Health Insurance Policy Provisions
Uniform mandatory provisions
Health policies contain standardized provisions designed to protect the insured: entire contract (policy plus attached papers and endorsements); a grace period tied to mode (commonly 7 days weekly, 10 days monthly, 31 days for other modes); reinstatement (automatic if the premium is accepted; otherwise evidence of insurability); a two-year time limit on certain defenses (incontestability for fraud/misstatement); claim procedures - notice of claim, claim forms, proof of loss, and time of payment of claims (often within 45 days of proof); physical examination at the insurer's expense; legal actions limits; change of beneficiary; and payment of claims.
Coordination and continuation
Coordination of benefits prevents double recovery when a person has two group plans: the primary plan pays, the secondary plan pays the remainder, with the birthday rule for dependent children. COBRA continuation generally runs 18 months (longer for disability or a second qualifying event), at the insured's expense. HIPAA provides portability, special enrollment rights, and privacy protections. Individual policies may offer a conversion privilege to a permanent policy without evidence of insurability.
Utilization and appeals
Preauthorization, concurrent review, and case management control costs; internal appeal and external independent review give members a route to challenge denials. Pre-existing-condition lookbacks and waiting periods apply only to grandfathered or non-ACA coverage.
Traps: the grace period varies with premium mode - a question offering only '31 days' may be wrong for a weekly payer. And a health policy's incontestability clause generally runs two years, but fraud may still void coverage.
Worked example: A claimant files proof of loss 60 days after a loss. The policy requires proof within 90 days, so the claim is timely - notice and proof windows are short and fixed.
Rule of thumb: find the timeline in the question, then match it to notice, proof of loss, payment, or contestability.