All of the following are mandatory provisions for health and accident policies, except:

The following provisions are optional at the discretion of the insurer as mandated by the NAIC Uniform Health Insurance Policy Provision Law.

Change of Occupation

The occupation of a person directly reflects his/her risk profile, mostly to the risk of disability. If a person changes his job to a more risky profession, the insurance company has the right to raise the premiums and change the benefit policy or vice versa if the person changes to a less risky profession. The benefit and premium changes take place as soon as a person changes jobs. Even if the insured doesn't notify the insurer of the job change in advance, changes to the benefit will still take place (up or down accordingly) if disability occurs.

Misstatement of Age

This provision is the same as in life insurance, with a slightly different end result. This provision, in health insurance, allows the insurer to go back and make changes to the benefits so that they match the correct age. This means if a person stated originally that they were younger, the premiums they had been paying were lower than they should have been, and benefits would be adjusted (decreased) accordingly. Conversely, if a person stated originally that they were older than they really were at the time of application, then they would have been paying a higher premium and, therefore, benefits would be adjusted (increased) accordingly.

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. A person may occupy more than one policy with an insurer; however, this provision protects the company and does not allow the coverage to exceed a specified amount.

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." This provision states that benefits payable will be prorated and excess premiums will be refunded to the policyowner.

Insurance With Other Insurers

As you can see, this is similar to the above provision. This provision is to allow people to have insurance with more than one company, however, while still avoiding over-insurance. It calls for prorating benefits on any other reason than "expenses incurred," usually in regard to disability income.

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. If disability income benefits from all disability income policies for the same loss exceed the insured's monthly earnings at the time of disability (or the average monthly earnings for two years preceding), the insurer is liable only for that proportionate amount of benefits as the insured's earnings bear to the total benefits under all such coverage.

In Florida, total indemnities payable to the insured may not be reduced below $500 or the sum total benefits under all applicable coverage, whichever is less. Any premiums paid for the excess coverage are refunded.

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.

Intoxicants and Narcotics

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.

The following standard provisions are mandatory in every insurance contract as mandated by the NAIC Uniform Health Insurance Policy Provision Law.

Entire Contract

The entire contract provision states that the insurance policy represents the contract between the insurer and the policyowner in its entirety, assuring the policyowner that no changes to the contract can be made once the contract has been issued. This clause in health insurance policies is the same as in life insurance policies.

Time Limit on Certain Defenses

The time limit on certain defenses provision is akin to the incontestability clause in life insurance policies, except that a fraudulent statement on a health application can be contested at any time unless the policy is guaranteed renewable, in which case it cannot be contested for any reason after the contestable period expires - usually two years. The insurer is also prohibited from denying a claim on the basis of a preexisting condition after the contestable period expires.

Grace Period

The grace period allows the policyowner a little leeway in paying premiums on time. Florida law requires minimum grace periods of 7 days on weekly premium health insurance policies, 10 days for health policies with premiums payable monthly and 31 days for other health policies.

The Affordable Care Act (ACA) provides that individuals who purchase coverage on the health insurance exchange/marketplace and who qualify for premium tax credits may have a 90-day grace period to pay outstanding premiums.

Helpful Hint

Reinstatement

The reinstatement provision allows the restoration of a policy that lapsed due to late premium payments back to its original active status rather than being considered canceled and reissued. After the grace period has expired, the insurer may request an updated application in order to reissue the policy. The insurer has the discretion to approve the application and issue a policy or to reject it. However, if the insurer takes no action either way within 45 days, the policy is considered reinstated automatically. If the delinquent premium payment is accepted by the insurer, and no new application for reinstatement is requested, benefits become effective immediately.

Notice of Claim

The notice of claim provision pertains to the timely notice given to the insurer when a claim is being made (within 20 days). If the claim is for disability income payments for two or more years, the insured must submit proof of loss every six months.

Claim Forms

The claim forms provision outlines the insurer's responsibility to provide the claimant with the specific forms the insurer requires within 15 days after receiving the insured's notice of claim.

Proof of Loss

The proof of loss provision means that the insured must supply the insurer with some evidence that the loss actually occurred and to what extent. The claimant has 90 days to supply the proof, if reasonably possible.

Time Payment of Claims

The time payment of claims provision allows insurers 45 days after receiving notice and proof of loss in which to pay or deny the claim (in Florida).

Payment of Claims

The payment of claims provision specifies how and to whom claims payments are to be made.

Physical Exam and Autopsy

The physical exam and autopsy provision gives the insurer the right to have the insured physically examined periodically; and if the insured dies, the insurer has the right to order an autopsy of the deceased.

Legal Actions

The legal actions provision prohibits insureds from taking legal action against the insurer due to a claim for 60 days from the date of proof of loss if the claim is disputed. Legal action in Florida cannot be taken before 60 days (from the date of proof of loss), nor after five years.

Change of Beneficiary

The change of beneficiary provision allows the policyowner to change the policy beneficiary if so desired as long as the beneficiary designation is revocable. This provision also gives the policyowner the right to surrender or assign the policy without obtaining the beneficiary's permission.

What provision is mandatory for health insurance policies?

Which of the following provisions is optional in an individual health insurance policy?

Which of these are considered mandatory provisions?

Which of the following is a required mandatory uniform policy provision that appears in an accident and health contract?