Mandatory provisions III: physical exam, legal actions, and beneficiary/occupation changes

Mandatory provisions III: exams, lawsuits, and changes

Every individual accident and health policy delivered in Texas must contain a standard set of uniform provisions, and it may contain a list of optional ones as long as they are no less favorable to the insured than the statutory wording (Tex. Ins. Code ch. 1201). This lesson covers the last group of required provisions plus the one optional provision that is almost always tested alongside them.

Physical Examination and Autopsy

This provision protects the insurer's ability to verify a claim. While a claim is pending, the company has the right to have the insured person examined as often as it may reasonably require, and to make an autopsy in case of death where it is not forbidden by law (Tex. Ins. Code ch. 1201).

Three details carry the exam questions:

• The examinations are at the insurer's expense, not the claimant's.
• The right exists only while a claim is pending — it is not an open-ended license to examine an insured.
• The autopsy right yields to any law that prohibits autopsy, including a religious objection recognized by law.

Legal Actions

This provision sets the window in which a claimant may sue the insurer, and it runs on two clocks.

No action may be brought until 60 days after written proof of loss has been furnished, and no action may be brought after the outer limit stated in the policy — commonly three years from the date written proof of loss was required to be furnished.

The 60-day floor gives the insurer a fair chance to investigate and pay before it is dragged into court. The outer limit is a policy-based time bar; a claimant who waits past it loses the right to sue even on an otherwise valid claim. A policy may not shorten these protections to the insured's disadvantage (Tex. Ins. Code Title 8).

Change of Beneficiary

Unless the insured has made an irrevocable designation, the right to change the beneficiary is reserved to the insured, and the consent of the beneficiary is not required to:

• change the beneficiary,
• surrender or assign the policy,
• or agree to any other change in the policy.

If the designation is irrevocable, the named beneficiary has a vested interest and must consent to those actions. In health coverage, the beneficiary matters chiefly for death or dismemberment benefits, such as an accidental death and dismemberment rider; ordinary medical benefits are payable to the insured or, under an assignment, to the provider.

Change of Occupation (optional)

This is an optional uniform provision — the insurer may include it, but it is not required (Tex. Ins. Code ch. 1201). It works in two directions:

• More hazardous occupation. If the insured is injured or becomes sick after changing to a more hazardous occupation, benefits are reduced to the amount the premium already paid would have purchased at the more hazardous rate. Coverage is not voided; the payout shrinks.
• Less hazardous occupation. The insurer reduces the premium rate and refunds the pro-rata unearned premium, effective as of the date of the change or the policy anniversary immediately preceding proof of the change, whichever is later.

Memory hook: the exam belongs to the insurer, the lawsuit clock belongs to the claimant, and the beneficiary belongs to the insured — unless it was made irrevocable.