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| Section | Objectives |
|---|---|
| Topic 1: Insurance Basics | - Risk Management and Insurance Concepts
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| Topic 2: General Insurance Regulation | - Nevada Insurance Department and Regulatory Authority
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| Topic 3: Health Insurance Policy Provisions | - Mandatory and Optional Provisions
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| Topic 4: Producer Duties and Ethics | - Ethical Responsibilities
|
| Topic 5: Government Health Insurance Programs | - Medicaid and Other Programs
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| Topic 6: Accident and Health Insurance Fundamentals | - Types of Health Insurance Policies
|
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NEW QUESTION # 130
A life insurance policy owner has paid $1,200 in premiums in six months for a $250,000 policy. The policyowner dies suddenly and the insurer pays the beneficiary $250,000. This exchange of unequal values reflects which of the following insurance contract features?
Answer: B
Explanation:
An insurance contract is aleatory because the values exchanged by the parties may be unequal and depend on an uncertain event. Choice A is correct. In this example, the policyowner paid only $1,200 in premiums before death, while the insurer paid a $250,000 death benefit. The insurer's obligation was much greater than the premium amount received because the insured event occurred early in the policy period. If death had not occurred for many years, the total premiums paid could have been much closer to or greater than the eventual benefit value. That uncertainty is the defining aleatory feature. A personal contract is based on the insured's individual characteristics and insurable interest. A unilateral contract means only the insurer makes a legally enforceable promise to perform after the applicant accepts the contract and pays premium. A conditional contract requires stated conditions, such as premium payment and proof of loss, to be met before performance is due. None of those terms focuses on the unequal exchange demonstrated here. Study Guide References
/Topics: Policy Provisions, Clauses, and Riders; Insurance Contract Characteristics; Aleatory Contracts.
NEW QUESTION # 131
The statement that an insured MUST give an insurance company to show that a loss actually occurred is a:
Answer: C
Explanation:
The correct answer is C, Proof of Loss. Proof of loss is the written documentation supplied to the insurer to establish that a covered loss occurred and to provide the facts needed to evaluate the claim. It may include claim forms, medical records, bills, physician statements, dates of treatment, disability information, and other evidence required under the policy. Notice of claim is different: it simply informs the insurer that a loss has occurred or that a claim may be made. After receiving notice, the insurer ordinarily provides claim forms or instructions. A loss form may be one document used in the proof-of-loss process, but it is not the complete legal concept. An inspection report may be used by an insurer in some lines of insurance but is not the insured' s required statement establishing a health or disability claim. Timely proof of loss is important because it triggers the insurer's claim-review duties and helps determine when payment is due. Policy provisions specify the timing and form of proof required. Study Guide References/Topics: Policy Provisions, Clauses, and Riders; Notice of Claim; Proof of Loss; Claim Procedures.
NEW QUESTION # 132
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 # 133
Which of the following is true regarding Medicare Advantage Plans?
Answer: A
Explanation:
Medicare Advantage, also called Medicare Part C, is private-plan coverage approved by Medicare. These plans must provide at least the services covered by Original Medicare, subject to Medicare rules, but they may structure deductibles, copayments, and coinsurance differently. For many enrollees, a plan's benefit design can reduce or eliminate certain cost-sharing amounts that would otherwise apply under Original Medicare.
Medicare Advantage plans also include a yearly maximum out-of-pocket limit for covered Medicare services.
Vision, hearing, and dental benefits may be offered as supplemental benefits by many Medicare Advantage plans, but they are not universally mandated as a standard benefit in every plan. Drug coverage is commonly included, but it is not restricted to generic medications only. Part D formularies can include both generic and brand-name drugs, subject to plan rules and Medicare requirements.
The final option is incorrect because an enrollee does not receive a reduced premium merely by opting out of preventive care. Preventive benefits and plan premiums are governed by Medicare and plan design rules rather than by an individual's decision to decline a preventive program.
Study Guide references/topics: Medicare Part C; Medicare Advantage; deductibles; coinsurance; out-of- pocket limits; Medicare Advantage cost rules .
NEW QUESTION # 134
Basic cancer plans pay for all of the following EXCEPT:
Answer: A
Explanation:
Basic cancer policies are limited-benefit plans intended to supplement, rather than replace, comprehensive medical coverage. They commonly provide benefits for cancer-specific treatment such as chemotherapy, radiotherapy, and immunotherapy, subject to the policy's definitions, schedules, and limits. Therefore, choice C is correct because physical therapy is not ordinarily a core cancer-treatment benefit under a basic cancer policy. Physical therapy may be covered under a comprehensive medical plan or under a more expansive supplemental policy if expressly included, but it is not a standard basic cancer-plan benefit. Cancer policies can pay specified amounts for surgery, hospital confinement, physician services, diagnostic testing, drugs, radiation, chemotherapy, or other treatment tied directly to a covered cancer diagnosis. The insured should not assume that every medical expense arising during cancer treatment is covered. Benefits may be subject to waiting periods, preexisting-condition restrictions, recurrence rules, benefit schedules, and exclusions. The appropriate exam distinction is between benefits directly associated with treatment of cancer and general rehabilitative or medical services that are not expressly included in the cancer policy. Study Guide References
/Topics: Types of Health Insurance Policies; Limited-Coverage Health Policies; Cancer Insurance.
NEW QUESTION # 135
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