Chapter 6 (Health)

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The Notice of Claims provision requires a policyowner to

notify an insurer of a claim within a specified time

The policy provision that entitles the insurer to establish conditions the insured must meet while a claim is pending is

Time Limit on Certain Defenses

Which of the following statements describes the purpose of the Insuring clause in Health and Accident policies?

States the scope and limits of the coverage

If an individual has an Accidental Death and Dismemberment policy and dies, an autopsy can be performed in all these situations EXCEPT

When the state prohibits this by law

What type of renewability guarantees premium rates and renewability?

Guaranteed renewable

Which of the following BEST describes a short-term medical expense policy?


If an insurance company issues a Disability Income policy that it cannot cancel or for which it cannot increase premiums, the type of renewability that best desribes this policy is called


T files a claim on his Accident and Health policy after being treated for an illness. The insurance company believes that T misrepresented his actual health on the initial insurance application and is, therefore, disputing the claim’s validity. The provision that limits the time period during which the company may dispute a claim’s validity is called

Time Limit on Certain Defenses

K failed to pay a renewal premium within the time granted by the insurer. K then sends in a payment which the insurer subsequently accepts. Which policy provision specifies that coverage may be restored in this situation?


G is involved in an automobile accident as a result of driving while intoxicated and suffers numerous injuries. According to the Intoxicants and Narcotics exclusion in G’s policy, who is responsible for paying the medical bills?

The insured

Which Accident and Health policy provision addresses preexisting conditions?

Time Limit on Certain Defenses

Which of these is considered a mandatory provision?

Payment of Claims

What is considered to be a characteristic of a Conditionally Renewable Health Insurance policy?

Premiums may increase at time of renewal

Which of the following statements about a Guaranteed Renewable Health Insurance policy is CORRECT?

Premiums normally increase at time of renewal

Which of the following statements BEST describes what the Legal Actions provision of an Accident and Health policy requires?

An insured must wait at least 60 days after Proof of Loss has been submitted before a lawsuit can be filed

Which of these statements accurately describes the Waiver of Premium provision in an Accident and Health policy?

Premiums are waived after the insured has been totally disabled for a specified time period

Periodic health claim payments MUST be made at least


What should an insured do if the insurer does not send claims forms within the time period set forth in a health policy’s Claims Forms provision?

Submit the claim in any form

An insurance company receives E’s application for an individual health policy. E did not complete all of the medical history questions because she could not remember the exact dates. E signed the policy and submitted it to the insurance company anyway. A few weeks later, E suffers a heart attack and is hospitalized without completing the medical history questions and paying the initial premium. E is not insured. Which of the following clauses details the conditions that E did not meet?

Consideration Clause

Which of the following statements describes what an Accident and Health policyowner may NOT do?

Adjust the premium payments

J, an Accidental Death and Dismemberment (AD&D) policy holder, dies after injuries sustained in an accident. J’s age as stated on the application five years ago was found to be understated by ten years. Which of the following actions will the insurance company take?

The insurer will adjust the benefit to what the premiums paid would have purchased at the insured’s actual age

P is a Major Medical policyowner who is hospitalized as a result of injuries sustained from participating in a carjacking. How will the insurer most likely handle this claim?

Claim will be denied

After an insured gives notice of loss, what must he/she do if the insurer does not furnish forms?

file written proof of loss

When an insured changes to a more hazardous occupation, which disability policy provision allows an insurer to adjust policy benefits and rates?

change of occupation provision

With Optionally Renewable Health policies, the insurer may

review the policy annually and determine whether or not to renew it

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