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  1. When an individual needs to file a health ins. claim, what are his responsibilities?
    • -notice is required within 20 days
    • -proof of loss must be submitted within 90 days, no later than a yr.
  2. What are the grace periods for an individual policy?
    • -7 days for weekly pay
    • -10 days for monthly pay
    • -31 days for all others
  3. In what specific way would changing to a more dangerous occupation affect a person's insurance policy?
    Benefits would be reduced to that which the premium would have purchased assuming the more hazardous occupation
  4. Who has the authority to change a policy provision?
    Only an executive officer of the company (not an agent)
  5. Included in the entire contract:
    • _Health Insurance policy
    • -Copy of signed application
    • -Any attached endorsements
  6. Accidental Bodily Injury
    Unforeseen and unintended injury that resulted from an accident rather than a sickness
  7. Hospital Indemnity
    • -Specific Amount
    • -BAsed only on the # of days confined in a hopsital
  8. Travel Accident
    Coverage for death or injury occuring whil a fare-paying passenger on a common carrier
  9. How might an insurance co. offcer a sub-standard policy?
    • -Applicant has poor health history or dangerous a/vocation
    • -Higher rates
    • -Rider that excludes p.e.c.
  10. 2 types of insurance included in the term "heatl insurance"
    • -Accidental Injury
    • -Sickness
  11. Difference b/t limited and comprehensive policies
    • Limited: Only covers specific accidents or disesases
    • Comprehensive: All sickness or accidents that are not specifically excluded
  12. What is the basic purpose of field underwriting for health insurance?
    Gather info from an applicant and select risks
  13. Outline of coverage
    must be delivered at the time of application or upon delivery of policy
  14. Sub-standard vs. standard policy
    Sub-standard as a higher premium and a rider excluding p.e.c.
  15. Credit Disability:
    In debt to a specific creditor
  16. Application Procedures
    • -form provided by insurance co.
    • -questions asked of the applicant
    • -hs/her responses recorded
    • -completed by agent
  17. comvin exclusions from coverage (5)
    • -p.e.c.
    • -intentional, self inflicted
    • -elective cosmetic surgery
    • -covered by workers comp
    • -govt plans
    • -criminal activity
  18. Under Ad&d coverage, when would the prncipal amount be paid?
    Paid in the event of accidental death
  19. In what different ways can AD&D coverage be written?
    Asa rider or as a separate policy
  20. When do advertising rules apply
    any health ins advertisement intended for presentation distribtuion dissemination etc when made directly or indirectly by or o/b/o insurance co
  21. Guarantee Assoc. Liabilities may not exceed
    • Lesser of contractual obligations or which ins co is liable, or
    • -300K in life ins death benefits but not more tha 100k in net cash surrender and net cash withdrawal values
    • -100k in health ins beneifts including any ncs and ncw values
    • -100k in present value of annuity benefits..
    • " "
  22. Blanket Policy
    • covers:
    • -particular group
    • -particular activity
    • -often the covered individual's name is not known
    • ex: students, sports teams, common carrier passengers
  23. Under AD&D coverage, when would capital amt be paid?
    in the case of loss of sight or accidental dismemberment
  24. Which risk class typically qualifies for lower premiums?
  25. How are dread disease policies different?
    • provide beneifts for a specific disease,
    • also has a high maximum
  26. Who is the field underwriter?
    The agent who actually has personal contact with the applicant and gathers info on the applicant
  27. What is identified in the insuring clause?
    The insured, the insurance co and states what kind of loss is covered
  28. Where is the consideration clause usually located?
    Usually on 1st page
  29. What is the dfference betwen a guaranteed renewable and a noncancelable policy?
    • GR - insurer can increase premiums on anniversary date, but on a class basis only
    • NC - insurance co can't increase premium
  30. Which renewal provision gives the insured the right to renew the policy for the life of the contract but allows the insurer to alter premiums?
    Guararnteed renewable
  31. What is the difference betyween a conditionally renewable policy and one whose renwability is optional?
    CR - insurer mminate contract only for certain stated stipulations
  32. Once a disability policy is paying a claim, how long will it pay?
    1, 2, or 5 yrs or to age 65 as specified by the Benefit Period
  33. When does the elimination period occur?
    From onset of disability until payments commence
  34. How long does the elimination period usually last (range)?
    30-180 days
  35. If an insured is disabled and has the waiver of premium benefit, generally what happens to the premiums paid during the waiting period?
