Same; when provisions of a not applicable. Health coverage; jurisdiction of commissioner; exceptions. Same; associations not subject to jurisdiction of commissioner to provide applicants with written notice of nature of coverage. Same; premium tax, rate, computation, return and payment. Same; examination; subject to insurance laws. Same; disclosure to purchaser required. Long-term care insurance; name and citation of act.
Same; application and construction of act. Same; rules and regulations; prohibitions; preexisting condition provisions; delivery of outline of coverage upon application required.
Long-term care policies and certificates; reinstatement of lapsed policies or certificates due to cognitive impairment or loss of functional capacity. Same; notice of lapse or termination; designation of person in addition to applicant to receive notice, waiver; change of designation. Same; payment of premiums through payroll or pension deduction plan; requirements under b; application or enrollment form. Same; lapse or termination of policy or certificate; requirements; notice.
Same; reinstatement, conditions. Long-term care insurance prompt payment act; effective date. Same; claims; procedures; rules and regulations. Mammogram and pap smear coverage; policies to which mandated coverage applicable.
Same; when reimbursement or indemnification required; deductibles, coinsurance and other limitations permissible. Continuing care contracts; definitions.
Same; provider's annual disclosure statement; contents; requirement to furnish. Same; annual disclosure statement, contract and annual audit; filing with commissioner. Same; providing form to commissioner; contents and attachments.
Same; certificate of registration, application, fee, renewal. Same; change of ownership or management of provider or home. Small employer health benefit plans; definitions.
Same; establishment; assistance by commissioner. Same; contracts with carriers; coverage options; application of and Same; qualification for employer participation. Same; employee and employer contributions; employee's enrollment in multiple options; enrollment not required, when; payroll deductions. Same; employer income tax credit, computation of amount, reduction of deductions, election to claim, refunds; no inclusion of employer expenses in employee income; application date.
The insurer is not responsible for any loss that occurs while the insured is intoxicated or under the influence of narcotics unless drugs were administered by a physician. Misstatement of Age This provision is the same as in life insurance, with a slightly different end result.
Other Insurance In This Insurer There is a maximum amount an insurer is allowed to cover an individual in order to limit the company's risk. Insurance With Other Insurer This provision protects the insurance company against over-insurance in case a person has the same coverage from two different insurance policies and only one is notified when "expenses are incurred. Insurance With Other Insurers As you can see, this is similar to the above provision.
Relation of Earnings to Insurance This has to do with the amount of monies from premium payments the insurer received versus the loss the insurer suffered through claims payments.
Unpaid Premiums When a benefit is payable to the insured or beneficiary, if there are any unpaid premiums they will be deducted at this time. Cancelation When the insurance company exercises its right to cancel a policy, the insured must be notified 45 days in advance and must be reimbursed for any prepaid premiums.
Conformity with State Statutes All conflicts regarding state statutes of the state the insured lives in are automatically adjusted at the time the policy is issued. Illegal Occupation If the insured is connected with a felony or has an illegal occupation and incurs injury, the insurance company is not held responsible.
The Uniform Individual Accident and Sickness Policy Provision Law also called uniform or standard policy provisions include 12 mandatory provisions. The 12 mandatory provisions are:. Change of Beneficiary. Notice of Claim. Claim Forms. Entire contract and changes. Premium grace period. Legal Actions. Payment of Claims. Proof of Loss. Policy Reinstatement. Time limit for Paying Claims. Time limit on Certain Defenses.
Changing of beneficiaries is a provision included in any type of policy. The provision allows the policyowner to change beneficiaries in writing as long as an irrevocable beneficiary designation has not been made. An irrevocable designation would be one where the beneficiary cannot be changed by the insured. A policy that allows the insured to change the beneficiary is called revocable.
The irrevocable beneficiary has a vested right in the contract. The revocable beneficiary has no right to the proceeds until the death of the insured. Insurance policies provide that if the irrevocable beneficiary dies before the insured, the insured may proceed to name a new beneficiary.
Notice of claims sets the time parameters during which the claim must be filed. For instance, the policy may state that a claim must be filed within 20 days of the occurrence or commencement of any loss covered by the policy.
