Standard health policy provisions and group health eligibility

Correct answer: 10 days

The grace period is 7 days for weekly premiums, 10 days for monthly premiums and 31 days for all other modes. A monthly-premium policy therefore has a 10-day grace period.

Correct answer: 31 days

Any premium mode other than weekly or monthly, including annual, gets a 31-day grace period, during which the policy stays in force.

Correct answer: It is covered, because the policy remains in force during the grace period

A monthly-premium policy has a 10-day grace period, and coverage continues during it. A loss on day 6 is covered.

Correct answer: Only an executive officer of the insurer, by endorsement or attached rider

The entire contract provision makes the policy, attached application and riders the whole contract, and allows changes only when approved by an executive officer of the insurer. Agents cannot change or waive provisions.

Correct answer: None; an agent cannot change or waive any policy provision

Under the entire contract provision, only an executive officer of the insurer can approve a change to the policy. An agent's promise to waive an exclusion has no effect on the contract.

Correct answer: Nothing; it can no longer void the policy or deny claims for a non-fraudulent misstatement

The time limit on certain defenses provision bars the insurer, after the stated period, from voiding the policy or denying claims based on misstatements in the application, other than fraudulent misstatements. An innocent misstatement cannot be used.

Correct answer: A fraudulent misstatement

The time limit on certain defenses provision cuts off the insurer's right to contest the policy for non-fraudulent misstatements after the stated period. Fraudulent misstatements are excepted.

Correct answer: 45 days after the date of the conditional receipt

Under the reinstatement provision, if the insurer issues a conditional receipt and does not approve or disapprove the application within 45 days, the policy is reinstated automatically.

Correct answer: Only the broken wrist

After reinstatement, accidental injuries are covered immediately, but sickness is covered only if it begins more than 10 days after reinstatement. The wrist (accident) is covered; the pneumonia (sickness, day 6) is not.

Correct answer: 20 days, or as soon as reasonably possible

The notice of claim provision requires written notice within 20 days of the loss, or as soon as reasonably possible.

Correct answer: Submit written proof of the loss in any form, which satisfies the proof requirement

The insurer must furnish claim forms within 15 days of notice. If it does not, the claimant complies by submitting written proof of the occurrence, character and extent of the loss in any form.

Correct answer: Within 90 days

Written proof of loss is due within 90 days after the loss.

Correct answer: One year from the time proof was otherwise required

Failure to furnish proof within 90 days does not invalidate the claim if it was not reasonably possible, provided proof is furnished as soon as reasonably possible and in no event later than one year from the time proof was otherwise required, except in the absence of legal capacity.

Correct answer: At least monthly

Claims other than periodic benefits are paid immediately upon receipt of proof of loss; periodic benefits such as disability income are paid at least monthly.

Correct answer: The insurer

The insurer may have the claimant examined as often as reasonably required while a claim is pending, and may request an autopsy where not forbidden by law, all at its own expense.

Correct answer: 60 days after April 1

The legal actions provision bars a lawsuit until 60 days after written proof of loss has been furnished, giving the insurer time to process the claim.

Correct answer: The brother's consent, because the designation is irrevocable

The change of beneficiary provision lets the insured change the beneficiary unless the designation is irrevocable. An irrevocable beneficiary must consent to the change.

Correct answer: The named beneficiary

The payment of claims provision directs death benefits to the named beneficiary and all other benefits to the insured.

Correct answer: Change of occupation

Change of occupation is one of the optional provisions an insurer may add; grace period, notice of claim and entire contract are mandatory uniform provisions.

Correct answer: Notice of claim, claim forms furnished, proof of loss

The insured gives notice (20 days), the insurer furnishes claim forms (15 days after notice), and the claimant then files proof of loss (90 days after the loss).

Correct answer: Health insurance covering groups of persons under a master policy issued to one of the groups the statute lists

Florida defines group health insurance as health insurance covering groups of persons under a master group health insurance policy issued to one of the groups listed in ss. 627.653-627.656.

