ACCIDENT HEALTH LAWS
COMPREHENSIVE EXAMS SET VERIFIED
QUESTIONS AND SOLUTIONS
●● Minimum Standards for Individual Policies - Definitions
Answer: - Individual accident and health policies may only include
terms that are in compliance with the state Administrative Code for
health insurance policies
- The Code defines terms such as:
- Accident and accidental injury
- Sickness
- Total, partial, and residual disability
- Excepted benefits
- Hospital
- Medicare
- and other terms
●● Minimum Standards for Individual Policies - Prohibited Provisions
Answer: The Administrative Code defines the following prohibited
provisions:
- Accident policies may not contain a probationary or waiting period
- Probationary period under sickness policies may not exceed 6 months
except for certain specified causes not treated on an emergency basis
,- Policies or riders for additional coverage cannot be issued as a
dividend unless a cash equivalent is also offered as an option
- Policies may not contain provisions excluding coverage for:
- Confinement in a hospital operated by a federal, state, or local
government
- Charges for medical services provided by a federal, state, or local
government
●● Policies Cannot Limit or Exclude Coverage by Type of Illness,
Accident, Treatment or Medical Condition EXCEPT for the Following:
Answer: - Intentional self-inflicted injury or losses resulting from war or
military service
- Cosmetic surgery, except necessary reconstructive surgery following an
accident or disease
- Benefits provided by Medicare or workers compensation, or services
performed by a member of the family
- Expenses related to eye glasses, hearing aids, or dental care
- Rest cures, custodial care, transportation or routine physical exams
- Tests or X-rays not related to diagnosis
- Territorial limitations
●● Coverage Exclusions or Limitations in Respect to Excepted Benefit
Policies and Grandfatherd Health Plans, in Which an Individual Was
Enrolled on the Date of the Enactment of the Affordable Care Act:
,Answer: - Pre-existing illness or conditions
- Addictions, emotional or mental disorders
- Pregnancy, but not complications thereof
- Infertility
- Sex change surgery or surgical sterilization
- Rehabilitative care
- Weight reduction procedures, unless for morbid obesity
- Smoking cessation classes or patches
●● Minimum Standards for Individual Policies - Benefit Standards
Answer: Individual policies in Illinois must meet the following
standards:
- If a loss covered by a policy continues when the policy is terminated,
coverage for loss must be extended for 1 year, unless benefit period or
maximum benefit amount is reached at an earlier time
- Except for nonpayment of premium, coverage on a spouse cannot be
terminated soley because an insurer can terminate coverage on the
insured. If insured dies, a covered spouse automatically becomes the
insured
- Live donors of insureds receiving transplants must be covered
- Pregnancy benefits must be extended even if coverage ends if the
pregnancy began while the policy was in force
- A recurrent disability provision may not specify that recurrent
disabilities can be separated by more than 6 months
, - Accidental death and dismemberment benefits must be payable if the
loss occurs within 90 days of the accident
- Disability income benefits must be payable if the loss occurs within 30
days of the accident
●● Minimum Standards for Individual Policies - Disclosure
Answer: The following must appear on the first page of a policy:
- Notice of the insured's unconditional right to return the policy within
10 days for a full refund (does not apply to single premium
nonrenewable policies)
- In regards to accident-only or specified diseases policies, a prominent
notice that coverage or benefits are limited
- A provision describing a policy's renewability provisions
- If the policy issued is different from the one applied for, it must be
noted on the first page
●● Minimum Standards for Individual Policies - Disclosure (Cont.)
Answer: - Outline of coverage must be delivered with the policy
- Policies providing excepted benefits or a grandfathered health plan that
contains limitations of pre-existing conditions must appear as a separate
paragraph and labeled as "Pre-existing Condition Limitations"
- Riders or endorsements added after the policy issue must be accepted
in writing by the insured
COMPREHENSIVE EXAMS SET VERIFIED
QUESTIONS AND SOLUTIONS
●● Minimum Standards for Individual Policies - Definitions
Answer: - Individual accident and health policies may only include
terms that are in compliance with the state Administrative Code for
health insurance policies
- The Code defines terms such as:
- Accident and accidental injury
- Sickness
- Total, partial, and residual disability
- Excepted benefits
- Hospital
- Medicare
- and other terms
●● Minimum Standards for Individual Policies - Prohibited Provisions
Answer: The Administrative Code defines the following prohibited
provisions:
- Accident policies may not contain a probationary or waiting period
- Probationary period under sickness policies may not exceed 6 months
except for certain specified causes not treated on an emergency basis
,- Policies or riders for additional coverage cannot be issued as a
dividend unless a cash equivalent is also offered as an option
- Policies may not contain provisions excluding coverage for:
- Confinement in a hospital operated by a federal, state, or local
government
- Charges for medical services provided by a federal, state, or local
government
●● Policies Cannot Limit or Exclude Coverage by Type of Illness,
Accident, Treatment or Medical Condition EXCEPT for the Following:
Answer: - Intentional self-inflicted injury or losses resulting from war or
military service
- Cosmetic surgery, except necessary reconstructive surgery following an
accident or disease
- Benefits provided by Medicare or workers compensation, or services
performed by a member of the family
- Expenses related to eye glasses, hearing aids, or dental care
- Rest cures, custodial care, transportation or routine physical exams
- Tests or X-rays not related to diagnosis
- Territorial limitations
●● Coverage Exclusions or Limitations in Respect to Excepted Benefit
Policies and Grandfatherd Health Plans, in Which an Individual Was
Enrolled on the Date of the Enactment of the Affordable Care Act:
,Answer: - Pre-existing illness or conditions
- Addictions, emotional or mental disorders
- Pregnancy, but not complications thereof
- Infertility
- Sex change surgery or surgical sterilization
- Rehabilitative care
- Weight reduction procedures, unless for morbid obesity
- Smoking cessation classes or patches
●● Minimum Standards for Individual Policies - Benefit Standards
Answer: Individual policies in Illinois must meet the following
standards:
- If a loss covered by a policy continues when the policy is terminated,
coverage for loss must be extended for 1 year, unless benefit period or
maximum benefit amount is reached at an earlier time
- Except for nonpayment of premium, coverage on a spouse cannot be
terminated soley because an insurer can terminate coverage on the
insured. If insured dies, a covered spouse automatically becomes the
insured
- Live donors of insureds receiving transplants must be covered
- Pregnancy benefits must be extended even if coverage ends if the
pregnancy began while the policy was in force
- A recurrent disability provision may not specify that recurrent
disabilities can be separated by more than 6 months
, - Accidental death and dismemberment benefits must be payable if the
loss occurs within 90 days of the accident
- Disability income benefits must be payable if the loss occurs within 30
days of the accident
●● Minimum Standards for Individual Policies - Disclosure
Answer: The following must appear on the first page of a policy:
- Notice of the insured's unconditional right to return the policy within
10 days for a full refund (does not apply to single premium
nonrenewable policies)
- In regards to accident-only or specified diseases policies, a prominent
notice that coverage or benefits are limited
- A provision describing a policy's renewability provisions
- If the policy issued is different from the one applied for, it must be
noted on the first page
●● Minimum Standards for Individual Policies - Disclosure (Cont.)
Answer: - Outline of coverage must be delivered with the policy
- Policies providing excepted benefits or a grandfathered health plan that
contains limitations of pre-existing conditions must appear as a separate
paragraph and labeled as "Pre-existing Condition Limitations"
- Riders or endorsements added after the policy issue must be accepted
in writing by the insured
