EXAMFX Health Policy Provisions 3 — Questions and Answers
Question 1: 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?
- Only once per claim
- As often as reasonably required (Correct answer)
- Twice per calendar year
- Only before the claim is filed
Correct 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.
Question 2: Which mandatory provision requires that health insurers furnish claim forms to the insured within how many days of receiving notice of a claim?
- 10 days
- 15 days (Correct answer)
- 20 days
- 30 days
Correct 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.
Question 3: 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?
- 30 days
- 60 days (Correct answer)
- 90 days
- 6 months
Correct 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.
Question 4: Under the Unpaid Premium provision, if an insured dies with an outstanding premium balance, the insurer may:
- Deny the claim entirely
- Deduct the unpaid premium from the benefit payment (Correct answer)
- Charge interest on the premium and require repayment within 90 days
- Void the policy retroactively to the last paid period
Correct 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.
Question 5: Which provision in a health insurance policy addresses what happens when the insured also has coverage under other insurance plans for the same loss?
- Coordination of Benefits provision
- Subrogation provision
- Other Insurance provision (Correct answer)
- Non-Duplication provision
Correct 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.
Question 6: The Conformity with State Statutes provision states that if any policy term conflicts with state law, the provision is automatically:
- Voided, making the entire policy unenforceable
- Amended to conform to the minimum requirements of state law (Correct answer)
- Subject to arbitration between insurer and state regulators
- Grandfathered unless the insured files a complaint
Correct 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.
Question 7: Under the Notice of Claim provision, an insured must typically notify the insurer of a covered loss within how many days?
- 10 days
- 20 days (Correct answer)
- 30 days
- 60 days
Correct 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.
EXAMFX Health Policy Provisions 3
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?