Individual Health Insurance

Front 1

Uniform Individual Accident and Sickness Policy Provisions Law

Back 1

Provisions made in order to make Insurance policies ethical and competitive. Governed by the NAIC (National Association of Insurance Commissioners)

Front 2

Entire Contract

Back 2

Sign application attached to riders and amendments. Only executives can make policy changes

Front 3

Term Limit on Certain Defenses

Back 3

No statement of misstatement ( except fraudulent misstatements) will be used to terminate the policy after a certain number of years. A pre-existing condition will not be covered during the first few years. In Michigan its 3 years.

Front 4

Grace Period

Back 4

Time in which the premium is not paid but the policy does not lapse. 7 days weekly, 10 days for monthly, 31 days for all other modes

Front 5

Reinstatement

Back 5

Premium has not been paid by grace period must be reinstated. Upon reinstatement process the insurer has the right to accept or deny policy if conditional receipt and reinstatement application is required.Any payment accepted goes to the pre-existing premium charge. Accidents are covered immediately, sickness is 10 days.

Front 6

Notice of Claim

Back 6

Insured's duty to provide the insurer with notice of a loss within a 20 day period. Notice to the agent is the equivalent of noticing an insurer.

Front 7

Proof of Loss

Back 7

documentation of loss must be submitted within 90 days, but cannot exceed one year's time.

Front 8

Claims Forms

Back 8

Written proof of loss, nature of loss, and extent of loss to the insurer must be completed within stated time frame to insurer. On year limit does not apply to those who are not legally competent Varies from state to state.

Front 9

Time of Payment of Claims

Back 9

Claims are paid immediately upon written proof of loss. Time is specified in the contract (60 days, 45 days, 30 days etc.) If the claim has disability benefits, the claim will not be paid less frequently than monthly.

Front 10

Payment of Claims

Back 10

Claims are received in this order: to the insured, insured beneficiary, to insured's estate, or any assignment the insured has made if he or she is not alive.

Front 11

Physical Examination and Autopsy

Back 11

The physical examination and autopsy can be done as reasonably necessary as requested if the insurer pays. However, the insurer, depending on state provisions, can conduct its own autopsy.

Front 12

Legal Actions

Back 12

Limits the time the claimant can seek recovery from the insurance company. The insured must wait 60 days, and no later than 3 years after proof of loss in order to conduct any legal actions against insurer

Front 13

Right to Examine (Free Look)

Back 13

Allows insured 10 days to get a full refund on a policy if he or she is not satisfied.

Front 14

Optional Provisions

Back 14

An insurer can change the language of the policy as long as it is not adverse to the insured

Front 15

Change of Occupation

Back 15

Benefits are subject to change. If the insurer has a more hazardous job then, the benefits are reduced. If the insured takes on a less hazardous occupation, the insured can apply for a rate reduction.

Front 16

Illegal Occupation

Back 16

Denied the right if the insured is injured while committing an illegal act or engaged in a illegal occupation.

Front 17

Misstatement of Age

Back 17

If the insured does not provide the correct age, the premium will reflect the adjustment for the correct age.

Front 18

Insurance and Other Insurers

Back 18

If insured had 2 or more policies from different insurers and they provide the same benefits then the insurers will pay the appropriate proportion of the claim to prevent overinsurance.

Front 19

Unpaid Premium

Back 19

Any unpaid premiums will be deducted from the claim and the policy holder will get paid a net amount.

Front 20

Renewability Clause

Back 20

The first page of the health insurance contract should detail the conditions in which the policy can be renewed. If the insurer denies the policy, then the insured has to receive a notice in the mail. If the insured has a term policy he or she can refuse renewal. The absence of cancellation does not mean the continuing of protection.

Front 21

Noncancellable

Back 21

The premium cannot be increased nor cancelled beyond what is in the policy.When the specified year that was stated in the policy is present upon increasing the premium , the insured has the right to refuse renewal.

Front 22

Guaranteed renewable

Back 22

Noncancellable provision, with the exception that the insurer may increase premiums on the anniversary date of the premium. However this can only be done on a class basis.

Front 23

Conditionally renewable

Back 23

May terminate contract only at renewal if certain conditions in the policy are met.

Front 24

Renewable at Option of Insurer

Back 24

Insurer may cancel the policy on premium due date or anniversary of policy. ss

Front 25

Riders

Back 25

Represents additional benefits at an additional cost to an insurance policy.