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Professional Development
Indiv. Health Ins. Policy Provisions & Medical Plans
29 questions
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- 1. Multiple Choice
Which is NOT among basic medical expense insurance?
hospital expense insurance
surgical expense insurance
physician expense insurance
nursing home insurance
- 2. Multiple Choice
Under a health insurance contract's consideration clause, which of the following best describes the insurance company's consideration when issuing a health insurance policy?
The insurance company's consideration is the promise to pay a benefit if the insured continues to pay the premiums.
The insurance company's consideration is the promise to pay a benefit if a stated future event occurs.
The insurance company's consideration is the payment of a benefit if the insured suffers a loss.
The insurance company's consideration is the payment of benefits at the end of the consideration period.
- 3. Multiple Choice
Who or what defines the probationary period used in group insurance?
The state insurance department defines this period.
The employee union or collective bargaining group defines this period.
The insurer sets the period used in the group policy.
The employer sets the period used in the group policy.
- 4. Multiple Choice
Under a health insurance contract's consideration clause, which of the following best describes the applicant's consideration?
The applicant's consideration is the first premium he or she pays.
The applicant's consideration is the application.
The applicant's consideration is the application and the signed receipt of the delivered policy.
The applicant's consideration is the application and the first premium he or she pays.
- 5. Multiple Choice
Which of the following optional provisions either allows the insurer to reduce benefits or requires the insurer to reduce the premium rate under certain conditions?
the entire contract provision
the other insurance in this insurer provision
the change of occupation provision
the other insurance with other insurer provision
- 6. Multiple Choice
The other insurance in this insurer provision in a health insurance policy limits:
the number of policies a person can own
the amount of claims an insurer will pay
the total coverage the insurer provides to a particular insured
the number of riders in a single policy
- 7. Multiple Choice
When health care services incur a coinsurance payment, the insured must:
pay costs that exceed the limitation on coverage for the service
pay half of the cost of each service rendered
pay the annual deductible amount before the insurer pays a benefit
find a second health care plan to coordinate payment of the expense.
- 8. Multiple Choice
Which is NOT among the 12 provisions that are required in health insurance policies?
entire contract
time limit on certain defenses
misstatement of age
proof of loss
- 9. Multiple Choice
Bethany was injured in a car accident. Within how many days must she typically notify her health insurance company about the claim?
5
7
20
45
- 10. Multiple Choice
Sarah misstated her age on her health insurance application. The insurer discovers this after receiving notice of Sarah's claim. What result will come from her misstatement?
The claim will not be paid.
The claim will be paid, but she must reapply for coverage.
A penalty will be deducted from the claim payment.
The benefit payment will be adjusted for her age.
- 11. Multiple Choice
Jackson was traveling through Europe when he realized that he forgot to pay the premium for his health insurance policy. Which provision will keep the policy in force until he pays the premium?
free-look provision
grace period
policy loan provision
incontestability provision
- 12. Multiple Choice
Individual and group health insurance policies both can include a probationary period. When used in an individual health insurance policy, what is a probationary period?
the period that must pass between the policy's effective date and the time when benefits are payable
the period that must pass between the application and the time the initial premium is paid
the period that must pass between the policy's issue date and the time premiums are payable
the period that must pass between the policy application date and the acceptance of the risk by the insurer
- 13. Multiple Choice
Mallory submitted a notice of claim with ABC Insurers but receives no response from ABC after several weeks. What should Mallory do to make sure ABC knows of her claim?
Contact ABC Insurers again for the claim forms.
Notify the Insurance Commissioner that ABC Insurers failed to provide the necessary forms.
Sue ABC Insurers for breach of contract.
Submit a written statement that describes the loss.
- 14. Multiple Choice
A person who is covered by an individual medical expense insurance plan is:
a participant
an enrollee
a provider
an insured
- 15. Multiple Choice
Why does an individual health insurance policy include a probationary period?
It helps the insurer to assess the level of risk being assumed.
It allows the insurer to verify the information provided on the application.
It helps the insurer avoid adverse selection.
It helps the insurer determine the insured's financial well-being.
- 16. Multiple Choice
How are medical savings accounts similar to health savings accounts?
Both are typically used by large companies.
Both help fund tax-free medical expenses.
Both combine a high-deductible health insurance plan with a tax-advantaged savings account.
Both offer the same contribution limits each year.
- 17. Multiple Choice
A health insurance policy's insuring clause does all the following EXCEPT:
describe the type and scope of coverage
state the premium ranges for covered risks
define terms used in the policy
state the conditions that must be met for the policy to pay a benefit
- 18. Multiple Choice
The fee schedules that were once used to determine appropriate costs of medical care and services have been replaced by:
resource utility groups
third-party adjusters
the usual, customary, and reasonable fee standard
surgical unit values
- 19. Multiple Choice
Dental insurance typically does NOT cover what kind of treatment?
cosmetic treatment
orthodontics
oral surgery
diagnostic and preventive care
- 20. Multiple Choice
As a contract, issuance of a health insurance policy requires all of the following elements EXCEPT:
an offer
consideration
a counteroffer
acceptance
- 21. Multiple Choice
Your client was injured in an accident and submits proof of loss in a timely manner to Alpha Insurers. Alpha refuses to pay the claim. Your client wants to sue Alpha. What should you recommend?
The client cannot take legal action until at least 90 days after submitting proof of loss to Alpha.
The client should first report Alpha's refusal to the state's insurance department.
The client cannot take legal action until at least 60 days after submitting proof of loss to Alpha.
The client cannot take legal action against Alpha for denying a claim.
- 22. Multiple Choice
An HMO that provides services or coverage outside its network is:
an open-panel plan
a closed-panel plan
a primary care physician plan
a staff-based HMO
- 23. Multiple Choice
When Cooper was completing his application for an individual health insurance policy, he intentionally omitted information concerning his history of skin cancer. What will the insurer do when it discovers this omission one year later?
void the policy or exclude losses related to skin cancer
increase the premium
increase the premium
refuse payment of a benefit for a loss related to any cancer
pay a reduced benefit for any loss related to cancer
- 24. Multiple Choice
Jonah has a traditional medical expense insurance policy. He pays each health-care provider for services rendered, and the insurer reimburses him for the costs incurred. What type of policy is this?
managed care
fee-for-service
reimbursement
prepaid
- 25. Multiple Choice
The NAIC's model law sets forth certain optional provisions that insurers can but are not required to add to a health insurance policy. How many optional provisions are on the list?
5
6
11
12
- 26. Multiple Choice
Which is NOT a type of basic medical expense plan?
long-term care insurance
hospital insurance
physician expense insurance
surgical expense insurance
- 27. Multiple Choice
Roberto let his individual health insurance policy lapse two months ago. He pays the premium to reinstate the policy. How many days must Roberto wait before any illnesses will be covered?
5
10
75
90
- 28. Multiple Choice
Which statement about HMOs is NOT correct?
Members sign a contract to join the organization.
The provider network is limited to a town or city.
It is responsible for the health care it delivers.
Member pay premiums monthly, quarterly, semi-annually, or annually.
- 29. Multiple Choice
Medical savings accounts (MSAs) have been replaced by:
POS accounts
flexible spending accounts (FSAs)
health savings accounts (HSAs)
individual retirement accounts (IRAs)
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