General knowledge · Section VI · Life, Accident and Health only
Policy provisions, clauses, and riders (health)
The provisions, clauses and riders of health policies: mandatory and optional provisions, other clauses, riders, and renewability, from noncancellable to cancellable. Many questions ask what a specific provision requires or allows.
Questions on the exam
- Life, Accident and Health: 15 questions
- Life Agent: Not on this exam
Life, Accident and Health exam
What the official outline lists
- Mandatory and optional provisions
- Other provisions and clauses
- Riders
- Rights of renewability
Practice questions
Choose your answer, then open “Show the answer” to see why each option is right or wrong and the exact source text.
1. For a claim under which the policy provides periodic payments contingent on continuing loss, from what event does the period for giving written proof of loss to the insurer begin to run?
- The termination of the period for which the insurer is liable
- The date the claimant first receives a claim form
- The first day of the period for which the insurer is liable
- The date the insurer's designated office receives the notice of claim
Show the answer
Correct answer: A. The termination of the period for which the insurer is liable
According to TIC §1201.213, for a claim with periodic payments contingent on continuing loss, written proof must be provided before the 91st day after the termination of the period for which the insurer is liable.
Why the other options are wrong
- B. The quoted text does not tie the deadline to receipt of a claim form; it counts from the termination of the period for which the insurer is liable.
- C. The deadline is not counted from the start of the liability period; the provision counts from the termination of that period.
- D. The provision does not count from receipt of a notice of claim; it counts from the termination of the period for which the insurer is liable.
For a claim for loss for which this policy provides any periodic payment contingent on continuing loss, a written proof of loss must be provided to the insurer at the insurer's designated office before the 91st day after the termination of the period for which the insurer is liable.
2. Rowan gives an insurer notice of a claim under an individual accident and health policy. The insurer never sends claim forms. Before the 16th day after the date of the notice, Rowan has still received no forms. Later, within the time fixed in the policy for filing proofs of loss, Rowan sends written proof covering the occurrence, character, and extent of the loss. What is the effect under the Claim Forms provision?
- Rowan is considered to have complied with the proof of loss requirements
- Rowan must wait until the insurer eventually supplies its forms before proving the loss
- Rowan's written proof is invalid because it was not made on the insurer's forms
- Rowan must send a second notice of claim before the written proof is accepted
Show the answer
Correct answer: A. Rowan is considered to have complied with the proof of loss requirements
Per TIC §1201.212, if the forms are not provided before the 16th day after the date of the notice, the claimant shall be considered to have complied with the policy's proof of loss requirements on submitting, within the time fixed in the policy, written proof covering the occurrence, the character, and the extent of the loss.
Why the other options are wrong
- B. The quoted provision lets the claimant comply by submitting written proof within the time fixed in the policy; it does not require waiting for the forms.
- C. The quoted provision treats written proof submitted within the policy's time as compliance when the forms were not provided in time, so the absence of the insurer's forms does not invalidate it.
- D. The quoted provision does not require a second notice of claim; written proof submitted within the time fixed in the policy is enough for compliance.
If the forms are not provided before the 16th day after the date of the notice, the claimant shall be considered to have complied with the requirements of this policy as to proof of loss on submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character, and the extent of the loss for which the claim is made.
3. Dana's individual accident and health policy contains the standard proof of loss provision. Dana did not give written proof within the required time because it was not reasonably possible to do so. Which statement describes the effect on the claim and the time limit for giving proof?
- The claim is not invalidated or reduced, and proof is due as soon as reasonably possible, within one year of the original deadline
- The claim is invalidated, and Dana must file a new claim within one year after the loss
- The claim is reduced by the late filing, and proof must be given within 90 days after the original deadline
- The claim is not reduced, and proof may be given at any later time with no outer limit
Show the answer
Correct answer: A. The claim is not invalidated or reduced, and proof is due as soon as reasonably possible, within one year of the original deadline
According to TIC §1201.213, failure to provide proof within the required time does not invalidate or reduce any claim if it was not reasonably possible to give proof in time. Proof must then be provided as soon as reasonably possible but not later than one year after the time proof is otherwise required, except in the event of a legal incapacity.
