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25 Cards in this Set
- Front
- Back
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What kinds of risks does a health insurance policy cover during the ten day waiting period after it has been reinstated? * A) Sickness.* B) Accidents and sickness. * C) Accidents. * D) Neither accidents nor sickness. |
c For the first ten days after reinstatement, the reinstated policy covers only loss resulting from accidental injury. After ten days, it must cover loss resulting from sickness as well. |
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The time of payment of claims provision in an accident and health insurance policy requires that: * A) claims will be paid immediately after the insurer receives written proof of the loss.* B) the insured must submit proof of loss within a specified time, or the claim may be denied. * C) the insured must periodically submit proof of loss in order to receive payment of the claim. * D) the insurer must furnish the insured with the forms required for filing proof of loss. |
a In an accident and health insurance policy, the time of payment of claims provision provides for immediate payment of the claim after the insurer receives written proof of the loss. The claim forms provision states that the insurer, no later than 15 days after receiving notice of the claim, must furnish the claimant with the forms required for filing proof of loss. The notice of claim provision requires that written notice be given to the insurer within 20 days after any loss. |
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All of the following statements pertaining to health insurance policy notice of claim and claim forms provisions are correct EXCEPT: * A) Charlotte is injured January 5. Later, she wishes to file a policy claim for expenses incurred in connection with the injury. Generally, she would be required to submit a notice of claim to the company by February 5.* B) Gail submits notice of claim to her insurance company after she becomes totally disabled. The company is to supply a claim form to her within 15 days. * C) Furnishing claim forms is the responsibility of the insurance company. * D) Rex, the insured in a disability income policy, has been totally disabled and receiving benefits for 25 months. The notice of claims provision in his policy requires that he submit proof of loss every 6 months. |
Generally, a claimant must notify the insurance company within 20 days of an accident under a health insurance policy. Proof of loss must be submitted within 90 days of the loss, but if it is not reasonably possible for the insured to do so, the deadline will be extended to one year. The company must supply its claim forms to the insured within 15 days of notice of a claim. |
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After proof of loss is submitted, legal action may be taken to recover on an individual health insurance policy only during what time period? * A) Between 30 and 60 days.* B) Between 60 days and 3 years. * C) Between 30 days and 10 years. * D) Between 30 days and 1 year. |
b The statute of limitations stipulates that lawsuits may not be initiated to recover on the policy for 60 days after written proof of loss has been submitted to the insurer and that lawsuits may not be initiated beyond three years after the time written proof of loss was required. |
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A broad statement that generally appears on the first page of a health insurance policy and specifies conditions under which benefits will be paid is known as the: * A) guaranty provision.* B) insuring clause. * C) assurance clause. * D) warranty provision. |
b The insuring clause identifies the insurer and insured, specifies benefits and includes the insurer's promise to pay benefits for specific kinds of losses. |
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If an insurer receives a notice of claim, it must supply a claim form to the insured within: * A) 20 days.* B) 10 days. * C) 15 days. * D) 30 days. |
c After an insurer receives a notice of claim, it must supply a claim form to the insured within 15 days. If it fails to do so, the claimant may submit proof of loss in any form so long as it explains the occurrence, character, and extent of the loss for which the claim is submitted. |
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Which of the following statements about reinstated health insurance policies is CORRECT? * A) Health insurance policies cannot be reinstated.* B) They only cover sicknesses that begin more than 10 days after the policy is reinstated. * C) They only cover accidents that occur more than one month after reinstatement. * D) Coverage for accidents and sickness begins immediately. |
b All individual accident and health insurance policies must contain a reinstatement provision stating that any lapsed policy can be put back in force if payment is accepted by the insurer. The reinstated policy will only cover accidents that happen after the policy is reinstated and loss caused by sickness beginning more than 10 days after the reinstated policy is accepted. |
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The time of payment of claims provision requires that: * A) claims must be paid after the insurer is notified and receives proof of loss.* B) the insured must submit proof of loss within a specified time, or the claim may be denied. * C) claims must be paid after the insurer is notified of a loss. * D) the insured must periodically submit proof of loss in order to receive the claim. |
a The time of payment of claims provision provides for immediate payment of the claim after the insurer receives notification and proof of loss. |
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All of the following are considered to be viable medical plan cost-saving options EXCEPT: * A) skilled nursing facilities.* B) hospice care. * C) emergency room preadmission testing. * D) specialized birthing centers. |
c Emergency care must be provided when needed, so many plans waive the deductible and coinsurance. Preadmission testing would be impractical. The other three choices are proven cost reducers. |
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Which of the following terms relates directly to the consideration clause? * A) Beneficiary.* B) Premium. * C) Endorsement. * D) Exclusion. |
b The consideration clause describes the amount and frequency of the premium payments. |
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Assured Insurance Company issues a health insurance policy it describes as noncancellable. This means that: * A) the insured is entitled to renew the policy indefinitely, though the insurer can change policy provisions.* B) the company cannot cancel the policy for any reason. * C) the insured can continue the policy by paying premiums until at least age 65. * D) the company cannot cancel the policy after the insured becomes eligible for Medicare. |
c A policy that is noncancellable or guaranteed renewable gives the insured the right to continue it in force by the timely payment of premiums at least until age 65 or until the insured becomes eligible for Medicare. The insurer cannot unilaterally change any provision while the policy is in force. |
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Which one of the following statements regarding proof of loss is CORRECT? * A) The insurer must file proof of loss within 90 days of the date of loss.* B) The insured must file proof of loss within 90 days of the receipt of claims forms. * C) The insured must file proof of loss within 90 days of the date of loss. * D) The insurer must file proof of loss within 90 days of the receipt of claim forms. |
