question

A medical care provider which typically delivers health services at its own local medical facility is known as a

answer

Health Maintenance Organization

question

Which type of provider is known for stressing preventative medical care?

answer

Health Maintenance Organizations (HMO's)

question

Which of the following BEST describes how a Preferred Provider Organization is less restrictive than a Health Maintenance Organization?

answer

More physicians to choose from

question

The individual who provides general medical care for a patient as well as the referral for specialized care is known as a

answer

Primary Care Physician

question

A 66 year-old is covered under a group health plan while employed with a business that has 40 employees. If she injures herself while walking in the park, what coverage would be considered primary?

answer

Her group health plan

question

Medicare Part A and Part B do NOT pay for

answer

dental work

question

The health insurance program which is administered by each state and funded by both the federal and state governments is called

answer

Medicaid

question

M is insured under a basic Hospital/Surgical Expense policy. A physician performs surgery on M. What determines the claim M is eligible for?

answer

Determined by the terms of the policy

question

J is a subscriber to a plan which contracts with doctors and hospitals to provide medical benefits at a preset price. What type of plan does J belong to?

answer

Health Maintenance Organization

question

C was injured while deep sea diving and requires a hospital stay. C has a Major Medical policy with a 80/20 coinsurance clause and a $400 deductible. What is the MAXIMUM C will pay if the covered medical expenses are $2000?

answer

$720

question

Which of these is considered a true statement regarding Medicaid?

answer

Funded by both state and federal governments

question

If a retiree on Medicare required five hospital stays in one year, which policy would provide the best insurance for excess hospital expenses?

answer

Medicare Supplement

question

Which of the following types of health coverage frequently uses a deductible?

answer

Major Medical policy

question

S wants to open a tax-exempt Health Savings Account. To qualify for this type of account, Federal law dictates that S must be enrolled in a

answer

High-deductible health plan

question

Which of the following will a Long Term Care plan typically provide benefits for?

answer

home health care

question

The individual most likely to buy a Medicare Supplement policy would be a(n)

answer

68-year old male covered by Medicare

question

Pre-hospitalization authorization is considered an example of

answer

managed care

question

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 is an acceptable risk by completing standard underwriting procedures

question

Which of the following actions will an insurance company most likely NOT take if an applicant, who has diabetes, applies for a Disability Income policy?

answer

Issue the policy with an altered Time of Payment of Claims provision

question

Which of the following statements about the classification of applicants is INCORRECT?

answer

Substandard applicants are never declined by underwriters

question

Which of these options can an individual use their medical flexible spending account to pay for?

answer

Prescription drugs

question

Which of the following situations does a Critical Illness plan cover?

answer

Leukemia

question

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

question

Which of the following statements BEST describes dental care indemnity coverage?

answer

Services are reimbursed after insurer receives the invoice

question

Which of the following BEST describes how pre-admission certifications are used?

answer

Used to prevent nonessential medical costs

question

Major Medical policies typically

answer

contain a deductible and coinsurance

question

Comprehensive Major Medical policies usually combine

answer

Major Medical with Basic Hospital/Surgical coverage

question

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

question

Which of the following statements is true about most Blue Cross/Blue Shield organizations?

answer

They are nonprofit organizations

question

Which of these statements is INCORRECT regarding a Preferred Provider Organization (PPO)?

answer

PPO's are NOT a type of managed care systems

question

The first portion of a covered Major Medical insurance expense that the insured is required to pay is called the

answer

initial deductible

question

Which of the following statements BEST describes the intent of a Coinsurance clause in a Major Medical policy?

answer

Discourages overutilization of the insurance coverage

question

An individual has a Major Medical policy with a $5,000 deductible and an 80/20 Coinsurance clause. How much will the INSURED have to pay if a total of $15,000 in covered medical expenses are incurred?

answer

$7,000

question

An insured covered by a group Major Medical plan is hospitalized after sustaining injuries that resulted from an automobile accident. Assuming the plan had a $1,000 deductible and an 80/20 Coinsurance clause, how much will the INSURED be responsible to pay with $11,000 in covered medical expenses?

answer

$3,000

question

Which of the following policy features allows an insured to defer current health charges to the following year's deductible instead of the current year's deducitble?

answer

Carryover provision

question

T was treated for an ailment 2 months prior to applying for a health insurance policy. This condition was noted on the application and the policy was issued shortly afterwards.How will the insurer likely consider this condition?

answer

Insurer will likely treat as a pre-existing condition which may not be covered for one year

question

With a Basic Medical Expense policy, what does the hospitalization expense cover?

answer

hospital room and board

question

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

question

In Major Medical Expense policies, what is the intent of a Stop Loss provision?

answer

Limits an insured's out-of-pocket medical expenses

question

Which of the following BEST describes a Hospital Indemnity policy?

