Chapter 3 Individual Health Insurance Policy General Provisions

Changes to a policy can only be made with a written agreement between the client and the company. This means that both parties must agree and document any modifications or updates to the policy. Verbal permission is not sufficient as it can be easily disputed or forgotten. Only the company's authorization is also not enough as it does not involve the client's consent. Permission from the Commissioner may not be necessary for every policy change and would depend on the specific regulations and requirements in place.

The illegal occupation uniform optional provision in an insurance policy ensures that the insurer is not responsible for any losses that occur while the policyholder is engaged in an illegal activity. This means that if the policyholder is participating in any unlawful actions, such as committing a crime or engaging in illegal activities, the insurer will not be liable for any damages or losses that may arise from those activities. This provision protects the insurer from having to cover losses that result from illegal actions by the policyholder.

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The correct answer is "Unpaid premium." The insurer may subtract the amount of the unpaid premium from the claim because Jennifer neglected to make her premium payment. This provision allows the insurer to withhold the unpaid premium amount from any claims made by the insured.

Rick's health insurance policy includes a provision that excludes coverage for injuries caused while under the influence of narcotics and intoxicants. Since Rick had been drinking alcohol before the accident, the insurance company will not provide coverage for his injuries. Therefore, Rick will receive no benefits from his policy.

The physical exam and autopsy provision allows the insurer to examine the insured as often as necessary. This means that there is no specific limit to the number of times the insurer can conduct these examinations. The insurer can request multiple examinations if they deem it necessary to assess the insured's health and determine their risk level.

The correct answer is that the amounts payable under the policy will reflect her correct age. This means that the insured will receive benefits based on her actual age of 37, rather than the age she misstated as 30. The misstatement of age provision allows for adjustments to be made to the policy based on the correct age of the insured.

The insured does have the right to change beneficiary designations unless the beneficiary is irrevocable. This means that the insured can make changes to who will receive the benefits from the insurance policy, unless there is a specific provision stating that the beneficiary cannot be changed. In the context of health insurance contracts, there is no concept of irrevocable beneficiaries, so the insured generally has the ability to change the beneficiary designation if desired.

The provision in this scenario is called "Unpaid premium." This is because the insured has not yet paid the premium owed to the insurer, and the insurer deducts this unpaid amount from the claim amount before paying the insured the difference.

Insurers issue health insurance policies for delivery in multiple states. Each state has its own regulations and requirements for policies delivered to their residents. Instead of creating a separate policy form for each state, the insurer attaches a "conformity with State Statutes" provision. This provision ensures that the policy complies with the regulations of the state where it is being delivered, allowing the insurer to meet the requirements of multiple states with a single policy form.

The policyholder is obligated to provide notification of claims to the insurer within 20 days of a loss. This time frame allows the insurer to promptly investigate the claim and take necessary actions. It is important for the policyholder to notify the insurer within this time period to ensure a smooth claims process and to avoid any potential issues or delays in receiving the coverage benefits.

Under a health insurance policy, benefits other than death benefits, that have not otherwise been assigned, will be paid to the insured. This means that if there are any benefits that the insured is entitled to, such as reimbursement for medical expenses or disability benefits, they will receive the payment. This is because the insured is the person who holds the insurance policy and is covered under it. The other options, such as creditors or the beneficiary of the death benefit, do not apply to benefits other than death benefits under a health insurance policy.

A guaranteed renewable health insurance policy allows the policyholder to renew the policy up to a specified age. However, the insurance company has the right to increase premiums for the entire class of policyholders. This means that the policyholder is guaranteed the option to renew their policy, but they may have to pay higher premiums in the future.

The Optional Renewability clause allows an insurer to choose to discontinue a policy on a premium due date. This means that the insurer has the option to not renew the policy if they decide to do so. It provides flexibility for the insurer to make decisions regarding the continuation of the policy based on various factors such as the insured's claims history or changes in risk factors.

The insuring clause in an insurance policy is the clause that clearly outlines the agreement between the insurance company and the insured. It specifies the coverage provided by the policy, including the risks that are covered and the limits of coverage. It also states the obligations and responsibilities of both parties, such as premium payments and claims procedures. Therefore, the insuring clause is the clause that identifies the agreement between the company and the insured.

The Guaranteed Renewable Provision allows the policy to be renewed with adjustable premiums, but only based on the classification of the insured individuals, not on an individual basis. This means that the premiums can be adjusted for a group of people who fall under a certain classification, but not for each individual within that group.

The insured should receive necessary claim forms within 15 days after notice of claim. This time frame allows the insurance company enough time to process the claim and provide the required forms to the insured. It ensures that there is a reasonable amount of time for the insured to complete and submit the necessary paperwork to initiate the claims process.

The Facility of Payment Clause gives the insured the right to expedite payments of urgently needed claims to a relative or individual that is entitled to the payment. This clause allows the insured to bypass the usual claims process and directly pay the beneficiary in urgent situations where immediate payment is necessary.

Under the Uniform Required provisions, proof of loss under a Health Insurance policy normally should be filed within 90 days of a loss. This means that policyholders are required to submit all necessary documentation and evidence supporting their claim within this timeframe. Failing to do so may result in the denial of the claim. This ensures that insurance companies can timely assess the validity of the claim and process it accordingly.

The correct answer is that the insurer must refund the excess premiums Hank paid after his 70th birthday. This is because Hank's contract stated that he had coverage until age 70, but the insurer discovered that he is actually 73. Since Hank paid premiums for the years beyond his coverage age, the insurer is obligated to refund those excess premiums.