Exam (elaborations)
DE Insurance Code - Life Producer Study Guide.
- Module
- RSM100 Midterm 1 Prep
- Institution
- RSM100 Midterm 1 Prep
DE Insurance Code - Life Producer Study Guide.
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DE Insurance Code - Life Producer StudyGuide
Balance Billing - ANS-a health-care provider's demand that a patient pay a greater
amount for a given service than the amount the individual's insurer has paid or will pay
for the service.
Proof of Loss Provision - ANS-The Proof of loss provision means that the insured must
supply the insurer with some evidence that that the loss actually occurred and to what
extent. The claimant has 90 days to supply the proof, if reasonably possible.
Legal Actions Provision - ANS-No legal action shall occur prior to 60 days after proof of
loss has been furnished. No such action shall be brought after the expiration of three
years after the time written proof of loss is required to be furnished.
Waiver of Premium Provision - ANS-Allows for the waiver of premium payments in the
event of the total disability of the insured
Third-party administrator - ANS-A person, firm or entity who underwrites, collects
charges or premiums, approves, denies, adjusts or settles claims for residents of this
State, in connection with health coverage by an insurer.
What are all 13 DE Prohibited Unfair Claim Settlement Practices? - ANS-1.
Misrepresentation of facts or policy provisions
2. Failure to acknowledge and respond to claims within 15 working days
3. Failing to implement prompt investigation of claims within 10 working days upon
notice of loss.
4. Refusing to pay claims without conducting an investigation when one is required.
5. Failing to affirm or deny coverage or advise the client in writing within 30 days of
proof of loss.
6. Not attempting in good faith to effectuate prompt, fair and equitable settlement of
claims in which liability has become clear.
7. Driving insureds to legal litigation by offering them far less than is reasonable for the
settlement of their claim.
8. Attempting to settle a claim for less than the amount referenced by advertising
material attached to an application.
9. Attempting to settle claims on the basis of an application which was altered without
notice or knowledge of insured.
,10. Making claims payments to insured or beneficiaries without a statement setting forth
the coverage under which payment has been made.
11. Delaying the investigation or payment of claims by requiring an insured, claimant of
physician to submit a preliminary claim report and then subsequently a formal proof of
loss form, both of which contain substantially the same information.
12. Failing to promptly settle claims for any reason related to an insurer's strategic
interests as a business.
13. Failure to provide a prompt explanation as for the reason of insurer's inability to
settle a claim or denial of such. Such explanation may be given verbally but when given,
must be documented in the claims file.
Twisting - ANS-To make or issue any statement misrepresenting or making incomplete
comparisons as to the terms, conditions or benefits in any policy for the purpose of
inducing a policyowner to forfeit, lapse, or surrender
How Long is the DE Insurance Commissioner's term? Who are they commissioned by?
What date does the commissioner assume office? - ANS-4 years and shall be
commissioned by the Governor. Commissioner assumes office on the 1st Tuesday of
January after election.
A vacancy in the office of DE Commissioner shall be filled by appointment by - ANS-the
Governor of Delaware
Who is the insurance commissioner of Delaware as of 2017? - ANS-Trinidad Navarro
The DE Insurance Commissioner must conduct an examination of Life Producers at a
minimum - ANS-At a minimum every 5 years
The examiner in charge shall file with the Department a verified written report of
examination under oath. - ANS-No later than 60 days following the completion of the
examination, along with a notice that allows for rebuttals within 30 days to any findings
in the report
The commissioner shall conduct each examination in what manner and take what
preliminary step? - ANS-In an expeditious, fair, and impartial manner. They will also
serve an examination warrant to all parties at least 20 days in advance.
The commissioner shall give a copy of the report to the person examined - ANS-Not
less than 20 days prior to filing the same copy in the Department
, The expense of examination of an insurer or of any person shall be paid by - ANS-The
person examined
Any application/request for a Commissioner to examine a potential violation or
egregious act must be filed within how many days of person knew or reasonably
knowing about such act, threatened act, failure, report, rule, regulation or order. -
ANS-90 days
If a person is hesitant to testify to the Commissioner because the nature of his/her
statements may incriminate them, - ANS-they may be granted immunity from the
Commissioner.
The commissioner is always immune from liability as long as conduct and statements
were made - ANS-In good faith.
No person that communicates data to the Commissioner during the course of an
examination - ANS-Shall incur any penalty as long as statements were not made to
deceive.
Adverse Determination - ANS-A benefit denial, reduction, or termination, a denial of
certification or both.
Internal Review Process - ANS-IRP. Means the procedure for an internal review of an
adverse determination (benefit denial)
Arbitration decisions shall be rendered - ANS-Within 45 days of the Commissioner's
receipt of arbitration request
No person, association or other entity shall act as a workers' compensation
self-insurance group unless - ANS-it has been issued a certificate of authority by the
Commissioner.
Stock Insurers - ANS-An incorporated insurer with its capital divided into shares and
owned by its stockholders.
Mutual Insurers - ANS-an incorporated insurer without capital stock and the governing
body of which is elected by its policyholders
The Commissioner shall issue certificates of authority under - ANS-His or her seal of
office, showing the date of actual issuance, the kinds of insurance the insurer is
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