answer

Coverage that pays a stated amount per day of a covered hospitalization

question

Basic Medical Expense insurance

answer

has lower benefit limits than Major Medical insurance

question

For which of the following expenses does a Basic Hospital policy pay?

answer

Hospital room and board

question

M has a Major Medical insurance policy with a $200 flat deductible and an 80% Coinsurance clause. If M incurs a $2,200 claim for an eligible medical expense, how much will M receive in payment for this claim?

answer

$1,600

question

A Hospital/Surgical Expense policy was purchased for a family of four in March of 2013. The policy was issued with a $500 deductible and a limit of four deductibles per calendar year. Two claims were paid in September 2013, each incurring medical expenses in excess of the deductible. Two additional claims were filed in 2014, each in excess of the deductible amount as well. What would be this family's out-of-pocket medical expenses for 2013?

answer

$1,000

question

Which of the following statements about Health Reimbursement Arrangements (HRA) is CORRECT?

answer

If the employee paid for qualified medical expenses, the reimbursements may be tax-free

question

Deductibles are used in health policies to lower

answer

overuse of medical services

question

Basic Hospital and Surgical policy benefits are

answer

lower than the actual expenses incurred

question

A characteristic of Preferred Provider Organizations (PPOs) would be:

answer

Discounted fees for the patient

question

All of the following statements about Major Medical benefits are true EXCEPT

answer

Benefits have no maximum limit

question

Which of these circumstances is a Business Disability Buy-Sell policy designed to help in the sale of a business?

answer

Business owner becoming disabled

question

Many small business owners worry how their business would survive financially if the owner becomes disabled. The policy which BEST addresses this concern is

answer

Business Overhead Expense

question

How does group insurance differ from individual insurance?

answer

Premiums are lower

question

T is covered by two health insurance plans: a group plan through his employer and his spouse's plan as a dependent. When T submits a claim, his employer's plan is considered what type of carrier under the Model Group Coordination of Benefits provision?

answer

Primary carrier

question

J has an Accidental Death and Dismemberment policy with a principal sum of $50,000. While trimming the hedges, J cuts off one of his fingers. What is the MAXIMUM J will receive from his policy?

answer

$25,000

question

When an employee is required to pay a portion of the premium for an employer/employee group health plan, the employee is covered under which of the following plans?

answer

Contributory

question

Which of the following statements is correct regarding an employer/employee group health plan?

answer

the employer receives a master policy and the employees receive certificates

question

The federal income tax treatment of employer-provided group health insurance can be accurately described as

answer

Employee's coverage paid for by the employer is tax-deductible to the employer as a business expenditure

question

Which of the following statements BEST describes how a policy that uses the "accidental bodily injury" definition of an accident differs from one that uses the "accidental means" definition?

answer

Less restrictive

question

The reason for a business having a Business Overhead Expense Disability Plan is to cover

answer

fixed business expenses

question

Which of the following characteristics are associated with a large group disability income policy?

answer

No medical underwriting

question

Which contract permits the remaining partners to buy-out the interest of a disabled business partner?

answer

Disability Buy-Sell

question

Which of the following statements does NOT accurately describe the tax treatment of premiums and benefits of individual Accident and Health insurance?

answer

Disability income policy premiums are tax-deductible

question

XYZ Company pays the entire premium for its group health plan. The MINIMUM percentage of eligible employees that must be covered is

answer

100%

question

The provision in a Group Health policy that allows the insurer to postpone coverage for a covered illness 30 days after the policy's effective date is referred to as the

answer

Waiting Period

question

A Business Overhead Expense policy

answer

covers business expenses such as rent and utilities

question

All students attending a large university could be covered by

answer

a blanket policy

question

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

question

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

question

B is a teacher who was injured in a car accident and cannot work. She is now receiving monthly benefits as a result of this accident. Which type of policy does B have?

answer

Disability Income

question

M becomes disabled and is unable to work for six months. M dies soon after from complications arising from this disability. M has a Disability Income policy that pays $2,000 a month. Which of the following statements BEST describes what is owed to her estate?

answer

earned, but unpaid benefits

question

Disability policies do NOT normally pay for disabilities arising from which of the following?

answer

War

question

The provision in a health insurance policy that interrupts premiums being paid to the insurer while the insured is disabled is called the

answer

Waiver of Premium

question

When an insured has the same disability within a specified time period and the insurance company provides the same benefits without a new waiting period, the second disability is covered under which of the following benefits?

answer

Recurrent Disability

question

T has Disability Income policy that pays a monthly benefit of $5000. If T becomes partially disabled, what can he likely expect?

answer

Less than $5,000 per month benefit regardless of the cause

question

With Disability Income insurance, an insurance company may limit the monthly benefit amount a prospective policy holder may obtain because of the insured's

answer

gross income at the time of purchase

question

Which of the following is the MOST important factor when deciding how much Disability Income coverage an applicant should purchase?