Correct answer: As a group health policy, with the employer treated as the insurer

In Florida's group health part, 'policy' and 'group health insurance policy' include plans of self-insurance, and 'insurer' includes any person or governmental unit providing a plan of self-insurance.

Correct answer: A governmental unit providing a plan of self-insurance

For Florida's group health part, the term 'insurer' includes any person or governmental unit providing a plan of self-insurance.

Correct answer: A certificate of coverage

Group coverage is written as one master policy held by the group; each covered person receives a certificate evidencing coverage.

Correct answer: Teacher and student groups

Florida's group health part has separate sections for employee groups, labor union, association and small employer health alliance groups, debtor groups, teacher and student groups, additional groups and trustee groups.

Correct answer: Labor union and association groups

Florida's group health part has a single section covering labor union, association, and small employer health alliance groups.

Correct answer: A debtor group

A group made up of a creditor's borrowers is a debtor group, which Florida's group health part addresses in its own section.

Correct answer: The policy must comply with Florida's group health part in the same manner as a policy issued in Florida

Any group health policy issued or delivered outside Florida under which a Florida resident is covered must comply with Florida's group health part in the same manner as policies issued in Florida, unless an exemption applies.

Correct answer: In contrasting color and at least 10-point type

Certificates issued to Florida residents must state, in contrasting color and not less than 10-point type, that the benefits are governed primarily by the law of a state other than Florida.

Correct answer: The exemption fails, so the policy must comply with Florida's group health part

The exemption applies only if the policy is issued to a qualifying group, certificates carry the required notice, and the policy provides the listed benefits. Missing any one means Florida's group health part applies.

Correct answer: A group of insurance agents of an insurer, where the insurer is the policyholder

The out-of-state exemption's list of qualifying groups includes a group of insurance agents of an insurer, where the insurer is the policyholder.

Correct answer: Benefits must be reasonable in relation to premiums, and the policy must result in economies of administration

Florida's out-of-state section lets a group established primarily to provide group insurance qualify, provided the benefits are reasonable in relation to the premiums and the policy has resulted, or will result, in economies of administration.

Correct answer: To give continued access to coverage for small employers' employees and dependents not protected by federal COBRA

The act's purpose is to ensure continued access to affordable health insurance coverage for employees of small employers and their dependents and other qualified beneficiaries not protected by COBRA.

Correct answer: No; the act does not apply when federal continuation benefits are available

The act does not apply if continuation coverage is available under the federal provisions (the Internal Revenue Code, ERISA or the Public Health Service Act) that make up COBRA.

Correct answer: No; an employee terminated for gross misconduct is not a qualified beneficiary, and the employer's decision is conclusive as to the carrier

A covered employee is a qualified beneficiary except if terminated for gross misconduct, and the employer's decision to terminate for gross misconduct is conclusive as to the carrier.

Correct answer: 29 months

A qualified beneficiary determined disabled under Title II or XVI of the Social Security Act at the time of the qualifying event may continue for an additional 11 months, 29 months in total.

Correct answer: Up to 150 percent of the group rate

During the 11-month disability extension, the insurance carrier can charge up to 150 percent of the group rate.

Correct answer: She loses the extension, because the determination must reach the carrier before the 18-month period ends

To obtain the 11-month extension, the beneficiary must provide the SSA disability determination to the carrier within 60 days of the determination and before the end of the 18-month continuation period.

Correct answer: It ends on the date he becomes entitled to Medicare

Continuation ends on the date a qualified beneficiary is entitled to benefits under Part A or Part B of Medicare.

Correct answer: She may become covered under the new plan for the rest of her continuation period, treated like an active beneficiary

If the employer terminates the plan for all employees and replaces it with similar coverage, the qualified beneficiary has the right to be covered under the new plan for the balance of the period she would have remained covered under the prior plan, treated the same as an active beneficiary.