Colorado Health Insurance Mandatory Provisions and Optional Clauses, Exams of Public Health

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Colorado Health Insurance 2023 – 2024 Complete Solution Mandatory Uniform Provisions - Must be included in every individual accident policy, no additional provisions may be included which otherwise restrict or modify a uniform provision, designed to protect the insured's interest Entire Contract Clause- Mandatory Uniform - Includes the policy and provisions, c a copy of the application and any riders, waivers, or endorsements Time Limit on Certain Defenses-Mandatory Uniform - No statement or misstatement may be contested after 2 years, no time limit for fraud Grace Period-Mandatory Uniform - Period after premium due date before policy lapse, (7-10-31) 7 days for weekly premium; 10 days for a monthly premium; 31 days of every thing else Reinstatement Provision- Mandatory Uniform - Applies to the time frame that an insurer hasn't paid premium but wants the policy back, allows insured to reinstate by paying past due premiums, proof of insurability may be required, sickness begins after 10 days, accidents are covered immediately - If you haven't heard back in 45 days, then the policy has been reinstated Notice of Claim provision-Mandatory Uniform - Policy owner must notify Insurer of loss either in writing, in person or by phone w/in 20 days. claim forms provision-Mandatory Uniform - The insurer is required to send the insured a claim form within 15 days after notice is received Proof of Loss provision-Mandatory Uniform - Policy owner has 90 days from date of loss to submit proof of loss to Insurer; valid claim must be paid immediately upon receipt. Time of Payment of Claims-Mandatory Uniform - Provides for immediate payment of the claim after the insurer receives notification and proof of loss. Payment of Claims Provision-Mandatory Uniform - Payment of claims to the policyowner unless otherwise specified or there is an assignment of benefits(required) defines how proceeds are to be paid out + requirements to initiate death benefit claim Physical Exam and Autopsy-Mandatory Uniform - A provision that allows an insurer, at its own expense, to have an insured physically examined when a claim is pending or to have an autopsy performed where not prohibited by law. legal action - Insured must wait 60 days but no later than 3 years after proof of loss (POL) before legal action may be brought against the isurer Change of Beneficiary Provision-Mandatory Uniform - Stipulates that the policy owner may change the beneficiary at any time by providing a written request to the insurer, unless the beneficiary is designated as irrevocable. Optional Uniform Provisions - These provisions are included at the insurer's option; however, if used they must conform to the state's insurance code. These provisions are designed to protect the insurer. Change of Occupation Provision-Optional - If Insured changes to: more hazardous job - benefits reduced; less hazardous job - premiums reduce. Misstatement of Age-Optioanl - This clause protects the insurance company against an applicant who lies about his age The insurance company has the right to adjust your face amount up or down to coincide with the face amount or policy limit the correct premium would have purchased if you had not lied about your age This is a separate clause from the Incontestability Clause and will not ever cause the policy to be voided Relation of Earnings to Insurance-Optional - Amount of monies from premium payments the insurer received versus the loss the insurer suffered through claims payments Illegal Occupation-Optional - If the insured is connected with a felony or has an illegal occupation and incurs injury, the insurance company is not held responsible Free Look Provision( Right to Examine )-other - Generally 10 days after policy delivery to cancel policy w/ full refund, except 30 days for seniors or for replacement policies. Insuring Clause-other - Appears on first page of contract has a summary of all the main points of the contract like the "promise to pay" death benefit Consideration Clause-other - Payments and promise Preexisting condition-other - A health problem that existed before the date your insurance coverage became effective. Prior Conditions which insured should have received medical advice or treatment. self-employed person - May deduct up to 100% of the cost of health insurance for themselves and their dependents Benefits Received - Benefits received under any medical expense and dental plan, regardless of the premium payer, are not taxable Continuation of Coverage COBRA - Act states that employers with 20 or more employees must provide health continuation coverage to all covered employees and dependents up to 18 months in event of :Termination of employee :Reduction of hours as they no longer qualify for full time :Coverage may continue up to 29 months if an employee(or dependent) is totally disabled Continuation (COBRA) - Coverage may also continue for dependents up to 36 months if certain qualifying events happen :Death of employee :Divorce or legal separation :Empolyees entitlement to Medicare benefits :A child ages