Questões de Policy Provisions, Clauses, and Riders (Health)

1. TDI-PEARSONVUE — 2026

The Entire Contract provision in a health policy typically includes all of the following EXCEPT:

1. A)The policy itself
2. B)The application attached to the policy
3. C)Any attached riders or endorsements
4. D)Statements made by the agent during the sales presentation

Gabarito: D

The Entire Contract provision (mandatory) states that the policy, application, and any attached riders constitute the complete agreement. Oral statements or sales presentations are not part of the contract.

2. TDI-PEARSONVUE — 2026

The Time of Payment of Claims provision requires that disability income benefits be paid at least:

1. A)Weekly
2. B)Biweekly
3. C)Monthly
4. D)Quarterly

Gabarito: C

Under the Time of Payment of Claims provision, income benefits (disability or similar periodic payments) must be paid at least monthly. Other benefits (such as medical expense reimbursement) must be paid immediately upon receipt of proof of loss.

3. TDI-PEARSONVUE — 2026

The Legal Actions provision in a health policy specifies that an insured cannot file a lawsuit against the insurer until at least how long after proof of loss is submitted?

1. A)30 days
2. B)60 days
3. C)90 days
4. D)6 months

Gabarito: B

The Legal Actions provision (mandatory) prohibits lawsuits until at least 60 days after proof of loss is filed (giving the insurer time to investigate) but requires action within a specified period (typically 3 years) or rights are lost.

4. TDI-PEARSONVUE — 2026

A health insurance policy includes an Intoxicants and Narcotics provision. This optional provision allows the insurer to:

1. A)Deny claims if the loss was caused while the insured was intoxicated or under the influence of narcotics
2. B)Cancel the policy if the insured uses alcohol
3. C)Increase premiums if the insured has substance abuse history
4. D)Require annual drug testing

Gabarito: A

The optional Intoxicants and Narcotics provision allows the insurer to deny coverage for losses sustained or contracted while the insured is under the influence of intoxicants or narcotics, unless administered on the advice of a physician.

5. TDI-PEARSONVUE — 2026

Lisa's guaranteed renewable health policy is up for renewal. Under this renewability provision, the insurer:

1. A)Must renew and cannot change premiums
2. B)Must renew but may increase premiums for her class
3. C)May refuse renewal if Lisa has filed claims
4. D)May refuse renewal if Lisa's health has deteriorated

Gabarito: B

A guaranteed renewable policy must be renewed at the insured's option, but the insurer may increase premiums on a class basis. The insurer cannot single out individual insureds for rate increases or refuse renewal based on claims or health status.

6. TDI-PEARSONVUE — 2026

James has a disability income policy with a Relation of Earnings to Insurance provision. At the time of claim, the insurer discovers his benefit amount exceeds his average earnings. What will the insurer do?

1. A)Deny the claim entirely
2. B)Pay the full benefit but cancel future coverage
3. C)Reduce the benefit to match his earnings and refund excess premiums
4. D)Pay the claim but increase future premiums

Gabarito: C

The Relation of Earnings to Insurance provision (also called Overinsurance) allows the insurer to reduce benefits to an amount that bears the same ratio to earnings as the original benefit bore to earnings stated in the application. Excess premiums for the reduced coverage are refunded.