Health Insurance Policy Provisions and Characteristics, Exams of Advanced Education

Download Health Insurance Policy Provisions and Characteristics and more Exams Advanced Education in PDF only on Docsity! GA Health Insurance Exam Graded A+ 2024 A "reimbursement policy" pays what amount of covered Long-Term Care expenses? - ANSWER-actual covered expenses up to the daily maximum A characteristic of Preferred Provider Organization (PPO) would be: - ANSWER- discounted fees for the patient A comprehensive major medical health insurance policy contains an Eligible Expenses provisions which identifies the types of health care services that are converted. All of the following health care services are typically converted, EXCEPT for: - ANSWER- experimental and investigative services A domestic insurance company in Georgia is considered a company that: - ANSWER-is incorporated and formed in Georgia A domestic insurance company MUST be examined by the Commissioner every ___ years. - ANSWER-5 A major medical policy typically: - ANSWER-provides benefits for reasonable and necessary medical expenses, subject to policy limits A policy owner would like to change the beneficiary on an Accidental Death and Dismemberment (AD&D) insurance policy and make the change permanent. Which type of designation would fulfill this need? - ANSWER-Irrevocable A prepaid application for individual Disability Income insurance was recently submitted to an insurer. When the insurer received the Medical Information Bureau (MIB) report, the report showed that the applicant had suffered a stroke 18 months ago, something that was not disclosed on the application. Which of the following actions would the insurance company NOT take? - ANSWER-send a notice to the MIB that the applicant was declined A producer must notify the Commissioner within ___ days of an address change. - ANSWER-30 Accidental Death coverage is provided to commercial airline passengers in which of the following types of policies? - ANSWER-Blanket Accident policy According to the Time Payment of Claims provision, the insurer must pay Disability Income benefits no less frequently than which of the following options? - ANSWER- monthly After an insured gives notice of loss, what must he/she do if the insurer does not furnish forms? - ANSWER-file written proof of loss Agent J takes an application and initial premium from an applicant and sends the application and premium check to the insurance company. The insurance company returns the check back to J because the check is made out to J instead of the insurance company. What action should J take? - ANSWER-return to the customer, collect a new check made out to the insurance company, and send the new check out to the insurance company All accident and sickness plans MUST provide coverage on newborn children for ___ days - ANSWER-31 All of the following are limited benefit plans: - ANSWER-cancer policies, dental policies, critical illness policies An agent takes an individual Disability Income application, collects the appropriate premium, and issues the prospective insured a conditional receipt. The next step the insurance company will take is to: - ANSWER-determine if the applicant in an acceptable risk by completing standard underwriting procedures An agent's license can be suspended or revoked by: - ANSWER-writing primarily controlled business An example of an unfair claims practice would be: - ANSWER-failing to effectuate prompt, fair, and equitable settlements of a claim An example of an unfair claims settlement practice is: - ANSWER-turning down a claim without providing the basis of denial An insurance agent is guilty of ___ if the agent misrepresents a policy to induce a policy owner to surrender an existing policy. - ANSWER-twisting An insurance agent is in violation of the Rules Governing Advertisement of Life Insurance and Annuities if the agent takes which of the following actions during a sales presentation? - ANSWER-refers to guaranteed policy dividends An insurance company normally has 2 years to contest information provided on an accident and health application. This 2 year period begins on the date that the: - ANSWER-insurer dates the policy An insurance company which engages in boycott, coercion, and intimidation that results in the unreasonable restraint of trade is committing a prohibited act under Georgia insurance laws covering: - ANSWER-unfair trade policies An insured covered by Accidental Death and Dismemberment (AD&D) insurance has just died. What will happen if the primary beneficiary had already died before the K failed to pay a renewal premium within the time granted by the insurer. K then sends in a payment which the insurer subsequently accepts. Which policy provision specifies that coverage may be restored in this situation? - ANSWER-reinstatment K has an Accidental Death and Dismemberment (AD&D) insurance policy where her husband is beneficiary and her daughter is contingent beneficiary. Under the Common Disaster clause, if K and her husband are both killed in an automobile accident, where would the death proceeds be directed? - ANSWER-daughter Long Term Care policies will usually pay for eligible benefit using which of the following methods? - ANSWER-expense incurred Medicaid was designed to assist individuals who are: - ANSWER-below a specific income limit Medicare Part B does NOT cover: - ANSWER-inpatient hospital services N has a Major Medical policy that only pays a portion of N's medical expenses. N is responsible for paying the remaining