Health Insurance Policy Provisions, Riders, and Benefits
Required provisions
Health policies contain required uniform provisions. The entire contract clause limits the agreement to the policy and attached papers. The time limit on certain defenses (incontestability) bars the insurer from denying a claim for misrepresentation after two years, and after two years the claim can be denied only for fraud or nonpayment. The grace period allows late payment. Reinstatement restores coverage after lapse, with new contestability and often a waiting period for sickness. The claim process requires the insured to give notice of claim (commonly within 20 days), the insurer to furnish claim forms (typically within 15 days), proof of loss (commonly within 90 days), and payment promptly after proof. Legal action may not begin before 60 days or after a set period, commonly three years.
Other provisions
Change of occupation adjusts benefits if the insured moves to a riskier job. Misstatement of age or sex adjusts the benefit. The physical examination and autopsy provision allows the insurer to require evidence at its expense. Illegal occupation, war, and self-inflicted injury exclusions apply. Other-insurance provisions and relation-of-earnings clauses limit total benefits to avoid overinsurance.
Riders and benefits
Accidental death and dismemberment pays for accidental loss within 90 days and typically excludes sickness, self-inflicted injury, and aviation. Other riders: maternity, dental, vision, prescription, hospital indemnity, critical illness, long-term care, and impairment riders that exclude a named condition.
Rule of thumb
Claim-timeline question example: an insured fails to submit proof of loss within 90 days. The insurer may reasonably deny the claim for lack of proof, but not because of a misstatement on the application after two years.