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| Section | Weight | Objectives |
|---|---|---|
| Nevada Statutes, Rules and Regulations | ~32% | - Nevada Health-Specific Regulations
|
| Accident and Health — General Knowledge | ~68% | - Insurance Concepts and Underwriting
|
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NEW QUESTION # 124
An insured purchases a rider that pays an additional amount only if death results from a covered accident.
This rider is best described as:
Answer: B
Explanation:
An accidental death benefit rider provides an additional death benefit when the insured dies as the direct result of a covered accident. It is often described as "double indemnity" when the additional benefit equals the policy's face amount, although the actual amount and conditions depend on the rider. The rider supplements the base life policy; it does not replace the base death benefit. If the insured dies from a covered accident, the beneficiary may receive the base policy amount plus the rider benefit. If death results from illness or a noncovered cause, only the base policy benefit is generally payable.
Accidental-death riders contain important limitations. They typically require death to occur within a stated time after the accident and may exclude deaths resulting from specified causes, such as war, suicide, certain hazardous activities, intoxication, or illegal acts, depending on the contract. The producer must explain that the benefit is conditional and is not the same as comprehensive life insurance.
A guaranteed-insurability rider permits future coverage increases without new evidence of insurability. A cost- of-living rider increases coverage under specified inflation-related terms. A return-of-premium feature returns qualifying premiums under stated conditions, usually at the end of a term period.
References/topics from the Study Guide: Accidental Death Benefit Rider; Double Indemnity; Exclusions; Supplementary Benefits; Policy Riders.
NEW QUESTION # 125
Under an individual Major Medical policy, a married policyowner has the right to take which of the following actions?
Answer: C
Explanation:
Choice D is correct. A family health policy must provide coverage for a newborn child without requiring evidence of insurability at birth, subject to the policy's notice and premium requirements for continuation of coverage. This protects the child during the period when medical needs can arise immediately after birth and prevents underwriting from becoming a barrier to initial coverage. Nevada law recognizes family coverage for dependent children from birth and establishes rules governing newborn coverage. The policy may require notice and any additional premium within the specified period to continue coverage beyond the initial statutory protection. The other choices do not state standard rights under an individual major medical policy.
Arbitration is not automatically available merely because an insured disagrees with a claim decision. A proof of loss does not create an automatic right to sue precisely 30 days after submission. Reinstatement rights also operate under the policy's reinstatement provision and are not a universal three-year right. Nevada's statutory framework specifically addresses dependent and newborn coverage under individual health insurance. See NRS Chapter 689A . Study Guide References/Topics: Nevada-Specific Health Insurance Mandates and Rules; Individual Major Medical; Newborn Coverage.
NEW QUESTION # 126
A life policy lapses because a premium was not paid. To reinstate the policy, the insurer will generally require all of the following EXCEPT:
Answer: A
Explanation:
Reinstatement restores a lapsed life insurance policy to active status if the policyowner satisfies the policy's requirements. Those requirements generally include applying for reinstatement within the permitted period, providing evidence of insurability satisfactory to the insurer, and paying overdue premiums plus interest. The exact reinstatement period and underwriting requirements are controlled by the policy and applicable law.
A new medical examination is not required in every case. The insurer may request medical information or an examination when needed to evaluate the applicant's current insurability, but it is not an automatic universal requirement. The key examination principle is that evidence of insurability is required, not that a physical examination must always occur. Reinstatement is often preferable to purchasing a new policy because the existing policy may have more favorable premium rates, accumulated cash value, or a prior issue age.
However, the policyowner must understand that contestability and certain exclusions may begin again with respect to the reinstatement.
A producer should explain the difference between reinstatement and renewal. Reinstatement restores a policy that lapsed; renewal continues or extends a policy under its existing terms. Neither should be assumed available without reviewing the contract.
References/topics from the Study Guide: Reinstatement Provision; Policy Lapse; Evidence of Insurability; Premium Payment; NRS 688A.130.
NEW QUESTION # 127
In a typical HMO arrangement, what is the primary role of the primary care provider?
Answer: A
Explanation:
In a typical health maintenance organization, the primary care provider acts as the central coordinator of the insured's routine medical care. The primary care provider may deliver preventive and basic medical services, maintain the patient's care plan, and refer the patient to specialists or other facilities when required by the HMO's rules. This gatekeeper function is intended to coordinate care, reduce unnecessary duplication, and manage costs through the plan's provider network.
The precise referral rules depend on the particular HMO. Some plans may allow direct access to certain specialists, such as obstetricians or behavioral-health providers, while others require prior referral or authorization. Emergency services are subject to separate protections and should not be described as ordinary out-of-network elective care. The producer must explain the network, referral, prior-authorization, and out-of- network rules before enrollment.
A PPO also has a preferred provider network but commonly allows members to use nonnetwork providers at a reduced benefit level and without the same referral structure. An indemnity plan may provide broader provider choice but may have different reimbursement limits and cost sharing. The test distinction is that an HMO commonly emphasizes coordinated, network-based care through a primary care provider.
References/topics from the Study Guide: Managed Care; HMO; Primary Care Provider; Gatekeeper Model; Provider Networks.
NEW QUESTION # 128
If coverage has stayed in force with the same insurance company, what is the maximum number of years for which reconstructive surgery (mastectomy) benefits must be provided?
Answer: B
Explanation:
If reconstructive surgery is begun within three years after a mastectomy, the amount of benefits for that surgery must equal the amount provided by the policy at the time of the mastectomy. Therefore, the tested maximum period is three years.
Nevada requires a policy that covers mastectomy to provide commensurate coverage for reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to create symmetry, prostheses, and treatment of physical complications of all stages of mastectomy, including lymphedema. The attending physician and patient determine the appropriate care.
The three-year rule protects an insured from losing the original level of reconstruction benefits merely because reconstruction is delayed. If surgery begins more than three years after the mastectomy, benefits are governed by the policy terms, conditions, and exclusions in effect at the time reconstructive surgery begins.
This question does not ask how long all reconstruction coverage disappears. It tests the period during which the policy must preserve the benefit amount available at the time of mastectomy.
Study Guide references/topics: mastectomy coverage; reconstructive surgery; breast reconstruction; mandated health benefits; NRS 689B.0375 .
NEW QUESTION # 129
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