  36. What is the difference between occupational and nonoccupational coverage?
    • Occupational - on the job or off
    • Non-Occ - Off the job only, assumed workers comp covers on-job)
  37. What is partial disability
    Inability to perform regular duties of own occupation or inability to work on full time basis
  38. What does partil disability cover
    Partial loss of income, typically 50% of total disability benefit
  39. What is residual disability
    provides benefits when a person returns to work after a total disability but still not able to work as long or at the same level
  40. What does residual disability cover
    Difference between present earnings and what they were earning before
  41. With key person insurance, who are the owner, premium payer, the beneficiary and the insured?
    • Owner - business
    • Payer - Business
    • Beneficiary - business
    • Insured - Key person
  42. How is the Social Security definiton of disability different fromat in most disability income policies?
    • The SS definition of disability is not as liberal as most definitions of disability found in most insurance policies
    • -the inability to engage in any substantially gainful activity by reason of:a medicaly determinable physical or mental impairment that has lasted (or is expected to last) 12 mnths OR result in an early death
  43. What policy covers an emplotee that is hurt on the job?>
    • Workers compensation
    • -also: occupational disability coverage from insurance co
  44. What are the usual, reasonable and customary charges based on?
    avg charge for a specific procedure in that specific geographic area
  45. What is the difference b/t insureds and subscribers?
    • Insureds - people covered by insurance
    • Subscribers - people covered by pre-paid health plans
  46. Explain the gatekeeper concept
    The hmo member initially chooses his PCP. must be referred by pcp if specialist attention is needed
  47. Why do hmo's encourage members to get regular checkups?
    in hopes of catching diseases in their earliest stages when the treatment has the best chance for success
  48. How does a POS plan differ from a traditional hmo?
    POS - not locked into one plan. allowed to use physicians outside the hmo but pateient will have ti pay a higher co-pay
  49. What is a primary care physician?
    an hmo's regularly compenstaed physician who is responsible for his care
  50. on what basis does a managed care plan preferably provide care?
    preventative care, outpatient svcs, controlled access to providers, etc
  51. What is another name for prospective review?
    precertification provision
  52. What is the purpose of concurrent review?
    monitor the insred's stay to make sure that everything is proceeding according to schedule
  53. name at least 3 criteria that would make an individual eligible for HIPAA
    • -have at least 18 mnths of continuous creditable cvg
    • -under a group plan in most recent insurance
    • -have used any COBRA or state cont. cvg
    • -not eligible for medicare or medicaid
  54. Which type of insurance provides funds for a business
    organization to purchase the business interest of a disabled partner?
    disability buy out
  55. Can a group that is formed for the sole purpose of obtaining group insurance qualify for group coverage?
  56. What plan is a combo of Hmo and PPo plans
    Point of service plans
  57. Purpose of POS plan
    employees do not have t be locked into one plan or make a choice b/t two plans. difference choice can be made every time
  58. What is a PPO
    Preferred Provider Org.
  59. Benefit of a PPo member choosing a PPO physician
    PPO may provide 90% of the cost of a physician on thir approved list vs 70% if memer chooses an outside phys.
  60. presumptive disability specifies___
    specifies the conditions tht will automatically qualify the insured for full disability benefts
  61. what will presumptive disability generally pay for
    • loss of any 2 limbs, *
    • total and permanent blindness,
    • loss of speech
    • loss of hearing

    *some policies require actual severance of limbs rather than loss of use
  62. Guarantee of insurability option allows:
    insured to periodically increase benefit levels without providing evidence of insurablity. usually limited to a 5% annual increase
  63. What is ADEA
    age discrimination in employment act
  64. what is unlawful for an employer to do (ADEA)
    • -fire or refuse to hire a person based on age
    • -segregate or classify emps in a way which would deprive them of employment opps
    • -recude the wage rate of any employee in order to comply with ADEA
  65. A Pre Existing Cond is one which the emp has sought
    • medical diagnosis
    • medical advice
    • medical treatment
  66. What is the time period for a pre-existing condition
    previous 2 years
  67. best way for an underwriter to evaluate an insured's ´╗┐medical history
    attending physician's statement
  68. what does attending physician's statement include
    • past diagnoses
    • treatments
    • lenghts of recovery time
    • prognoses
  69. Home health care includes occasional visits to the person’s home by
    • registered nurses,
    • licensed practical nurses,
    • licensed vocational nurses,
    • hospice care
  70. under Key Person, premium payments - tax deductible or non tax deductible
    not tax deducitble
  71. under Key Person, benefits - tax free or taxable
    tax free
  72. What does Disability Buy Sell ins. provide
    provides funds for business organizations to purchase the business interest of a disabled partner.
