered by workers comp
-govt plans
-criminal activity
Under Ad&d coverage, when would the prncipal amount be paid?
Paid in the event of accidental death
In what different ways can AD&D coverage be written?
Asa rider or as a separate policy
When do advertising rules apply
any health ins advertisement intended for presentation distribtuion dissemination etc when made directly or indirectly by or o/b/o insurance co
Guarantee Assoc. Liabilities may not exceed
Lesser of contractual obligations or which ins co is liable, or
-300K in life ins death benefits but not more tha 100k in net cash surrender and net cash withdrawal values
-100k in health ins beneifts including any ncs and ncw values
-100k in present value of annuity benefits..
" "
Blanket Policy
covers:
-particular group
-particular activity
-often the covered individual's name is not known
ex: students, sports teams, common carrier passengers
Under AD&D coverage, when would capital amt be paid?
in the case of loss of sight or accidental dismemberment
Which risk class typically qualifies for lower premiums?
non-smokers
How are dread disease policies different?
provide beneifts for a specific disease,
also has a high maximum
Who is the field underwriter?
The agent who actually has personal contact with the applicant and gathers info on the applicant
What is identified in the insuring clause?
The insured, the insurance co and states what kind of loss is covered
Where is the consideration clause usually located?
Usually on 1st page
What is the dfference betwen a guaranteed renewable and a noncancelable policy?
GR - insurer can increase premiums on anniversary date, but on a class basis only
NC - insurance co can't increase premium
Which renewal provision gives the insured the right to renew the policy for the life of the contract but allows the insurer to alter premiums?
Guararnteed renewable
What is the difference betyween a conditionally renewable policy and one whose renwability is optional?
CR - insurer mminate contract only for certain stated stipulations
Once a disability policy is paying a claim, how long will it pay?
1, 2, or 5 yrs or to age 65 as specified by the Benefit Period
When does the elimination period occur?
From onset of disability until payments commence
How long does the elimination period usually last (range)?
30-180 days
If an insured is disabled and has the waiver of premium benefit, generally what happens to the premiums paid during the waiting period?
reimbursed/refunded
What is the difference between occupational and nonoccupational coverage?
Occupational - on the job or off
Non-Occ - Off the job only, assumed workers comp covers on-job)
What is partial disability
Inability to perform regular duties of own occupation or inability to work on full time basis
What does partil disability cover
Partial loss of income, typically 50% of total disability benefit
What is residual disability
provides benefits when a person returns to work after a total disability but still not able to work as long or at the same level
What does residual disability cover
Difference between present earnings and what they were earning before
With key person insurance, who are the owner, premium payer, the beneficiary and the insured?
Owner - business
Payer - Business
Beneficiary - business
Insured - Key person
How is the Social Security definiton of disability different fromat in most disability income policies?
The SS definition of disability is not as liberal as most definitions of disability found in most insurance policies
-the inability to engage in any substantially gainful activity by reason of:a medicaly determinable physical or mental impairment that has lasted (or is expected to last) 12 mnths OR result in an early death
What policy covers an emplotee that is hurt on the job?>
Workers compensation
-also: occupational disability coverage from insurance co
What are the usual, reasonable and customary charges based on?
avg charge for a specific procedure in that specific geographic area
What is the difference b/t insureds and subscribers?
Insureds - people covered by insurance
Subscribers - people covered by pre-paid health plans
Explain the gatekeeper concept
The hmo member initially chooses his PCP. must be referred by pcp if specialist attention is needed
Why do hmo's encourage members to get regular checkups?
in hopes of catching diseases in their earliest stages when the treatment has the best chance for success
How does a POS plan differ from a traditional hmo?
POS - not locked into one plan. allowed to use physicians outside the hmo but pateient will have ti pay a higher co-pay
What is a primary care physician?
an hmo's regularly compenstaed physician who is responsible for his care
on what basis does a managed care plan preferably provide care?
preventative care, outpatient svcs, controlled access to providers, etc
What is another name for prospective review?
precertification provision
What is the purpose of concurrent review?
monitor the insred's stay to make sure that everything is proceeding according to schedule
name at least 3 criteria that would make an individual eligible for HIPAA
-have at least 18 mnths of continuous creditable cvg
-under a group plan in most recent insurance
-have used any COBRA or state cont. cvg
-not eligible for medicare or medicaid
Which type of insurance provides funds for a business
organization to purchase the business interest of a disabled partner?
disability buy out
Can a group that is formed for the sole purpose of obtaining group insurance qualify for group coverage?
No
What plan is a combo of Hmo and PPo plans
Point of service plans
Purpose of POS plan
employees do not have t be locked into one plan or make a choice b/t two plans. difference choice can be made every time
What is a PPO
Preferred Provider Org.