c Under a health insurance policy, the insured has 90 days from the date of the loss to file proof of loss with the insurer . Failure to file within 90 days does not invalidate a claim as long as the proof of loss is furnished as soon as reasonably possible. With the exception of the absence of legal capacity, proof of loss is required no later than one year from the date of loss. |
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With what provision of a standard health insurance policy would the following clause be associated: "The insured and the insurer shall have the same rights thereunder as they had under the policy immediately before the due date of the defaulted premium." * A) Time limit on certain defenses provision.* B) Reinstatement provision. * C) Grace period provision. * D) Cancellation provision. |
b The reinstatement provision provides that when a policy lapses due to nonpayment of premium, but the insured subsequently pays the renewal premium (which the insurer accepts without requiring an application for a new policy), the policy will be reinstated with the same provisions and rights as before (with the exception of coverage for sickness-related losses within the first ten days after reinstatement). |
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Any standard health insurance policy provision that is in conflict with a state statute: * A) is deleted entirely from the policy.* B) is automatically amended to conform to the state statute. * C) is kept in the policy verbatim, but with a rider added. * D) supersedes the statute, and remains in force. |
b In accordance with state regulation of the insurance industry, any health insurance policy provision that conflicts with state law is automatically amended to conform to the statute. |
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At the time the policy was applied for, to the best of her knowledge Mary answered all of the questions on her individual health insurance application truthfully. Two and one-half years later she is diagnosed with cancer. Is her insurer obligated to cover her expenses? * A) Yes, if she can prove she developed the cancer after she signed the application.* B) No, because she most likely had the cancer when she completed the application, even if she didn't know it at the time. * C) No, because she must have known there was something wrong with her health when she signed the application. * D) Yes, as long as Mary did not make any fraudulent misstatements and this condition was not excluded from coverage. |
d Even though it is possible the cancer could have existed prior to the effective date of the policy, this policy has now been in force beyond the two year incontestability period. As long as Mary did not make any fraudulent statements, and cancer was not exluded at the time of issue, the insurer will be obligated to cover Mary's expenses. |
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All of the following are examples of medical cost management EXCEPT: * A) ambulatory surgery.* B) denying claims. * C) mandatory second opinion. * D) precertification review. |
b Medical cost management is an effective means of controlling costs. It is the process of controlling how policyholders utilize their policies. There are five general approaches insurers use for cost management: mandatory second opinion, precertification review, ambulatory surgery, case management, and utilization management. Denying claims outright is not a legal or ethical method of controlling costs. |
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Lisa is in the hospital awaiting surgery. The doctors meet in the morning to discuss the best way to proceed as a routine procedure in their PPO. This is an example of: * A) provider credentialing.* B) concurrent review. * C) gatekeeping. * D) retrospective review. |
b This is a cost-containment process known as concurrent review, whereby providers review cases on an ongoing basis and assess the best course of action. |
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All accident and health insurance policies must contain a proof of loss provision stating that the insured must send the insurer a completed claim form no later than how long after the date of the loss? * A) 2 years.* B) 90 days. * C) 2 weeks. * D) 10 days. |
b |
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How many days from the date of loss does the insured have to submit a completed claim form to the insurer? * A) 10 days.* B) 60 days. * C) 90 days. * D) 20 days. |
c |
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At what point after the effective date of an accident and health insurance policy does it become incontestable? * A) 3 years.* B) 2 years. * C) 18 months. * D) 1 year. |
b |
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Thomas, an insured, submits a claim and proof of loss for medical expenses covered by his major medical policy. According to the time of payment of claims provision, how soon must the company pay the claim? * A) Within 150 days.* B) Within 30 days. * C) Immediately. * D) Within 90 days. |
c According to the time payment of claims provision of a major medical policy, the company must pay the claim immediately. |
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Beth's health insurance policy contains a provision that allows her to renew coverage up to age 65. However, the policy also states that should Beth lose her job, the insurance company will cancel the policy, regardless of Beth's age. In terms of renewability, what type of policy does Beth have? * A) Cancellable.* B) Optionally renewable. * C) Guaranteed renewable. * D) Conditionally renewable. |
d A conditionally renewable policy allows an insurer to terminate the coverage, but only in the event of one or more conditions stated in the contract. These conditions cannot apply to the insured's health. Most frequently, they are related to the insured reaching a certain age or losing gainful employment. |
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All individual health insurance policies must include a notice of claim provision requiring that a written notice of claim must be given to the insurer within how long after the occurrence of the loss? * A) 24 hours.* B) 10 days. * C) 20 days. * D) 5 days. |
All individual health insurance policies must include a notice of claim provision. According to this provision, written notice of a claim must be given to the insurer within 20 days after a covered loss starts, or as soon as possible thereafter. The insurer must provide a claims form to the insured within 15 days of receiving notice of a claim. Failure to do so means that the insured may meet the time requirement for proof of loss by giving the insurer a written statement verifying the loss. |
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Under what circumstances can a claim associated with a preexisting condition be denied, assuming the policy's contestable period has expired? * A) Losses associated with preexisting conditions are always excluded; an associated claim would never be paid.* B) The applicant concealed the condition and it was not noted on the application. * C) The condition has been specifically excluded from the policy, by name or description. * D) Losses associated with preexisting conditions are always covered, assuming the contestable period has expired. |
c A claim associated with a preexisting condition will be covered after the policy's contestable period (usually two or three years) has expired, unless that condition has been specifically excluded from the policy by name or description. |
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Which accident and health insurance renewability clause means the insurer cannot unilaterally change any provision while the policy is in force but can change premium rates by classes? * A) Guaranteed renewable.* B) Noncancellable. * C) Transitional. * D) Provisional. |
a A guaranteed renewable health insurance policy cannot be changed unilaterally by the insurer. Nevertheless, the insurer can change premium rates for the policy by class. |
