FL statutes rules and regulations pertinent to Health insurance Exam Questions With Correct Answers

Health Insurance Marketing Practices - Answer Each state has its own laws, rules, and regulations that apply to insurance business transacted in the state or affecting risks located in the state. While many principles and concepts of insurance are common to all states, it is through these insurance laws that states regulate insurance within their state lines for the protection and welfare of their own citizens, businesses, and interests. The following lessons will examine those laws and regulations that apply specifically to health insurance transactions in Florida. Insurer and Agent Responsibilities Insurance Application - Answer A health insurance policy must specify that the policy, any endorsements, and any attached documents constitutes the entire insurance contract. Changes to an application for a health insurance policy are invalid unless they are approved by the applicant. An insurer or agent cannot change the application. A policy must contain a provision that all statements made by the insured are considered representations and not warranties. Such statements may not void the contract, unless they are fraudulent or material to accepting the risk. The insurer's name must be displayed on the first page of the application form along with the agent's name and license identification number. Outline of Coverage - Answer An individual or family accident and health insurance policy cannot be issued or delivered in Florida unless an outline of coverage is delivered with it. An insurer or agent may instead deliver an outline of coverage at the time of application and must obtain a signed receipt from the applicant. The outline of coverage contains the following information about the policy for the new policyholder: the type of coverage provided a description of the benefits a description of the exceptions and limitations the conditions for renewal, including any reservation by the insurer of its right to change the premium a statement that the outline summarizes the policy and that the policyholder should refer to the policy for the governing provisions a statement that home health care coverage is provided, if applicable to the policy Health Insurance Rates - Answer Before an insurer can issue a health insurance policy in Florida, it must file its rating manual and rating schedule (or premium rates) with the Office for approval. However, prior approval is not required for group health insurance policies insuring 51 or more individuals (except for Medicare supplement insurance), long-term care insurance, and policies where the increase in claim costs over the lifetime of the contract due to age or duration is prefunded in the premium. An insurer must also submit a filing each year to show the reasonableness of benefits in relation to premium rates. The Office will consider past and prospective loss experience, expenses, risk and contingency margins, and acquisition costs in determining whether benefits are reasonable in relation to the premium charged. The Office may disapprove a policy form or withdraw its previous approval if the form provides benefits that are not reasonable in relation to the premium charged; contains provisions that are unfair, inequitable, or against public policy; applies rating practices that result in unfair discrimination; or excludes coverage for human immunodeficiency virus (HIV) infection or acquired immune deficiency syndrome (AIDS). Applicant Considerations Applicants with Sickle Cell Trait - Answer An insurer may not refuse to issue a policy or charge a higher premium solely because a person has sickle-cell trait. Sex or Marital Status of Applicants - Answer An insurer may not refuse to issue a policy or charge a higher premium based on a person's sex or marital status. For example, it is unlawful for an insurer to deny coverage to females employed at home or part-time or who work for relatives when coverage is offered to men who are similarly employed; deny policy riders to females when the riders are available to males; deny maternity benefits to insureds purchasing an individual contract when comparable family coverage contracts offer maternity benefits; deny dependent coverage to husbands of female employees under group contracts, when dependent coverage is available to wives of male employees; deny disability income contracts to employed women when coverage is offered to men similarly employed; treat complications of pregnancy differently from other illness or sickness; restrict, reduce, or exclude benefits relating to coverage involving the genital organs of only one sex; offer lower maximum monthly benefits to women than to men; offer more restrictive benefit periods and definitions of disability to women than to men; establish different conditions by sex under which the policyholder may exercise benefit options contained in the contract; or limit the amount of coverage an insured may purchase based upon marital status unless such a limitation is used to determine individuals eligible for dependents' benefits. Fibrocystic Condition - Answer An insurer may not refuse coverage or cancel a policy because an insured has a fibrocystic condition, unless the condition is diagnosed through a breast biopsy that demonstrates an increased likelihood of developing breast cancer. Bone Marrow Transplants - Answer An insurer cannot exclude coverage for bone marrow transplants recommended by a physician, if the procedure is not considered experimental. Right to Examine (Free Look) - Answer The policyholder is entitled to review the policy for at least ten days after it is