If the state where the policyholder resides requires more than the insurance company normally allots, the insurance company must comply with that state's requirements. Claim forms must be sent by the insurer to the insured within 15 days after receiving a notice of claim.
If the insurance company does not comply with this 15 day requirement, the insurance company must allow the insured to submit the claim in any manner as long as all the information required is attached. The Entire Contract and Changes provision dictates that the insurance contract between the insured and the insurer insurance company , is contained in the insurance policy, the application, endorsements, and any or all riders attached to the policy.
Only these documents outline the enforceable parts of the contract. No changes can be made to the contract unless it is agreed upon in writing by both the insured and the insurer. The written agreement is then attached to the existing policy. No contract changes may be made unless agreed upon in writing by both the insurance company and the policyowner. All insurance policies must specify a grace period. A grace period is a specified amount of days following the premium due date during which the policyholder may pay unpaid premium without losing their insurance.
Depending on the type of insurance in question, the length of grace period can be anywhere from seven to 31 days. The grace period is also determined by how often the premiums are collected.
For instance, if a policyholder pays annually for their insurance policy, they may have a grace period of 31 days. If the policyholder pays monthly, the grace period might only be ten days. It should be mentioned that some states require the grace period to be 31 days, regardless of what the insurance company normally enforces.
During this grace period, the policy stays in force. Legal actions taken by the insured must be 60 days after written proof of loss has been furnished to the insurer in accordance with the policy guidelines. No more than three years can pass for an insured to take legal action against the insurer. Some states may allow for only two years, while some states may even go all the way up to six years.
Payment claims state any of the covered losses under the insurance policy that the insured would be entitled to. If the policy has accrued benefits unpaid, it will state where the funds will go, normally to the estate.
The insurer has the right to order a physical examination of the prospective insured, at their expense, as often as it may be reasonable to "require during the pendency of a claim here under.
Proof of loss must be submitted to the insured within 30 days as dictated by the policy and contingent on the state's laws. If the insured was not able to submit a claim within a day period, and if it was not reasonable to furnish such proof, the insured then has one year to submit their claim. The only exception to this is an absence of legal capacity. Reinstatement of the policy states the guidelines for which the insurer will reactivate a policy that has "lapsed" or where premiums were not sent in.
The insurer has the right to ask the insured to fill out an application for reinstatement before the policy can be activated again.
If the insured has submitted all required documentation to the insurer and they do not notify the insured within 45 days, the policy is reinstated. The insurer may require ten days to pass before they will cover a loss due to sickness , but the insurer will cover an accident immediately upon reinstatement of the policy. The time of payment of claims provision outlines when the insurer will pay the insured for a submitted claim. This is subject to the insured sending in the required documentation, or proof of loss.
DI benefits are paid monthly. The time limit on certain defenses is when the insurance company limits the ability to cancel or void an insurance policy because of representations made by the insured on their application. This is sometimes called the contestability provision and in each insurance contract a time limit is given. Normally it is two years. There is no time limit if the insured has engaged in fraud.
Unlike the old standard provisions law of , the uniform law does not require verbatim use by the insurers, nor must the provisions appear in a set order. The provisions must be followed in substance only. In fact, most insurers use provisions more favorable to the policyholder than the law demands. The standard provisions law was drafted by committees. The provisions were then recommended to and adopted by the individual states. The original recommendation included 15 provisions that had to be included verbatim in all health policies.
In addition, five optional provisions were available for use if the items covered by them were in the policy. Amendments by the various states to the standard provisions law diminished the degree of uniformity among them.
The new law contained 12 mandatory and 11 optional provisions. We have already discussed the 12 mandatory provisions. The 11 optional provisions are:. The Uniform Individual Accident and Sickness Policy Provision Law include other health insurance requirements, in addition to the mandatory and optional provisions. Description of the Optional Provisions:. The change in occupation provision allows the insurer to raise or lower premiums or benefits accordingly to change in the insured's occupation that may be more or less hazardous.
In DI policies a change in occupation can mean a more hazardous occupation, and this trickles down to the insured in the form of increased premium. Age is also a factor in DI policies when determining the premium cost. The younger an insured starts coverage, the lower the premium will be.
Since the annual premium on an insurance policy written with a level premium is based on the attained age of the insured at the inception of the policy, applicants sometimes deliberately misstate their age.
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