  73. Disabilty Buy Sell premiums - deductible or not
    not deductible
  74. Disability Buy Sell benefits - tax
    income tax-free
  75. Investigative Consumer Reports cannot be made unless the consumer is advised in writing about the report within
    3 days of the date the report was requested
  76. Reciprocity refers to
    Writing insurance across state lines
  77. How long may insurer constest statements made on an application
    2 yrs
  78. who is required to obtain a producer's license
    a person who sells, solicits or negotiates insurance, incl collecting premiums
  79. does a person who performs clerical or admin duties need to be licensed
  80. Insurance co must obtain this to transact business in NH
    certificate of authority
  81. max period of time for temp insurance license
    180 days
  82. how much time does an insurer have to acknowledge receipt of a claim
    10 working days
  83. T or F only written statements can be considered fraud
  84. Required to obtain a non-resident license:
    • must be licensed in good standing in home state
    • submitting required application
    • paying fees
  85. Changes of address (agent),...
    must be reported to commissioner within 30 days
  86. Insurance producers must complete a minimum of __ hrs of approved coursework during license renewal pd
    24 hrs
  87. How long is license renewal period
    2 YRS
  88. Franchise Insurance
    • Not group insurance
    • For groups to small to be Group Insurance
    • Individual policies are issued
    • Individual underwriting
    • Premiums less than individual policy but more than grp
    Uniform Individual Accident and Sickness Policy Provisions Law
  90. No statement or mis-statement (except fraudulent misstatements) made in the application at the time of issue will be used to deny a claim after the policy has been in force for __
    2 yrs (time limit on certain defenses provision)
  91. Reinstatement: Coverage is automatically reinstated if not refused within..
    ..within 45 days from the date the conditional receipt was issued
  92. legal actions against ins company by insured
    • not before 60 days after proof of loss
    • not after 3 years after proof of loss
  93. define blackout period for life insurance
    no SS benefits are paid between the time youngest child reaches age 16 and when surviving spouse qualifies for retirement benefits (as early as age 60)
  94. 4 main types of info needed to determine life value
    • debt status
    • income
    • mortgage
    • expenses
  95. who may complete a paramedical report
    registered nurse or paramedic
  96. if a consumer request addl infor egarding an Investgative Consumer Report, how long does the insurer or reporting agency have to comply?
    5 days
  97. max amt of controlled business commissions
  98. producers change of address must be reported to commissioner within
    30 days
  99. 3 class levels of risk for insured
    standard, substandard, preferred
  100. what is loading
    the cost of operating the company
  101. net premium
    premiums withot operating costs factored in
  102. gross premium
    net premium + loading
  103. mortality (cost of) - interest =
    net premium
  104. mortality - interest + loading =
    gross premium
  105. what factors in Human Life Value approach
    • future earnings
    • inflation
    • # yrs til retirement
    • expenses
  106. what factors in Needs Approach
    • debt
    • income
    • mortgage
    • expenses
  107. other name for Buy Sell agreement in a partership
    entity plan
  108. other name for Buy Sell agreement under corporate ownership
    stock redemption plan
  109. executive bonuses - tax status to employee
  110. executive bonuses - tax status to employER
  111. under a group plan, how much is taxable to employee
    over $50k
  112. cash value of insurance that can be borrowed at any time
  113. another name for substandard risk
  114. who gets paid dividends in a non participating policy
  115. key person liability doesnt cover this
    increased pension liability
  116. what qualification must an agent hold to sell variable life insurance policies?
    state and federal (financial industy regulatory authority)
  117. universal life is also known as
    flexible premium adjustable life
  118. group life insurance conversion
    can be converted to individual whole-life but not term policy
Card Set:
2011-12-05 02:15:44
health insurance medicare medicaid

Health Insurance NH
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