delivered. If unsatisfied with it for any reason, the policyholder can return it to the insurer for a full refund of the premium paid. Medicare Supplement Policies - Answer Medicare supplement policyholders have the right to return the policy within 30 days of delivery and receive a full refund of premium if, after examining the policy, they are not satisfied for any reason. The insurer must refund the premium paid in a timely manner. Use of Genetic Information Prohibited - Answer A health insurer may not cancel, limit, deny coverage, or charge different premium rates based on a person's genetic information, in the absence of a diagnosis of a medical condition. An insurer may not require genetic information, use genetic test results, or consider a person's actions relating to genetic testing for any insurance purpose. Protection Against Unintentional Lapse - Answer To protect a long-term care insurance policy from unintentionally lapsing, long-term care applicants may designate a person to receive notice of lapse or termination of the policy due to nonpayment of premium. The applicant may sign a written waiver electing not to designate another person to receive such notice. The waiver states as follows: "Protection against unintended lapse.—I understand that I have the right to designate at least one person other than myself to receive notice of lapse or termination of this long-term care or limited benefit insurance policy for nonpayment of premium. I understand that notice will not be given until 30 days after a premium is due and unpaid. I elect NOT to designate any person to receive such notice." Insurers must regularly notify insureds of the right to change their written designation, at least every year. An insurer may terminate an individual long-term care policy for nonpayment of premium only after giving the insured and his or her designee at least 30 days' notice. If a policy is cancelled due to a failure to pay the premium, the insured can have the policy reinstated if, within five months after the cancellation, the insured (or the other designated person) shows that the failure to pay the premium was unintentional and due to the insured's cognitive impairment, loss of functional capacity, or continuous confinement in a hospital, nursing or assisted living facility for more than 60 days. Florida Health Insurance Plan - Answer The Florida Health Insurance Plan makes health insurance available to Florida residents who are denied coverage in the regular insurance market because of prior medical conditions. The plan offers: a standard health insurance plan a basic health insurance plan catastrophic coverage (which includes a minimum level of primary care coverage) a high deductible plan that meets the federal requirements of a health savings account A Florida resident is eligible for a plan policy if he or she has been rejected or refused insurance coverage for health reasons from at least two health insurers or HMOs; or the person is enrolled in the Florida Comprehensive Health Association (a program designed to help residents who are uninsurable that has stopped accepting new enrollments). Dependents of Florida residents who are eligible for coverage are also entitled to benefits under the plan. A person is not eligible for coverage under the plan if he or she obtains similar health insurance or is eligible to obtain such coverage; is eligible for Medicaid, Medicare, the state's children's health insurance program, or another federal, state, or local government program that provides health benefits; voluntarily terminates plan coverage (unless 12 months have elapsed since the termination); is an inmate or resident of a public institution; or has premiums paid for or reimbursed by a government-sponsored program, agency, or health-care provider. Health Insurance Policy Regulations Required Policy Provisions - Answer Individual accident and health insurance policies issued in Florida must contain certain provisions, as required by law. Entire Contract - Answer A health insurance policy must specify that the policy, any endorsements, and any attached documents, constitutes the entire insurance contract. Changes to the contract are invalid unless they are approved and endorsed by an officer of the insurance company. A producer cannot change the terms of the policy. Time Limit on Certain Defenses - Answer After a health insurance policy has been in effect for two years, the insurer can void the policy or deny a claim only on the basis of a fraudulent misstatement the insured made in the application. An insurer cannot deny or limit a claim for loss or disability beginning after two years from the policy's issue date on the basis of a pre-existing condition that was not specifically excluded when the policy was issued. Grace Period - Answer A policyholder is entitled to the following grace periods following the premium due date, during which the policy remains in force at least seven days for policies with premiums that are due weekly; at least ten days for policies with premiums that are due monthly; and at least 31 days for all other policies. Policy Lapse - Answer Policies that cover persons age 64 or older and that have been in force for at least one year have an additional 21-day grace period before a policy will lapse due to nonpayment of premium. This means that a policyowner has a minimum grace period of 52 days for ordinary life insurance policies. However, this provision does not apply in cases where the premium is payable monthly or more often, or if the premium is automatically deducted from the policyowner's checking account, billed to a credit card, or regularly collected by an