balance. This provision is known as: - ANSWER- Coinsurance N is covered under an individual Disability policy with a 30-day Elimination period and a monthly benefit of $500. N is totally disabled for 3 1/2 months. N's total benefit received on this claim is: - ANSWER-$1,250 Non-occupational disability coverage is designed for: - ANSWER-employees who suffer non-work related disabilities, since work-related disabilities are covered by Worker's Compensation Nursing home benefits must be provided for at least 12 consecutive months in which of the following types of policies? - ANSWER-Long-Term Care P and Q are married and have three children. P is the primary beneficiary on Q's Accidental Death and Dismemberment (AD&D) policy and Q's sister R is the contingent beneficiary. P, Q, and R are involved in a car accident and Q and R are killed instantly. The Accidental Death benefits will be paid to: - ANSWER-P only P is self-employed and owns an Individual Disability Income policy. He becomes totally disabled on June 1 and receives $2,000 a month for the next 10 months. How much of this income is subject to federal income tax? - ANSWER-$0 P received Disability income benefits for 3 months then returns to work. She is able to work one month before her condition returns, leaving her disabled once again. What would the insurance company most likely regard this second period of disability as? - ANSWER-a recurrent disability Pre-hospitalization authorization is considered an example of: - ANSWER-managed care Prior to a hearing that could be potentially revoke an agent's license, what is required by the Commissioner - ANSWER-giving written notice to the agent R had received full disability income benefits for 6 months. When he returns to work, he is only able to resume half his normal daily workload. Which provision pays reduced benefits to R while he is not working at full capacity? - ANSWER-Residual Disability S filed a written Proof of Loss for a Disability Income claim on September 1. The insurance company did not respond to the claim. S can take legal action against the insurer beginning: - ANSWER-November 1 Someone who is appointed by an insurer to engage in insurance transactions is called a(n): - ANSWER-agent T is an agent and when hired, is reminded that he has a responsibility to handle clients' funds in an honest and ethical manner. This responsibility is referred to as: - ANSWER- fiduciary responsibility T owns an Accident & Health policy and notifies her insurance company that she has chosen a less hazardous occupation. Under the Change of Occupation provision, which of the following actions may her insurance company take? - ANSWER-increase her policy's coverage amount The ___ must provide an insured with proper disclosure concerning the replacement of an insurance policy. - ANSWER-agent The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers (and their families) whose employment has been terminated the right to: - ANSWER-continue group health benefits The Coordination of Benefits provision: - ANSWER-prevents an insured covered by two health plans from making a profit on a covered loss The percentage of an individual's Primary Insurance Amount (PIA) determines the benefits paid in which of the following programs? - ANSWER-Social Security Disability Income The sections of an insurance contract which limit coverage are called: - ANSWER- exclusions This type of deductible provision states that should more than one family member be involved in a common accident, or summer the same illness, only one individual deductible amount shall be applied. - ANSWER-common accident deductible Under what system do a group of doctors and hospitals in a designated area contract with an insurer to provide services at a prearranged cost to the insured? - ANSWER- PPO Under which of the following circumstances will the benefits under COBRA continuation coverage end? - ANSWER-all group health plans are terminated by the employer Using an existing life insurance policy's cash value to purchase another policy with the same insurer for the sole purpose of earning additional commissions is called: - ANSWER-churning What is an organization that solicits insurance only to its members? - ANSWER- Fraternal benefit society What is the purpose of Life and Health Insurance Guaranty Association - ANSWER- protects policy owners against insolvent insurance companies What must the policyowner provide to the insurer for validation that a loss has occurred? - ANSWER-Proof of Loss What should an insured do if the insurer does not send claims forms within the time period set forth in a health policy's Claims Forms provision? - ANSWER-submit the claim in any form What type of policy would only provide coverage for specific types of illnesses (cancer, stroke, etc)? - ANSWER-Dread disease insurance What type of renewability guarantees premium rates and renewability? - ANSWER- Noncancellable When advertising, an insurer is required to use its: - ANSWER-true corporate name When an insurance company sends a policy to the insured with an attached application, the element that makes the application part of the contract between the insured and the insurer is called the: - ANSWER-Entire Contract provision When an insured changes to a more hazardous occupation, which disability policy provision allows an insurer to adjust policy benefits and rates? - ANSWER-change of occupation provision When is a group accident and health policy required to provide coverage for a newborn child? - ANSWER-at the moment of birth