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| Section | Weight | Objectives |
|---|---|---|
| Underwriting, Marketing and Sales Practices | 15% | - Application and Underwriting Procedures
|
| Insurance Regulation and General Principles | 20% | - New York Insurance Code and Laws
|
| Accident and Health Insurance | 35% | - Policy Provisions and Claims
|
| Life Insurance Products and Provisions | 30% | - Policy Provisions, Riders and Options
|
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질문 # 112
According to Health Insurance Portability and Accountability Act (HIPAA), when can a group health policy renewal be denied?
정답：C
설명：
The correct answer is Participation or contribution rules have been violated . Under the Health Insurance Portability and Accountability Act (HIPAA), group health insurance plans are generally subject to guaranteed renewability requirements . This means that insurers must typically renew group coverage at the option of the employer or plan sponsor. However, HIPAA provides a few limited exceptions where renewal may legally be denied.
One of these exceptions occurs when the employer or group policyholder fails to comply with the insurer's participation or employer contribution requirements . Participation rules usually require a minimum percentage of eligible employees to enroll in the plan, while contribution rules require the employer to pay a specified portion of the premium. If the employer fails to meet these requirements or violates the contractual conditions, the insurer may have grounds to deny renewal of the group policy .
The other choices are incorrect. HIPAA does not allow insurers to deny renewal simply because the group had high claims experience , because the group size increased , or because contribution rules were changed . The critical factor is violation of participation or contribution requirements , making Option C the correct answer.
질문 # 113
The cause of a loss is called
정답：B
설명：
In insurance terminology, the cause of a loss is known as a peril . A peril is the specific event or cause that results in damage, injury, or financial loss. Common examples of perils include fire, theft, accident, illness, disability, or death . In life and health insurance, the insured event-such as death in life insurance or sickness and accidental injury in health insurance-is considered the peril that triggers the insurer's obligation to pay benefits under the policy. Insurance policies are designed to provide financial protection against losses that result from covered perils.
It is important to distinguish a peril from other related insurance concepts. A hazard is a condition or situation that increases the likelihood or severity of a loss caused by a peril. Hazards are typically categorized as physical hazards (such as icy roads or faulty wiring), moral hazards (dishonesty or fraudulent behavior), and morale hazards (carelessness because of insurance coverage). An exposure refers to the possibility of loss, while risk refers to the uncertainty regarding the occurrence of a loss. Therefore, the term that specifically describes the direct cause of a loss is a peril .
질문 # 114
A Medicare Supplement policy must NOT contain benefits which
정답：A
설명：
A Medicare Supplement policy (Medigap) is designed specifically to fill the gaps in coverage left by Medicare Parts A and B . These policies are standardized and regulated to ensure that they supplement, rather than replace or duplicate, Medicare benefits. The purpose of Medigap coverage is to help pay for certain out- of-pocket expenses , such as deductibles, copayments, coinsurance, and other costs that original Medicare does not fully cover. Because of this purpose, Medicare Supplement policies are not allowed to duplicate benefits that Medicare already provides . If a benefit were duplicated, it would violate the fundamental principle that Medigap policies are intended only to supplement existing Medicare coverage , not provide overlapping payments for the same services.
Option A is incorrect because insurers may charge premiums for the coverage provided under the policy.
Option C is incorrect because Medigap plans may include benefits that help pay expenses beyond Medicare's basic coverage limits (such as additional hospital days). Option D is incorrect because Workers' Compensation operates separately and is not the defining restriction placed on Medigap benefits. Therefore, Medicare Supplement policies must not duplicate Medicare benefits .
질문 # 115
With respect to small group health benefit plans, a carrier may discontinue coverage or may refuse to renew such a plan if the employer
정답：A
설명：
Under New York small group health benefit plan rules, carriers generally must renew coverage for an employer group, but there are specific exceptions where a carrier is permitted to discontinue or refuse renewal
. One of the primary permitted reasons is nonpayment of premium -if the employer does not pay required premiums within the policy's allowed timeframes (including any required grace period), the carrier may terminate or nonrenew coverage because the group is no longer meeting the contractual payment obligation.
The other options do not typically qualify as valid statutory reasons for nonrenewal in the small group market.
Merely employing fewer than 15 full-time employees is not a trigger for termination (small group status is based on employer size definitions, but size alone doesn't justify cancellation). Filing for bankruptcy is not, by itself, a standard guaranteed-renewability exception. Having supplemental coverage with another carrier also does not allow a carrier to cancel, because employers may coordinate coverage arrangements. Therefore, the only option that matches an allowed discontinuance/nonrenewal basis is failure to pay premiums before the end of the grace period .
질문 # 116
Which of the following statements BEST describes a disability elimination period?
정답：D
질문 # 117
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