agent. Insurers must send a lapse notice to these policyowners at the end of the regular grace period and allow an additional 21 days for payment of the past-due premium. In cases where the policy already includes an extended grace period (52 or more days), the lapse notice must be sent 21 days before the expiration of policy's grace period. Insurers must notify policyowners age 64 or older that they have the right to name a secondary addressee—that is, a person who will also be notified in the event of an impending lapse. Policy Reinstatement - Answer If a policyholder fails to pay the renewal premium within the grace period and the policy lapses, the policy will nevertheless be reinstated if the insurer accepts payment at a later date. However, if the insured must also apply for reinstatement, the insurer will issue a conditional receipt to the insured until the application for reinstatement is approved. If the insurer fails to approve the application within 45 days, the policy will be automatically reinstated unless the insurer has given written notice to the insured that it will not reinstate the policy. The reinstated policy will cover losses resulting from accidental injury after the date of reinstatement and losses resulting from sickness that began more than ten days after reinstatement. In all other respects, the reinstated policy restores the same rights that the insurer and insured had before the policy lapsed. Claim Procedures Notice of Claim - Answer Upon receiving the claimant's notice of claim, the insurer has 15 days in which to send the claimant the forms for filing proof of loss. If the insurer fails to do so, the claimant can instead provide proof of loss by giving a written statement describing the loss Time Limit for Notice of Claim - Answer A claimant must give written notice of a claim to the insurer within 20 days after a loss or as soon thereafter as reasonably possible. Proof of Loss - Answer If the policy provides benefits for a continuing loss (such as an ongoing disability), the claimant is required to give written proof of loss to the insurer within 90 days after the end of each period for which the insurer is obligated to pay benefits. For all other losses, the claimant has up to 90 days after the loss to file written proof of loss. If it is not reasonably possible for the claimant to give this written proof within the time allowed, the claimant must provide it as soon as reasonably possible. However, the claimant cannot submit this proof more than one year after it is required, unless the claimant was legally incapacitated. Duties of Agent - Answer A policyowner can report a claim either to the insurer or to the insurer's agent. If an agent is notified, he or she must immediately report the claim to the insurance company. Legal Actions - Answer An insured cannot sue the insurer on a claim before 60 days have passed since filing written proof of loss. However, an insured cannot bring suit after five years has passed since filing proof of loss. Time of Payment of Claims - Answer Once the insurer receives proof of loss, it will pay the benefits due to the insured, the beneficiary, or the insured's estate. If benefits are to be paid over a period of time, they cannot be paid any less often than monthly. Health insurers must reimburse claims within 45 days after receiving the claim. If a claim is contested, the insurer must pay or deny the claim within 60 days after receiving additional information requested regarding the claim. Medical Examination - Answer The insurer has the right to conduct a physical examination of the insured whenever and as often as reasonably necessary to investigate a claim. The insurer may also conduct an autopsy of the insured in Florida during the contestability period unless the law forbids it. Change of Beneficiary - Answer Unless the insured makes an irrevocable beneficiary designation, the insured retains the right to change the beneficiary by giving written notice to the insurer. Consent of any beneficiary is not required for the insured to surrender or assign the policy or to change any beneficiary, or for other changes in the policy. Optional Policy Provisions - Answer Accident and health insurance policies issued in Florida may contain certain optional provisions, which provide additional protection for the insurer as well as the insured. Though they are not required by law, they must follow approved standards in content and form. Change of Occupation - Answer The insurer is allowed to reduce the benefits payable under the policy if the insured changes his or her occupation to one that is more hazardous than the one for which the premiums were set. Conversely, if the insured changes his or her occupation to one that is less hazardous than the one for which the premiums were set, the insurer may reduce the premium. Any excess unearned premium will be returned to the insured. Misstatement of Age or Sex - Answer If the insured misstated his or her age or sex in the application, benefits payable will be what the premiums would have purchased at the correct age or sex. Other Insurance - Answer If a person has other insurance that provides benefits on an expense-incurred (or for-service) basis, the total amount of coverage the person can have from a single insurer will be limited to a specific maximum amount, no matter how many health insurance policies have been issued to the person. The benefits that an insurer will pay for expenses incurred will be prorated if the insurer was not notified of other existing coverage for the same risk. This prevents overinsurance of the person. Any premiums paid for excess coverage will be returned to the insured