answer

Applicant's monthly income

question

When determining the monthly benefit amount for a Disability Income policy, the factor that limits the amount a prospective insured may purchase is

answer

income

question

What does a Guaranteed Insurability rider provide a Disability Income policyowner?

answer

The ability to periodically increase the amount of coverage without evidence of insurability

question

When a person returns to work after a period of total disability but cannot earn as much as he or she did before the disability, this situation is called which of the following?

answer

Residual disability

question

An individual Disability Income insurance applicant may be required to submit all of the following information EXCEPT

answer

spouse's occupation

question

A Disability Income policyowner suffers a disability which was due to the same cause as a previous disability. Both disabilities occurred within a five-month period. The insurer may cover the second disability without a new elimination period under the

answer

Recurrent Disability provision

question

Which of the following health insurance policy provisions specifies the health care services a policy will cover?

answer

Insuring clause

question

S filed a written Proof of Loss for a Disability Income claim on September 1. The insurance company not responded to the claim. S can take legal action against the insurer beginning

answer

November 1

question

Which of the following provisions specifies how long a policyowner's health coverage will remain in effect if the policyowner does not pay the premium when it is due?

answer

Grace Period

question

Health insurance benefits NOT covered due to an act of war are

answer

excluded by the insurer in the contract provisions

question

The Notice of Claims provision requires a policyowner to

answer

notify an insurer of a claim within a specified time

question

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

question

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

question

Which health policy clause stipulates that an insurance company must attach a copy of the application to the policy to ensure that it is part of the contract?

answer

Entire Contract

question

The provision that defines to whom the insurer will pay benefits to is called

answer

Payment of Claims

question

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

question

With Accidental Death and Dismemberment policies, what is the purpose of the Grace Period?

answer

Gives the policyowner additional time to pay past due premiums

question

Which of the following statements describes the purpose of the Insuring clause in Health and Accident policies?

answer

States the scope and limits of the coverage

question

What must the policyowner provide to the insurer for validation that a loss has occurred?

answer

Proof of Loss

question

Which of these is considered a mandatory provision?

answer

Payment of Claims

question

What is considered to be a characteristic of a Conditionally Renewable Health Insurance policy?

answer

Premiums may increase at time of renewal

question

J, an Accidental Death and Dismemberment (AD&D) policy holder, dies after injuries sustained in an accident. J's age as stated on the application five years ago was found to be understated by ten years. Which of the following actions will the insurance company take?

answer

The insurer will adjust the benefit to what the premiums paid would have purchased at the insured's actual age

question

M's insurance company denied a reinstatement application for her lapsed health insurance policy. The company did not notify M of this denial. How many days from the reinstatement application date does the insurance company have to notify M of the denial before the policy will be automatically placed back in force?

answer

45 days

question

With Optionally Renewable Health policies, the insurer may

answer

review the policy annually and determine whether or not to renew it

question

What type of renewability guarantees premium rates and renewability?

answer

Guaranteed renewable

question

Which of the following BEST describes a short-term medical expense policy?

answer

Nonrenewable

question

The clause in an Accident and Health policy which defines the benefit amounts the insurer will pay is called the

answer

Insuring clause

question

Which of the following statements BEST describes what the Legal Actions provision of an Accident and Health policy requires?

answer

An insured must wait at least 60 days after Proof of Loss has been submitted before a lawsuit can be filed

question

What is the purpose of the Time of Payment of Claims provision?

answer

Prevents delayed claim payments made by the insurer

question

A Disability Income policyowner recently submitted a claim for a chronic neck problem that has now resulted in total disability. The original neck injury occurred before the application was taken 5 years prior. The neck injury was never disclosed to the insurer at the time of application. How will the insurer handle this claim?

answer

Claim will be paid and coverage will remain in force

question

T files a claim on his Accident and Health policy after being treated for an illness. The insurance company believes that T misrepresented his actual health on the initial insurance application and is, therefore, disputing the claim's validity. The provision that limits the period during which the company may dispute a claim's validity is called

answer

Time Limit on Certain Defenses

question

Which of these statements accurately describes the Waiver of Premium provision in an Accident and Health policy?

answer

Premiums are waived after the insured has been totally disabled for a specified time period

question

G is involved in an automobile accident as a result of driving while intoxicated and suffers numerous injuries. According to the Intoxicants and Narcotics exclusion in G's policy, who is responsible for paying the medical bills?

answer

The insured

question

P is a Major Medical policyowner who is hospitalized as a result of injuries sustained from participating in a carjacking. How will the insurer most likely handle this claim?