Benefit of a PPo member choosing a PPO physician
PPO may provide 90% of the cost of a physician on thir approved list vs 70% if memer chooses an outside phys.
presumptive disability specifies___
specifies the conditions tht will automatically qualify the insured for full disability benefts
what will presumptive disability generally pay for
loss of any 2 limbs, *
total and permanent blindness,
loss of speech
loss of hearing
*some policies require actual severance of limbs rather than loss of use
Guarantee of insurability option allows:
insured to periodically increase benefit levels without providing evidence of insurablity. usually limited to a 5% annual increase
What is ADEA
age discrimination in employment act
what is unlawful for an employer to do (ADEA)
-fire or refuse to hire a person based on age
-segregate or classify emps in a way which would deprive them of employment opps
-recude the wage rate of any employee in order to comply with ADEA
A Pre Existing Cond is one which the emp has sought
medical diagnosis
medical advice
medical treatment
What is the time period for a pre-existing condition
previous 2 years
best way for an underwriter to evaluate an insured's medical history
attending physician's statement
what does attending physician's statement include
past diagnoses
treatments
lenghts of recovery time
prognoses
Home health care includes occasional visits to the person’s home by
registered nurses,
licensed practical nurses,
licensed vocational nurses,
hospice care
under Key Person, premium payments - tax deductible or non tax deductible
not tax deducitble
under Key Person, benefits - tax free or taxable
tax free
What does Disability Buy Sell ins. provide
provides funds for business organizations to purchase the business interest of a disabled partner.
Disabilty Buy Sell premiums - deductible or not
not deductible
Disability Buy Sell benefits - tax
income tax-free
Investigative Consumer Reports cannot be made unless the consumer is advised in writing about the report within
3 days of the date the report was requested
Reciprocity refers to
Writing insurance across state lines
How long may insurer constest statements made on an application
2 yrs
who is required to obtain a producer's license
a person who sells, solicits or negotiates insurance, incl collecting premiums
does a person who performs clerical or admin duties need to be licensed
no
Insurance co must obtain this to transact business in NH
certificate of authority
max period of time for temp insurance license
180 days
how much time does an insurer have to acknowledge receipt of a claim
10 working days
T or F only written statements can be considered fraud
False
Required to obtain a non-resident license:
must be licensed in good standing in home state
submitting required application
paying fees
Changes of address (agent),...
must be reported to commissioner within 30 days
Insurance producers must complete a minimum of __ hrs of approved coursework during license renewal pd
24 hrs
How long is license renewal period
2 YRS
Franchise Insurance
Not group insurance
For groups to small to be Group Insurance
Individual policies are issued
Individual underwriting
Premiums less than individual policy but more than grp
UIASPPL
Uniform Individual Accident and Sickness Policy Provisions Law
No statement or mis-statement (except fraudulent misstatements) made in the application at the time of issue will be used to deny a claim after the policy has been in force for __
2 yrs (time limit on certain defenses provision)
Reinstatement: Coverage is automatically reinstated if not refused within..
..within 45 days from the date the conditional receipt was issued
legal actions against ins company by insured
not before 60 days after proof of loss
not after 3 years after proof of loss
define blackout period for life insurance
no SS benefits are paid between the time youngest child reaches age 16 and when surviving spouse qualifies for retirement benefits (as early as age 60)
4 main types of info needed to determine life value
debt status
income
mortgage
expenses
who may complete a paramedical report
registered nurse or paramedic
if a consumer request addl infor egarding an Investgative Consumer Report, how long does the insurer or reporting agency have to comply?
5 days
max amt of controlled business commissions
10%
producers change of address must be reported to commissioner within
30 days
3 class levels of risk for insured
standard, substandard, preferred
what is loading
the cost of operating the company
net premium
premiums withot operating costs factored in
gross premium
net premium + loading
mortality (cost of) - interest =
net premium
mortality - interest + loading =
gross premium
what factors in Human Life Value approach
future earnings
inflation
# yrs til retirement
expenses
what factors in Needs Approach
debt
income
mortgage
expenses
other name for Buy Sell agreement in a partership
entity plan
other name for Buy Sell agreement under corporate ownership
stock redemption plan
executive bonuses - tax status to employee
taxable
executive bonuses - tax status to employER
deductible
under a group plan, how much is taxable to employee
over $50k
cash value of insurance that can be borrowed at any time
liquidity
another name for substandard risk
rated
who gets paid dividends in a non participating policy
stockholders
key person liability doesnt cover this
increased pension liability
what qualification must an agent hold to sell variable life insurance policies?
state and federal (financial industy regulatory authority)
universal life is also known as
flexible premium adjustable life
group life insurance conversion
can be converted to individual whole-life but not term policy
