Health Insurance Policy Provisions - NAIC

Get Started. It's Free
or sign up with your email address
Health Insurance Policy Provisions - NAIC by Mind Map: Health Insurance Policy Provisions - NAIC

1. Twelve Mandatory Policy provisions

1.1. Entire contract

1.1.1. Actual Policy + application

1.1.2. Nothing outside the contract can be considered part of the contract

1.2. Time limit on certain defences

1.2.1. Incontestable after 2 years

1.3. Grace period

1.3.1. 7 days for weekly

1.3.2. 10 days for monthly

1.3.3. 31 days for others/yearly

1.3.4. After grace period policy lapse

1.4. Reinstatement

1.4.1. Automatic, If payment is accepted by the company

1.4.2. Automatic, If application is not responded by the insurer within 45 days

1.4.3. Sickness needs to occur after 10days of reinstatement for eligible for claims, Accident is immediate

1.5. Notice of claim

1.5.1. reasonable period is 20 days of occurrence or as soon as possible

1.5.2. Disability claim every six months

1.6. Claim forms

1.6.1. Insurer should send claim form within 15 days of notice. if not claim can be submitted in any form

1.7. Proof of loss

1.7.1. Proof of loss needed within 90 days after insurer is liable for payments. Periodic payment will start after providing proof of loss within max one year

1.8. Time of payment of claims

1.8.1. Immediate

1.8.2. Monthly for disability

1.9. Payment of claims

1.9.1. payable to the insured or provider. Death benefit to beneficiary or estate

1.10. Physical exam or Autopsy

1.10.1. Insurer has right on its own expense

1.11. Legal Actions

1.11.1. legal action after 60 days after the written proof of loss

1.12. Change of beneficiary

1.12.1. Anytime unless beneficiary is irrevocable

2. Eleven Optional provision

2.1. Change of occupation

2.1.1. Insure can reduce benefit for more hazardous occupation

2.2. Misstatement of age

2.2.1. can adjust the benefit for misstatement

2.3. Other insurance with the insurer

2.3.1. total amount of coverage restricted to specified max amount regardless of number of policy issued

2.4. Insurance with other insurer

2.4.1. Expenses will be prorated if not notified of other existing coverage of same risk

2.5. Insurance with other insurers

2.5.1. Expenses will be prorated if not notified of other health coverage from other insurers

2.6. Average earning clause or relation of earning to insurance

2.6.1. If benefits from all policies for disability> income, the insurer pays proportionate amount of the earning

2.7. Unpaid premiums

2.7.1. Premium is deducted if unpaid before claim payment

2.8. Cancellation

2.8.1. Some states give right to cancel with 45 days of written notice, 10 days for nonpayment of premium. All states have provision to cancel after the term

2.9. Conformity with State Statutes

2.9.1. policy is amended immediately for state statutes

2.10. Illegal occupation

2.10.1. not liable form losses for illegal occupation or being connected with felony

2.11. Intoxicants and narcotics

2.11.1. Insurer is not liable for losses attributed to narcotics or under influence

3. Other Health Insurance provision

3.1. No loss/No gain

3.1.1. no profiting from purchase of insurance

3.2. Accident & health insurance need approval of commissioner. Approved automatically if policy not approved within 90 days.

3.3. Free Look

3.3.1. 10 days or more - premium is returned if cancelled

3.4. Availability coverage to small employers (2-50)

3.5. Double indemnity

3.5.1. under specified circumstances - twice the regular benefit

3.6. Insuring clause

3.6.1. Specify scope, limits and conditions of the coverage provided

3.7. Consideration clause

3.7.1. From Insured

3.7.1.1. Date coverage starts

3.7.1.2. The initial period coverage

3.7.1.3. Initial full premium payment

3.7.1.4. The statements made in application

3.8. Assignment provision

3.8.1. Absolute assignment

3.8.1.1. All policy right

3.8.2. Collateral assignment

3.8.2.1. If only some right assigned

3.9. Accumulation benefits

3.9.1. for contract renewed continuously

3.9.1.1. additional percentage

3.10. Conversion privilege for dependants

3.10.1. 2010 Obama care

3.11. Waiver or premium

3.11.1. After disability for 90 days

3.12. Probationary period

3.12.1. Effective at the inception of the policy

3.13. Benefits payment

3.13.1. Lumpsum or periodic

3.14. Types of Beneficiary

3.14.1. Primary

3.14.1.1. Secondary

3.14.1.1.1. Tertiary

3.15. Dependent children

3.15.1. parents must cover until 26

3.16. Preexisting Condition

3.16.1. time bound exclusion of benefits for preExisting

3.17. Impairment rider

3.17.1. waiver of disability

3.18. Waivers of Impairment rider

3.18.1. not covered die to preexisting

4. Renewability Provisions

4.1. Cancellable policies

4.1.1. less premium

4.1.1.1. must return premium

4.1.1.1.1. provide notice

4.2. Optionally renewable policies

4.2.1. option for insurer whether to continue

4.3. Conditionally renewable

4.4. Noncancelable policies

4.4.1. higher premium

4.4.2. Disability income policies

4.4.3. Cancelable after 65

4.5. nonrenewable policies

5. Common Exclusion

5.1. injuries due to war

5.2. suspend disability coverage while serving in war

5.3. Extended stays - foreign travel

5.4. non-commercial air travel

5.5. losses from suicide, accidental injury, riots, use of drugs

5.6. Cosmetic surgery or experimental surgery or vision correction