Why the other options are wrong
- B. The provision says late proof does not invalidate the claim when timely proof was not reasonably possible, and it sets no requirement to file a new claim.
- C. The provision says the claim is not reduced in that situation, and the outer limit is one year after the time proof is otherwise required, not 90 days.
- D. The claim is not reduced, but the provision does set an outer limit: not later than one year after the time proof is otherwise required, except in the event of a legal incapacity.
Failure to provide the proof within the required time does not invalidate or reduce any claim if it was not reasonably possible to give proof within the required time. In that case, the proof must be provided as soon as reasonably possible but not later than one year after the time proof is otherwise required, except in the event of a legal incapacity.
4. According to TIC §1201.051, where may an individual accident and health insurance policy state the entire consideration for the policy?
- In the policy, or in the application if the application is made a part of the policy
- Only in a separate premium notice mailed after the policy is issued
- Only in the application, even if the application is not part of the policy
- In a rider, but never in the policy or in the application
Show the answer
Correct answer: A. In the policy, or in the application if the application is made a part of the policy
TIC §1201.051 allows the entire monetary and other consideration to be stated in the policy or in the application, if the application is made a part of the policy.
Why the other options are wrong
- B. Incorrect. TIC §1201.051 names the policy and the application (when made part of the policy), not a later premium notice.
- C. Incorrect. The application counts only if it is made a part of the policy.
- D. Incorrect. TIC §1201.051 refers to the policy or the application, not to a rider as the only place.
An individual accident and health insurance policy must state the entire monetary and other consideration for the policy in the policy or in the application, if the application is made a part of the policy.
5. According to the HealthCare.gov glossary, how do monthly premiums generally relate to copayments?
- Plans with lower monthly premiums generally have higher copayments
- Plans with lower monthly premiums generally have lower copayments
- Premium level decides whether a plan has copayments at all
- Monthly premiums and copayments are not related to each other
Show the answer
Correct answer: A. Plans with lower monthly premiums generally have higher copayments
According to the HealthCare.gov glossary (Copayment), generally plans with lower monthly premiums have higher copayments, and plans with higher monthly premiums usually have lower copayments.
Why the other options are wrong
- B. This reverses the relationship; the glossary says plans with lower monthly premiums generally have higher copayments.
- C. The glossary describes plans with lower and with higher monthly premiums as both having copayments; the premium level relates to how high the copayments are, not to whether they exist.
- D. The glossary states a general relationship between premiums and copayments, so they are not unrelated.
Generally plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have lower copayments.
6. In health insurance, which of the following best describes a pre-existing condition?
- A health problem, such as asthma or diabetes, that the person had before the date the new coverage starts
- A health problem that first appears after the date the new coverage starts
- Any condition for which the insurer has already paid claims under the new coverage
- Only a condition that a doctor has diagnosed in writing within the prior calendar year
Show the answer
Correct answer: A. A health problem, such as asthma or diabetes, that the person had before the date the new coverage starts
According to the HealthCare.gov glossary entry for pre-existing condition, it is a health problem, like asthma, diabetes, or cancer, that you had before the date that new health coverage starts.
Why the other options are wrong
- B. The glossary definition ties the term to a problem you had before the date new coverage starts, not to one that first appears afterward.
- C. The definition turns on whether the problem existed before the new coverage starts; it says nothing about claims paid under the new coverage.
- D. The definition covers a health problem you had before new coverage starts and sets no requirement of a written diagnosis or a one-year look-back.
A health problem, like asthma, diabetes, or cancer, you had before the date that new health coverage starts.
