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Colorado Health Insurance Exam (Latest
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Mandatory Uniform Provisions Must be included in every individual accident policy, no additional provisions may be included which otherwise restrict or modify a uniform provision, designed to protect the insured's interest Entire Contract Clause- Mandatory Uniform Includes the policy and provisions, c a copy of the application and any riders, waivers, or endorsements Time Limit on Certain Defenses-Mandatory Uniform No statement or misstatement may be contested after 2 years, no time limit for fraud Grace Period-Mandatory Uniform Period after premium due date before policy lapse, (7- 10 - 31) 7 days for weekly premium; 10 days for a monthly premium; 31 days of every thing else Reinstatement Provision- Mandatory Uniform Applies to the time frame that an insurer hasn't paid premium but wants the policy back, allows insured to reinstate by paying past due premiums, proof of insurability may be required, sickness begins after 10 days, accidents are covered immediately
- If you haven't heard back in 45 days, then the policy has been reinstated
Notice of Claim provision-Mandatory Uniform Policy owner must notify Insurer of loss either in writing, in person or by phone w/in 20 days. claim forms provision-Mandatory Uniform The insurer is required to send the insured a claim form within 15 days after notice is received Proof of Loss provision-Mandatory Uniform Policy owner has 90 days from date of loss to submit proof of loss to Insurer; valid claim must be paid immediately upon receipt. Time of Payment of Claims-Mandatory Uniform Provides for immediate payment of the claim after the insurer receives notification and proof of loss. Payment of Claims Provision-Mandatory Uniform Payment of claims to the policyowner unless otherwise specified or there is an assignment of benefits(required) defines how proceeds are to be paid out + requirements to initiate death benefit claim Physical Exam and Autopsy-Mandatory Uniform A provision that allows an insurer, at its own expense, to have an insured physically examined when a claim is pending or to have an autopsy performed where not prohibited by law. legal action
Illegal Occupation-Optional If the insured is connected with a felony or has an illegal occupation and incurs injury, the insurance company is not held responsible Free Look Provision( Right to Examine )-other Generally 10 days after policy delivery to cancel policy w/ full refund, except 30 days for seniors or for replacement policies. Insuring Clause-other Appears on first page of contract has a summary of all the main points of the contract like the "promise to pay" death benefit Consideration Clause-other Payments and promise Preexisting condition-other A health problem that existed before the date your insurance coverage became effective. Prior Conditions which insured should have received medical advice or treatment. Probationary period-other Number of days at the start of the policy with no coverage for loss due to sickness Elimination Period (Waiting Period)-other
A period of days (time) that must pass after the onset of an illness or occurrence of an accident befo re benefits will be payable. Waiver of Premium-other Premiums waved after stated period of time of disability First dollar coverage-other Provides that no out of pocket charges ( deductibles or co payments) will be paid by the insured before benefits are payable by the plan Coordination of benefits-other A provision that determines the method of reimbursement when more than one insurer is responsible for the loss Policy Renewal Provisions Each health policy must express conditions and provisions for coverage continuation. Noncancellable-PRP Most favorable to insured, only owner can terminate, rates never increase, benefits cannot be changed and premiums cannot be altered Guaranteed Renewable-PRP A clause in an insurance policy that means the insurance company must renew the policy as long as premium payments are made. However, the premium may be increased when it is renewed.
Prospective Review A method of reviewing possible hospitalization befConore admission to determine necessity and estimated length of stay. Concurrent review Determines whether length of time and scope of inpatient stay is justified, to determine medical necessity Pre-authorization Requirement for some health ins plans to obtain permission for a service or procedure before it is done. It indicates that a specific procedure or service is deemed "medical necessary" (not an emergency) Impairment Rider Excludes coverage for a specific ailment or condition that otherwise would be covered (e.g., previous back injury) Guaranteed Insurability Rider Optional rider that enables the policyowner to purchase additional amounts of coverage at predetermined times without proof of insurability. Multiple Indemnity Rider If someone dies under certain specified circumstances, AD&D policies with this rider will pay double (double indemnity) or triple (triple indemnity) the principal sum amount.
