Health - Health Insurance Policy Provisions And Options (1.3)

Front 1

1. entire contract
2. limit on certain defenses
3. grace period
4. reinstatement **proof of insurability is required occurrence
5. notice of claim **ED has 20 days after the
6. claims form **ED should apply within 15 days
7. proof of loss **have 90 days
8. time payment of claim
9. payment of claim
10. physical exam & autopsy
11. legan actions
12. change of beneficiary

Back 1

Required Provisions include:

Front 2

1. change of occupation
2. misstatement of age
3. other insurance with the same ER
4 & 5. Insurance with another ER
6. relation of earnings to insurance average earnings clause
7. unpaid premiums
8. cancellation
9. conformity with state statues
10. legal occupation
11. narcotics

Back 2

Optional Provisions include:

Front 3

insuring clause

Back 3

the ER's comtractual promise to pay benefits for specific kinds of losses resulting from sickness or accidents as stated in the policy

Front 4

free look

Back 4

ER allows ED a period of normally 10 days to examine the new policy

Front 5

1. full min premium required
2. statements made in policy
3. effective date
4. length of coverage

Back 5

consideration clause states the following:

Front 6

1. flat amount
2. percent of income amount

Back 6

2 techniques used to determine the amuont of the individuals monthly disability benefits:

Front 7

flat amount

Back 7

a flat income benefit will be paid if the ED's becomes totally disabled and is not changed by any other income benefits received by the ED

Front 8

percent of income method

Back 8

uses a percentage of teh ED's earnings before the disabilty and takes into account other sources of income

Front 9

"any occupation"

Back 9

Ed cannot perform any occupation for which he/she is reasonably qualified by education, training, or experience
**more restrictive than "own"

Front 10

"own occupation"

Back 10

Ed must be capable of working at their own occupation

Front 11

presumptive disability

Back 11

under certain conditions the ED automatically qualifies for full benefits

Front 12

permanent disability

Back 12

impairs a persons ability to work for the remainder of his/her life

Front 13

temporary disability

Back 13

person is expected to make a full recovery

Front 14

partial disability

Back 14

ED's inability to perform every duty of his/her own occupation, but they can perform one or more job duties of their occupation or a different occupation

Front 15

Residual disabilty

Back 15

illness that causes an ED's income to be reduced by at least 20%

Front 16

elimination period

Back 16

time immediately following the start of a disability when benefits are not payable

Front 17

recurrent disability provision

Back 17

an indiviadual can recover and relapse weeks/months later
**typical recurrence period is 6 months

Front 18

1. principal sum -payable as a life insurance death benefit to beneficiary
2. capital sum -benefit is payable to the ED for loss of sight or dismemberment from an accident

Back 18

AD&D benefits are paid in 2 different ways:

Front 19

Waiver of Premium

Back 19

rider provides that in the event of disablilty, premiums will be waived retroactively back to the beginning of a disability

Front 20

1. permanent total
2. permanent partial
3. temporary total
4. temporary partial

Back 20

4 types of disability defined under workers compensation law: