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Health Insurance Policy Provisions

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Health Insurance Policy Provisions

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1. Entire contract - changes provision

For disability income policies: ins. co. has the right to either reduce the benefits or the premium if insured changes their occupation during the policy period.If insured is receiving benefits from health ins. policy - ins. co. has right to asked insured to take physical exam at reasonable intervals of time; ins. co. may conduct autopsy for any health policy with a death benefit as long as not prohibited by lawStates that entire contract includes anything attached to the contract; insurance company can not reference anything else when it comes to paying a claim; plus no one can alter the policy unless they are an executive officer of the ins. co. (ceo - cfo - coo)Based on premium mode: weekly premium=7 days; monthly=10days; quarterly - semi-annual - or annual=31 days

2. Physical examination and autopsies

3. Grace period provisions

If insured is receiving benefits from health ins. policy - ins. co. has right to asked insured to take physical exam at reasonable intervals of time; ins. co. may conduct autopsy for any health policy with a death benefit as long as not prohibited by lawStates that entire contract includes anything attached to the contract; insurance company can not reference anything else when it comes to paying a claim; plus no one can alter the policy unless they are an executive officer of the ins. co. (ceo - cfo - coo)For disability income policies: ins. co. has the right to either reduce the benefits or the premium if insured changes their occupation during the policy period.Based on premium mode: weekly premium=7 days; monthly=10days; quarterly - semi-annual - or annual=31 days

4. Change of occupation provision (optional)

5. Reinstatement provisions

If insured is receiving benefits from health ins. policy - ins. co. has right to asked insured to take physical exam at reasonable intervals of time; ins. co. may conduct autopsy for any health policy with a death benefit as long as not prohibited by law1) health ins. co. does not have to reinstate if a policy lapses; 2) if they decide to do so then: a) reinstatement application must be filled out; b) ins. co. has 45 days to make a decision; c) if insured does not hear back within 45 days then policy is automatically reinstated d) with new 10 day probationary period beginning on the effective date of coverage and excluding all illness during the 10 days - accidents will be covered; e) inso co has the right to collect up to 60 days of past due premiumBased on premium mode: weekly premium=7 days; monthly=10days; quarterly - semi-annual - or annual=31 daysStates that entire contract includes anything attached to the contract; insurance company can not reference anything else when it comes to paying a claim; plus no one can alter the policy unless they are an executive officer of the ins. co. (ceo - cfo - coo)

6. Unpaid premiums (optional)

If insured files a claim during the grace period - ins. co. can deduct amount of any overdue premium from the amount of benefits.If insured is receiving benefits from health ins. policy - ins. co. has right to asked insured to take physical exam at reasonable intervals of time; ins. co. may conduct autopsy for any health policy with a death benefit as long as not prohibited by lawStates that entire contract includes anything attached to the contract; insurance company can not reference anything else when it comes to paying a claim; plus no one can alter the policy unless they are an executive officer of the ins. co. (ceo - cfo - coo)Based on premium mode: weekly premium=7 days; monthly=10days; quarterly - semi-annual - or annual=31 days

7. Right to examine/ free look

If insured is receiving benefits from health ins. policy - ins. co. has right to asked insured to take physical exam at reasonable intervals of time; ins. co. may conduct autopsy for any health policy with a death benefit as long as not prohibited by lawBased on premium mode: weekly premium=7 days; monthly=10days; quarterly - semi-annual - or annual=31 daysStates that entire contract includes anything attached to the contract; insurance company can not reference anything else when it comes to paying a claim; plus no one can alter the policy unless they are an executive officer of the ins. co. (ceo - cfo - coo)Insured has right to a complete refund if they mail the policy back to ins. co. within 10 days of delivery

8. Claims procedures provisions: claim forms

Ins. co. has 15 days to give insured the blank claims forms necessary to file a claim (after the 15 days - insured can write claim on anything and company has to accept it)If insured is receiving benefits from health ins. policy - ins. co. has right to asked insured to take physical exam at reasonable intervals of time; ins. co. may conduct autopsy for any health policy with a death benefit as long as not prohibited by lawStates that entire contract includes anything attached to the contract; insurance company can not reference anything else when it comes to paying a claim; plus no one can alter the policy unless they are an executive officer of the ins. co. (ceo - cfo - coo)Based on premium mode: weekly premium=7 days; monthly=10days; quarterly - semi-annual - or annual=31 days

9. Time limit on certain defenses provision

Based on premium mode: weekly premium=7 days; monthly=10days; quarterly - semi-annual - or annual=31 daysStates that entire contract includes anything attached to the contract; insurance company can not reference anything else when it comes to paying a claim; plus no one can alter the policy unless they are an executive officer of the ins. co. (ceo - cfo - coo)If insured is receiving benefits from health ins. policy - ins. co. has right to asked insured to take physical exam at reasonable intervals of time; ins. co. may conduct autopsy for any health policy with a death benefit as long as not prohibited by law1) medical expense insurance: ins. co. has 2 years to determine if statements made on application are accurate; 2) disability income insurance: ins. co. has 2 years to verify the statements made on the application - and the 2 year clock stops ticking if insured is disabled - to start ticking again when they resume work

10. Renewal provisions

States that entire contract includes anything attached to the contract; insurance company can not reference anything else when it comes to paying a claim; plus no one can alter the policy unless they are an executive officer of the ins. co. (ceo - cfo - coo)1) noncancelable: ins. co. will guarantee the premium and coverage up to a specific age=disability income policy; 2) guaranteed renewable: coverage will be guaranteed to a specific age/does not guarantee premium; 3) conditionally renewable: does not guarantee premium or coverage - but can't be cancelled unless insured retired or changed to a more hazardous job=disability income policy; 4) optionally renewable: ins. co. can non-renew for a)over-utilization - b) discontinuance of a class of business - c) malingering - d) any other reason as long it is actuarial basedBased on premium mode: weekly premium=7 days; monthly=10days; quarterly - semi-annual - or annual=31 daysIf insured is receiving benefits from health ins. policy - ins. co. has right to asked insured to take physical exam at reasonable intervals of time; ins. co. may conduct autopsy for any health policy with a death benefit as long as not prohibited by law