Master Policy The policy contract issued to the employer under a Group insurance plan. Remember, the employees covered by a group plan are considered to be insureds, but they only receive certificates. Certificate of Insurance and Summary of Benefits A document provided to the individual employees of a group insurance contract. Experience Rating Rating system that bases insurance rates on claims history community rating Determines premiums by examining the claims history of a particular geographic region Contributory A group insurance plan that requires the employees to pay part of the premium. Usually 75% of eligible employees Non-contributory Group Plan requires 100% of participation of eligible employees, employer pays entire amount Eligibility for Coverage Minimum of 30 hour week, empolyer can not discriminate when determining eligibility and employee benefit
Any substantial gainful activity Social Security uses which definition to determine total disability? An insured with a cognitive impairment has how many days to reinstate the LTC policy that was cancelled for nonpayment of premium? 90 days Insured Before a policy will be issued, an insurable interest must exist between the owner (applicant) and th If a policy is issued with a surcharge, this means that the policy Policy was issued with a higher premium due to the increased risk. Overinsurance When an individual carries more accident and health insurance than he/she would need for a loss, it is called: Coordination of Benefits Which provision in a health insurance plan is used to avoid overinsurance when a person is covered by more than one plan? Which of the following is true concerning the Benefit Period of a LTC Policy
Once the elimination period has been satisfied, it is how long benefits will be payable When the insurer issues a policy An applicant completes the application and submits it to the insurer along with a premium check. When is the applicant's offer considered accepted? The Guaranteed Renewable Provision states that the policy is: Renewable with premiums that may be increased for entire classes of insureds What do ADLs trigger? Long-Term Care Insurance, Activities of Daily Living (ADLs) are triggers used to begin Long-Term Care Insurance benefits. Social Security Disability Medicare is available to individuals who have been receiving ______________ benefits for 24 months. Medicare is available to individuals regardless of age if they have received Social Security disability benefits for 24 months. Supplementary Major Medical A policy which utilizes a Corridor Deductible after Basic Medical Expense Coverage benefits have b een exhausted and before Major Medical benefits begin? Utilization Review
Unfair Claims Practices Misrepresenting pertinent facts or insurance policy provisions relating to coverage at issue Failing to acknowledge and act reasonably promptly upon communications with respect to claims arising under insurance policies Failing to adopt and implement reasonable standards for the prompt investigation of claims arising under insurance policies Refusing to pay claims without conducting a reasonable investigation based on all available information Failing to affirm or deny coverage of claims within a reasonable time after proof of loss statements have been completed Not attempting in good faith to effectuate prompt, fair, and equitable settlements of claims in which liability has become reasonably clear Compelling insureds to institute litigation to recover amounts due under an insurance policy by offering substantially less than the amounts ultimately recovered in actions brought by such insureds Attempting to settle a claim for less than the amount to which a reasonable person would have believed he was entitled by reference to written or principal advertising material accompanying or made part of an application Attempting to settle claims on the basis of an application that was altered without notice, knowledge, or consent of the insured Making claims payments to insureds or beneficiaries not accompanied by statements setting forth the coverage under which the payments are being made Making known to insureds or claimants a policy of appealing arbitration awards in favor of insureds or claimants for the purpose of compelling them to accept settlements or compromises less than the amount awarded in arbitration Delaying the investigation or payment of a claim by requiring an insured, claimant, or the physician of either to submit a preliminary claim report and then requiring the subsequent submission of formal proof of loss forms, both of which submissions contain substantially the same information Failing to promptly settle claims where liability has become reasonably clear under one portion of the insurance policy coverage to influence settlement under other portions of the insurance policy coverage Failing to promptly provide a reasonable explanation of the basis relied on in the insurance policy in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement Guaranteed Renewable means:
Renewable with adjustable premiums, by classification only
