Health Insurance Provisions Clauses and Riders

  • Guarateed Renewable
  • Irrevocable Beneficiary - policy owner not exercise certain rights.
    NAIC - National Association of Insurance Comissioners - regulatory issues.
  • Total Disability

Mandatory Provisions

  • Protect the policy holder or beneficiary

Entire Contract
The policy, singled application, riders and amendments.
Only a executive officer of the company has the autorithy to make changes to the policy.

Grace Period

  • Policy still in force even without a payment of minimum 7 days for weekly premiums, 10 days for months and 31 for other modes.

Reistatement
Takes 45 days if approved by the company.

  • Sickness covered only after 10 days.
  • Imediately coverage for accidents.

Change of beneficiary

  • If the beneficiary is irrevocable the Policyowner needs to have his permission to do it.

Claims Procedures

  • Notice of a claim is 20 days after the loss.
  • Usually 15 days after claim to the insurer to provide the forms.
  • 90 days to return the forms with the proof of loss. Extended to 1 year.
  • 45 days is the maximum waiting period to get the payment of a claim.

Physical Examination and Autopsy

  • Right of the insurer to examine and autopsy the insured.

Time Limit on Certain Defenses.

  • Incontestable.
  • 2 years for to the insurance company claim no statement or misstatement, except fraudulent.

Legal Actions

  • 60 days from the proof of loss to wait to get on a legal action.

Misstatement of Age

  • Premiums adjusted with the correct age.

Change of Occupation.

  • Insurer can adjust the benefits when insured change his occupation and not increase of premiums in case of a hazardous occupation.
  • Rate reduction application to less hazardous occupation.

Relation of Earnings to Insurance.

  • Limit the benefit paid over the last 24 months of the insureds income amount.

Other Provisions and Clauses

Insuring Clause

  • General statement that identifies the basic agreement between the company and insured and states what kind of loss is covered.

Free Look

  • Also called Right to Examine.
  • Usually 10 days to take a look at the policy.

Consideration Clause

  • Information about premium payment.

Probationary Period

  • Time after the payment that before the insured can start to use the benefits.

Elimination Period

  • Waiting time to get the benefit after reporting a illness. Or accident.
  • The longer is the elimination the lower is the premium or cost of coverage.

Waiver of Premium

  • In the event of total and permanent disability premiums will be waived.
  • Usually regulated by 3 to 6 months of disability. During this waiting period the insured needs to pay the premiums that will be retroactive to him.
  • Usually expires when achieving the age of 65 without paying premiuns.

Pre Existing Conditions

  • Are excluded to be covered in the plans due to the affordable care act.
    Can be covered by covered by Medicare supplement policies and long term care insurance.

Coinsurance

  • typically 80% the insurance company pays but others as 90/10, 75/25 and 50/50.
  • Control overutilization.
  • Stop-loss limit - amount more than the stipulated for a year, the insurance company have to pay 100% of the utilization.

Copayment - Set dollar amount that the insured needs to pay everyt time he uses a medical service.

Deductibles

  • Anual Deductible independent of the number of time they use it.
  • Individual deductible for member of the familyor family deductible.
  • Per occurrence or flat deductible.
  • Common accident provision - only one deductible is applied when family members suffer the same accident.
  • Integrateed Deductible - for regular policy and supplement.
  • Carry - over provision - when you didn’t used the hole deductible for an year, the amount will be add to your new “limite”
  • Considered as a copay in the total amount to pay for service.

Eligible Expenses

  • Medical expenses covered and specified in the policy.

Pre - authorization and Prior Approval Requirements

  • Some policies required that the insured inform the medical procedure or hospital stays in advance.

Usual, Reasonable and Customary URC Charges

  • Benefit schedule states what is covered and how much. Other have this provision that means the insurance company will pay the average for procedure at that area.

Lifetime, Anual or Per cause maximum benefits limits

Exclusions and Limitations

  • War, military duty, self inflicted, dental, cosmetic, eye refractions and care in government facilities.
    Suspended when living abroador serving the military.
  • Mental , emotional and substance abuse disorders - limit of visits and copay per year.

Riders

Impairment Rider

  • coverage excluded in case of pre existing condition. Even for a back problem.

Guaranteed Insurability

  • Future increase and guaranteed purchase also called.
  • Can also have the in the contract a limit amount to ad disability coverage without evidence of insurability and only attained by age.

Rights of Rewewability

  • Must be in the face page stated that is renewable but the insurer reserves the right to not do it???
  • Non cancellable - guaranteed until 65 - then after Medicare coverage but not increasing the premiuns.
  • Cancellable - not common and even ilegal in many states. Company cannot do that during a claim process.
  • Guaranteed Renewable - increase the policy premium on the anniversary date on a class basis, not individual.

Incontestability Clause

  • Insurer cannot refer to any document that is not contained in the contract.