Ch. 18 - Health Insurance Policy Provisions

An accident and health insurer has just received written proof of loss from one of its insureds. The insured must now wait 60 days before

a. submitting another claim
b. bringing legal action against the insurer
c. the insurer will pay the claim
d. purchasing more insurance from this insurer

The insured's consideration given for a health insurance policy is 

a. the first premium payment and the application
b. the initial premium payment only
c. the application
d. the initial premium and an investigative report

An accident and health insurance policy's premium requirements are set forth in which of the following provisions?

a. insurance clause
b. entire contract clause
c. consideration clause
d. premium mode

Which of the following statements accurately describes the "time limit on certain defenses"?

a. after a stated period of time, claims cannot be denied due to material misrepresentation of the application
b. all claims can be disputed after two years
c. an insured cannot file a lawsuit within 90 days of the claim being filed
d. the right to return an accident and health policy must be within 10 days of policy delivery

Who may terminate coverage under a cancelable health insurance policy?

a. the insured only
b. the insurer only
c. the insurer or the insured
d. an officer of the insurer

An insured files for an accident and health insurance policy claim eight days after the premium due date. The benefit payable is $500 and the overdue premium is $200. Assuming that the policy pays on a first-dollar basis and contains the unpaid premium provision, how much will the insurer pay?

a. $0
b. $200
c. $300
d. $500

The Change of Occupation provision in a Disability Income policy states that, in the event the insured changes to a less hazardous occupation, which of the following may apply?

a. benefits will remain the same in the event of a covered claim
b. premiums cannot be adjusted
c. benefits can be increased in the event of a covered claim
d. benefits can be reduced in the event of a covered claim

Tim is covered by an accident and health insurance policy that may not be changed in any way by the insurer up to a stated age, as long as the premiums are paid. What type of policy is this?

a. occupationally renewable
b. noncancelable
c. guaranteed renewable 
d. conditionally renewable

An insured is covered with a health insurance policy. If the insured would like to cancel the policy, he/she must

a. wait until the end of the calendar year
b. notify the insurance company in writing
c. notify the insurance company by telephone
d. provide a reason for cancelling

Which health policy clause specifies the amount of benefits to be paid?

a. insuring
b. consideration
c. free-look
d. payment mode

An insured must notify an insurer of a medical claim within how many days after an accident?

a. 10
b. 20
c. 30
d. 40

Omar is covered by a disability income policy. He is hurt performing an occupation more hazardous than the occupation listed in his policy. The policy's change of occupation provision will have what effect?

a. increase the benefit level
b. reduce the benefit level
c. increase the premiums
d. decrease the premiums

A Guaranteed Renewable provision allows 

a. discrimination of individuals who have an increased loss experience

b. premiums that may not be increased beyond contractual requirements

c. premiums which can only be increased per rate class

d. cancellation of the policy at the insurer's discretion

James is covered with health insurance by two different insurers. The "insurance with other insurers" provision in an individual health insurance policy allows an insurer to pay benefits to the insured on a pro-rata basis when

a. the policy's maximum lifetime benefit level has been paid
b. the policy is beyond the incontestable period
c. the insurer was not notified prior to the claim that the insured has other health coverage
d. the policy is beyond the free-look period

Which statement concerning the Entire Contract provision in an individual accident and health insurance policy is TRUE?

a. the agent can waiver policy provisions and change the policy with the insurer's consent
b. the agent has the authority to waive the policy's provisions under certain conditions
c. the agent has the authority to change the policy under certain conditions
d. the agent doesn't have the authority to change the policy or waive its provisions

Disability income insurance normally excludes coverage for disabilities that arise from

a. automobile accidents
b. injuries sustained while traveling abroad
c. occupational injuries
d. active military duty

Which of the following health insurance provisions requires that the application becomes part of the policy?

a. consideration clause
b. insuring clause
c. entire contract clause
d. application clause

How is an insured's accident and health claim handled by an insurer if it occurs during the policy's grace period?

a. the claim has to be approved by an officer of the insurer
b. no claim will be paid until premium is paid current
c. the claim is paid in full and the unpaid premium will be waived by the insurer
d. the unpaid premium may be subtracted from the reimbursement

Who is protected with the "other insurance with this insurer" provision?

a. insurance company
b. insured
c. policyowner
d. claimant

Which of the following health insurance plans charges a premium that cannot be increased?

a. guaranteed renewable
b. cancelable
c. noncancelable
d. conditionally renewable

A health insurance MUST provide a proof of loss form

a. within 10 days of the actual loss
b. within 10 days of receipt of the notice of loss
c. within 15 days of receipt of the notice of loss
d. within 15 days of the actual loss

Under what circumstance does an accident and health insurer have the right to request an autopsy?

a. when the claim exceeds an amount specified in the policy
b. when 2 days have passed after death
c. when not prohibited by state law
d. when consent is given by the beneficiary

Kelly purchases a health insurance policy issued on a conditionally renewable basis. The insurance company has a right to refuse renewal of the policy for

a. any change in Kelly's health
b. specific reasons stated in the contract
c. any reason the insurer sees fit
d. profitability reasons

The standard provisions of an accident and health insurance policy require that the

a. policy, endorsements, and attached papers constitute the "entire contract"
b. policy summary, conditional receipt, and initial premium constitute the "entire contract"
c. change of occupation provision is mandatory
d. grace period be no shorter than 60 days

Periodic health claim payments MUST be made at least

a. monthly
b. weekly
c. daily
d. annually