Health Insurance Policy Provisions
Contract and claim provisions
The entire contract clause limits the agreement to the policy and attached endorsements. The grace period allows late premium payment before lapse; its length can differ between individual and group coverage. Reinstatement restores coverage after lapse, often requiring payment and evidence of insurability. The incontestability clause generally limits the insurer's ability to contest the policy for misrepresentation after a stated period, often two years. Misstatement of age adjusts benefits. Notice of claim and proof of loss provisions set deadlines for the insured. Legal actions provisions set when suit may be filed. The insurer may require an autopsy or authorization in some circumstances.
Limitations and changes
Preexisting condition provisions, if permitted, define lookback and exclusion periods. Change-of-occupation provisions may adjust benefits if the insured moves to a more hazardous occupation. Conversion privileges let an insured move from group to individual coverage. Coordination of benefits prevents duplicate payment when two plans cover the same loss. Subrogation allows recovery from a responsible third party.
Traps
Incontestability does not prevent denial for nonpayment or for lack of coverage. Reinstatement may create a new contestability period. A grace period is not an extension of coverage indefinitely. Read whether a provision is a condition, a limitation, or an exclusion.
Rule of thumb
For any claim question, check four things: premium paid and grace period, notice and proof deadlines, exclusions and limitations, and coordination with other coverage.
Worked example
An insured misses a premium but pays within the grace period. The policy remains in force. If the insured instead lets it lapse and later reinstates, the insurer may apply a new contestability period to the reinstated coverage.