out of group plan as a dependent at age 26 Any substantial gainful activity - Social Security uses which definition to determine total disability? An insured with a cognitive impairment has how many days to reinstate the LTC policy that was cancelled for nonpayment of premium? - 90 days Insured - Before a policy will be issued, an insurable interest must exist between the owner (applicant) and th If a policy is issued with a surcharge, this means that the policy - Policy was issued with a higher premium due to the increased risk. Overinsurance - When an individual carries more accident and health insurance than he/she would need for a loss, it is called: Coordination of Benefits - Which provision in a health insurance plan is used to avoid overinsurance when a person is covered by more than one plan? Which of the following is true concerning the Benefit Period of a LTC Policy - Once the elimination period has been satisfied, it is how long benefits will be payable When the insurer issues a policy - An applicant completes the application and submits it to the insurer along with a premium check. When is the applicant's offer considered accepted? The Guaranteed Renewable Provision states that the policy is: - Renewable with premiums that may be increased for entire classes of insureds What do ADLs trigger? - Long-Term Care Insurance, Activities of Daily Living (ADLs) are triggers used to begin Long-Term Care Insurance benefits. Social Security Disability - Medicare is available to individuals who have been receiving ______________ benefits for 24 months. Medicare is available to individuals regardless of age if they have received Social Security disability benefits for 24 months. Supplementary Major Medical - A policy which utilizes a Corridor Deductible after Basic Medical Expense Coverage benefits have been exhausted and before Major Medical benefits begin? Utilization Review - Is a set of formal techniques for monitoring the use or clinical necessity of health care, or for determining if an exclusion applies or a treatment is medically necessary. Unauthorized entities - Every person acting as an advisor, counselor, or analyst must report every unauthorized policy or contract to the Commissioner. $750,000 - The maximum penalty for a knowing violation of Unfair Trade Practices law is: Misrepresentation - Making a statement that is misleading about a policy, its dividends, or its share of surplus receivable or paid in the past, or about a person's financial condition or a life insurer's legal reserve system. Free Look Period = - Right to Examine is the same as A small employer insurers must - Offer a basic and a standard health plan Unfair Claims Practices - Compelling insureds to sue by offering substantially less than what a lawsuit would award is an example of Unfair Claims Practices - Misrepresenting pertinent facts or insurance policy provisions relating to coverage at issue Failing to acknowledge and act reasonably promptly upon communications with respect to claims arising under insurance policies Failing to adopt and implement reasonable standards for the prompt investigation of claims arising under insurance policies Refusing to pay claims without conducting a reasonable investigation based on all available information Failing to affirm or deny coverage of claims within a reasonable time after proof of loss statements have been completed Not attempting in good faith to effectuate prompt, fair, and equitable settlements of claims in which liability has become reasonably clear Compelling insureds to institute litigation to recover amounts due under an insurance policy by offering substantially less than the amounts ultimately recovered in actions brought by such insureds Attempting to settle a claim for less than the amount to which a reasonable person would have believed he was entitled by reference to written or principal advertising material accompanying or made part of an application Attempting to settle claims on the basis of an application that was altered without notice, knowledge, or consent of the insured Making claims payments to insureds or beneficiaries not accompanied by statements setting forth the coverage under which the payments are being made Making known to insureds or claimants a policy of appealing arbitration awards in favor of insureds or claimants for the purpose of compelling them to accept settlements or compromises less than the amount awarded in arbitration Delaying the investigation or payment of a claim by requiring an insured, claimant, or the physician of either to submit a preliminary claim report and then requiring the subsequent submission of formal proof of loss forms, both of which submissions contain substantially the same information Failing to promptly settle claims where liability has become reasonably clear under one portion of the insurance policy coverage to influence settlement under other portions of the insurance policy coverage Failing to promptly provide a reasonable explanation of the basis relied on in the insurance policy in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement Guaranteed Renewable means: - Renewable with adjustable premiums, by classification only