7. Under the Texas rules on exceptions, exclusions, and reductions for individual accident and health policies, the acceptable exclusions listed in Exhibit A may not impair or limit an insurer's use of which of the following to limit coverage for a named pre-existing disease?
- Waivers
- Grace periods
- Free-look periods
- Premium refunds
Show the answer
Correct answer: A. Waivers
According to 28 TAC §3.3057(d), the acceptable exclusions set forth in Exhibit A may not impair or limit the use of waivers to exclude, limit, or reduce coverage or benefits for named or specifically described pre-existing disease, physical condition, or extra hazardous activity.
Why the other options are wrong
- B. Grace periods are not mentioned in 28 TAC §3.3057(d); the rule protects the use of waivers.
- C. Free-look periods are not mentioned in 28 TAC §3.3057(d); the rule protects the use of waivers.
- D. Premium refunds are not mentioned in 28 TAC §3.3057(d) as something the Exhibit A exclusions may not impair; the rule protects the use of waivers.
The acceptable exclusions set forth in Exhibit A may not impair or limit the use of waivers to exclude, limit, or reduce coverage or benefits for named or specifically described pre-existing disease, physical condition, or extra hazardous activity.
8. Under 28 TAC §3.3019, which statement applies to an insurer with respect to the provisions of a noncancellable policy while the policy is in force?
- The insurer may not unilaterally make any change in any provision of the policy
- The insurer may unilaterally change any provision after giving written notice
- The insurer may unilaterally change the premium rates for the policy's class
- The insurer may unilaterally change any provision other than the premium rate
Show the answer
Correct answer: A. The insurer may not unilaterally make any change in any provision of the policy
According to 28 TAC §3.3019(a), the insurer may not unilaterally make any change in any provision of the policy while the policy is in force.
Why the other options are wrong
- B. The rule contains no exception for written notice; it says the insurer may not unilaterally make any change in any provision of the policy while it is in force.
- C. The rule bars unilateral changes to any provision of the policy while it is in force and makes no exception for changes in premium rates by class.
- D. The rule covers any provision of the policy, not only the premium rate, so the insurer may not unilaterally change any of them while the policy is in force.
The insurer may not unilaterally make any change in any provision of the policy while the policy is in force.
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Key flashcards
Front and back, as in the app.
- TIC §1201.213: by when must written proof of loss be given to the insurer?
- Before the 91st day after the date of the loss. If the policy pays periodic payments contingent on continuing loss, before the 91st day after the termination of the period for which the insurer is liable. (Texas Insurance Code §1201.213, “Policy provision: proof of loss”)
- Under TIC §1201.051, an individual accident and health policy must state the entire monetary and other consideration in the policy or in the application. When may the application carry that statement?
- If the application is made a part of the policy. (Texas Insurance Code §1201.051, “Entire consideration”)
- 28 TAC §3.3057(d): what may the acceptable exclusions in Exhibit A NOT impair or limit?
- The use of waivers to exclude, limit, or reduce coverage or benefits for named or specifically described pre-existing disease, physical condition, or extra hazardous activity. (28 TAC §3.3057(d), “Standards for Exceptions, Exclusions, and Reductions Provision.”)
- Proof of loss: what if proof cannot reasonably be given in time?
- The claim is not invalidated or reduced. Proof must be given as soon as reasonably possible, but not later than one year after the time proof is otherwise required (except in the event of a legal incapacity). (Texas Insurance Code §1201.213, “Policy provision: proof of loss”)
- What is a pre-existing condition, and what can't insurance companies do about it (HealthCare.gov)?
- A health problem, like asthma, diabetes, or cancer, you had before the date new health coverage starts. Insurance companies can't refuse to cover treatment for it or charge you more. (HealthCare.gov Glossary: Pre-existing condition (Pre-existing condition))
Terms on this topic
- Consideration — Contraprestación
- Application — Solicitud
- Unilateral — Unilateral
- Claim forms — Formularios de reclamación
- Proof of loss — Comprobante de pérdida
- Copayment — Copago
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