11. Claims procedures provisions: time payment of claims

12. Optional provisions

13. Illegal occupation (optional)

Based on premium mode: weekly premium=7 days; monthly=10days; quarterly - semi-annual - or annual=31 daysStates that entire contract includes anything attached to the contract; insurance company can not reference anything else when it comes to paying a claim; plus no one can alter the policy unless they are an executive officer of the ins. co. (ceo - cfo - coo)Policy will not pay benefits if they are the result of insured committing any felony or being engaged in any illegal occupationIf insured is receiving benefits from health ins. policy - ins. co. has right to asked insured to take physical exam at reasonable intervals of time; ins. co. may conduct autopsy for any health policy with a death benefit as long as not prohibited by law

14. Required provisions

If insured is receiving benefits from health ins. policy - ins. co. has right to asked insured to take physical exam at reasonable intervals of time; ins. co. may conduct autopsy for any health policy with a death benefit as long as not prohibited by lawStates that entire contract includes anything attached to the contract; insurance company can not reference anything else when it comes to paying a claim; plus no one can alter the policy unless they are an executive officer of the ins. co. (ceo - cfo - coo)Based on premium mode: weekly premium=7 days; monthly=10days; quarterly - semi-annual - or annual=31 daysProtect the insured

15. Payment of claims

If insured is receiving benefits from health ins. policy - ins. co. has right to asked insured to take physical exam at reasonable intervals of time; ins. co. may conduct autopsy for any health policy with a death benefit as long as not prohibited by lawStates that entire contract includes anything attached to the contract; insurance company can not reference anything else when it comes to paying a claim; plus no one can alter the policy unless they are an executive officer of the ins. co. (ceo - cfo - coo)Based on premium mode: weekly premium=7 days; monthly=10days; quarterly - semi-annual - or annual=31 daysStates who will receive the benefits of the policy (disability = insured; medical expense could be insured or could be assigned to doctor)

16. Claims procedures provisions: notice of claim

If insured is receiving benefits from health ins. policy - ins. co. has right to asked insured to take physical exam at reasonable intervals of time; ins. co. may conduct autopsy for any health policy with a death benefit as long as not prohibited by lawStates that entire contract includes anything attached to the contract; insurance company can not reference anything else when it comes to paying a claim; plus no one can alter the policy unless they are an executive officer of the ins. co. (ceo - cfo - coo)Based on premium mode: weekly premium=7 days; monthly=10days; quarterly - semi-annual - or annual=31 daysMeans insured has 20 days to tell ins. co. that something happened and they plan to file a claim

17. Claims procedures provisions: proof of loss

90 time frame for insured to give ins. co. claims forms backBased on premium mode: weekly premium=7 days; monthly=10days; quarterly - semi-annual - or annual=31 daysIf insured is receiving benefits from health ins. policy - ins. co. has right to asked insured to take physical exam at reasonable intervals of time; ins. co. may conduct autopsy for any health policy with a death benefit as long as not prohibited by lawStates that entire contract includes anything attached to the contract; insurance company can not reference anything else when it comes to paying a claim; plus no one can alter the policy unless they are an executive officer of the ins. co. (ceo - cfo - coo)

18. Misstatement of age provision (optional)

Based on premium mode: weekly premium=7 days; monthly=10days; quarterly - semi-annual - or annual=31 daysIf insured is receiving benefits from health ins. policy - ins. co. has right to asked insured to take physical exam at reasonable intervals of time; ins. co. may conduct autopsy for any health policy with a death benefit as long as not prohibited by lawStates that entire contract includes anything attached to the contract; insurance company can not reference anything else when it comes to paying a claim; plus no one can alter the policy unless they are an executive officer of the ins. co. (ceo - cfo - coo)Ins. co. has the right to adjust death benefits if insured misstated their age; can not void the policy - only adjust the benefits

19. Other insurance with this insurer (optional)

20. Insurance with other insurers (optional)

States that entire contract includes anything attached to the contract; insurance company can not reference anything else when it comes to paying a claim; plus no one can alter the policy unless they are an executive officer of the ins. co. (ceo - cfo - coo)Based on premium mode: weekly premium=7 days; monthly=10days; quarterly - semi-annual - or annual=31 daysIf insured is receiving benefits from health ins. policy - ins. co. has right to asked insured to take physical exam at reasonable intervals of time; ins. co. may conduct autopsy for any health policy with a death benefit as long as not prohibited by lawThe two companies will pay the claim on a proportionate basis

21. Legal action against insurer

Based on premium mode: weekly premium=7 days; monthly=10days; quarterly - semi-annual - or annual=31 daysIf insured is receiving benefits from health ins. policy - ins. co. has right to asked insured to take physical exam at reasonable intervals of time; ins. co. may conduct autopsy for any health policy with a death benefit as long as not prohibited by lawInsured can't begin legal action until 60 days have passed since filing proof of loss; and can't begin legal proceedings after 3 years have passed since filing proof of lossStates that entire contract includes anything attached to the contract; insurance company can not reference anything else when it comes to paying a claim; plus no one can alter the policy unless they are an executive officer of the ins. co. (ceo - cfo - coo)

22. Conformity with state law (optional)

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