Health Policy Provisions Flashcards
7 cards from real EXAMFX practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Health Policy Provisions flashcards as text
The Physical Examination and Autopsy provision gives the insurer the right to examine the insured during a pending claim. How often may the insurer exercise this right?
Answer: As often as reasonably required
The insurer may require physical examinations as often as reasonably necessary during a pending claim to verify the nature and extent of a disability or illness.
Which mandatory provision requires that health insurers furnish claim forms to the insured within how many days of receiving notice of a claim?
Answer: 15 days
Insurers must provide claim forms to the insured within 15 days of receiving notice of a claim; if they fail to do so, the insured may submit proof of loss in any written form.
A policy's Legal Actions provision sets the minimum and maximum time an insured must wait before suing the insurer after proof of loss is submitted. What is the typical minimum waiting period?
Answer: 60 days
The Legal Actions provision typically requires that the insured wait at least 60 days after submitting proof of loss before initiating a lawsuit against the insurer.
Under the Unpaid Premium provision, if an insured dies with an outstanding premium balance, the insurer may:
Answer: Deduct the unpaid premium from the benefit payment
The Unpaid Premium provision allows the insurer to deduct any unpaid premium amounts from the claim benefit rather than denying the claim.
Which provision in a health insurance policy addresses what happens when the insured also has coverage under other insurance plans for the same loss?
Answer: Other Insurance provision
The Other Insurance provision outlines how benefits are calculated and paid when the insured has multiple policies covering the same loss to prevent over-indemnification.
The Conformity with State Statutes provision states that if any policy term conflicts with state law, the provision is automatically:
Answer: Amended to conform to the minimum requirements of state law
Any policy provision that conflicts with state statutes is automatically amended to meet the minimum standards required by the applicable state law.
Under the Notice of Claim provision, an insured must typically notify the insurer of a covered loss within how many days?
Answer: 20 days
The Notice of Claim provision generally requires the insured to notify the insurer within 20 days of a covered loss, or as soon as reasonably possible.