answer

Claim will be denied

question

An insurance agent who convinces a prospective insured to purchase a policy by exaggerating the benefits of the policy may be found guilty of

answer

misrepresentation

question

Under the Unfair Trade Practice law, agents may be found guilty of defamation if they make a false statement that is intended to

answer

malign another insurance company

question

Which of the following violations is considered an unfair trade practice?

answer

Coercion

question

An insurance company that publishes misleading information about insurance coverage may be found guilty of

answer

false advertising

question

Anyone who makes a fraudulent statement on an insurance application in order to obtain money benefits from an insurance company has committed an act of

answer

misrepresentation

question

Which of the following actions by an insurance company or an agent is considered rebating?

answer

Offering a prospect something of value that is not specified in a contract to induce the purchase of that contract

question

If an agent tells an applicant that an insurance policy is like a share of stock, the agent may be guilty of

answer

misrepresentation

question

Which of the following is an unfair claims practice?

answer

Failing to effectuate prompt, fair, and equitable settlements of claims

question

A stock insurance company is BEST defined as an incorporated company that has its capital divided into shares and

answer

is owned exclusively by its shareholders

question

Policyholders elect the governing bodies of which of the following types of insurance companies?

answer

Mutual

question

Which of the following would be considered misrepresentation by an insurance agent?

answer

Stating that dividends are guaranteed

question

Which of the following is an example of defamation?

answer

A brochure including an untrue statement regarding a competitor's ability to pay claims

question

An insurance company licensed in Georgia and domiciled in Pennsylvania is known as

answer

a foreign company

question

Inducing or attempting to induce any insured person through misrepresentation to lapse, forfeit, or surrender insurance is

answer

twisting

question

All of the following actions are considered rebating EXCEPT

answer

sharing commissions with other licensed and appointed agents

question

Which of the following actions by an insurance company is considered an unfair claims settlement practice?

answer

Denying an insured's claim without indicating the basis of denial under the policy

question

A stock insurance company is owned by it's

answer

stockholders

question

Which of the following is an example of rebating?

answer

returning a portion of a premium as inducement to purchase insurance

question

An agent who tells claimants that their rights may be impaired if they fail to complete a release form within a given period of time could be guilty of

answer

coercion

question

A creditor who requires a debtor to obtain insurance from a particular company or agent as a condition for a loan is guilty of

answer

coercion

question

An agent who intentionally makes an untrue or incomplete statement in the course of an insurance transaction may be guilty of

answer

misrepresentation

question

An insurance company that is organized or chartered in a country other than the United States is defined as

answer

alien

question

Knowingly making misleading statements that would cause an insured to lapse, assign, or terminate an insurance policy in order to switch companies is an example of

answer

twisting

question

Which of the following would be considered an unfair claim practice?

answer

Misrepresenting insurance policy provisions affecting a loss

question

Before a licensed agent is eligible to transact insurance sales, they must be

answer

appointed by an insurance company

question

The purpose of the Georgia Life and Health Insurance Guaranty Association is to

answer

ensure that claims filed against insolvent insurance companies will be paid

question

An applicant for an insurance agent's license in Georgia MUST meet which of the following requirements?

answer

Be 18 years of age or older

question

"Controlled business" is MOST ACCURATELY described as

answer

insurance placed by an agent on the agent's own life, property, or risks

question

An agent of less than 20 years must complete 24 hours of Continuing Education every

answer

2 years

question

Long-term care policies issued in Georgia must provide benefits for at least

answer

12 months

question

Coverage of newborn children is provided by individual and group accident and health contracts from

answer

the moment of birth

question

Georgia's Replacement Rule applies to all of the following situations EXCEPT

answer

the existing policy is kept in force and an additional policy is purchased from the same company

question

What does Medicare Parts A and B cover?

answer

Part A covers doctor's services; Part B covers hospitalization

question

Which of the following is the reimbursement of benefits for the treatment of a beneficiary's injuries caused by a third party?

answer

Subrogation

question

S is employed by a large corporation that provides group health coverage for its employees and their dependents. If S dies, the company must allow his surviving spouse and dependents to continue their group health coverage for a maximum of how many months under COBRA regulations?

answer

36

question

The Health Insurance Portability and Accountability Act (HIPAA) gives privacy protection for

answer

financial information

question

How long is the typical free look period for Long Term care insurance policies?

answer

30 days

question

Which of the following medical expenses does Cancer insurance NOT cover?

answer

Radiation treatment

question

Which mode of payment is NOT used by health insurance policies?

answer

Single premium

question

Which type of renewability best describes a Disability Income policy that covers an individual until the age of 65, but the insurer has the right to change the premium rate?

answer

Optionally Renewable

question

D is an architect receiving Disability Income benefits who is not able to return to work full time, but can work on a part-time basis. Which of these features would allow D to continue receiving benefits?

answer

Residual Benefit clause

kyla test 1 – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards