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| Section | Weight | Objectives |
|---|---|---|
| Nevada Statutes and Codes Common to Life, Health, Property, and Casualty Insurance | 20% | - Nevada Life and Health Insurance Guaranty Association - Licensing
|
| Accident & Health – General Knowledge | 50% | - Social Insurance
|
| Nevada Statutes and Codes Pertinent to Health Insurance Only | 14% | - Hospice care - Coverage for reconstructive surgery - Availability of coverage for mental health and treatment of alcohol abuse and drug abuse - Mandatory policy clauses and provisions
- Medicare
|
| Nevada Statutes and Codes Common to Life and Health Insurance Only | 4% | - Group life and health insurance
- Credit life and health insurance |
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NEW QUESTION # 28
An insured has a $1,000 deductible and then pays 20% of covered medical expenses, while the insurer pays
80%. What is the insured's 20% share called?
Answer: A
Explanation:
Coinsurance is the percentage of covered expenses that the insured shares with the insurer after the deductible has been satisfied. In this question, the insured pays 20% and the insurer pays 80%; this is commonly described as 80/20 coinsurance. The deductible is separate. It is the amount the insured must pay before the insurer begins sharing covered expenses, subject to any services that the policy covers before the deductible.
A copayment is a fixed dollar amount paid for a covered service, such as a stated amount for a physician visit or prescription. It is not normally expressed as a percentage. An elimination period is a waiting period in disability-income insurance before benefits begin. A stop-loss feature, also called an out-of-pocket maximum in many plans, limits the insured's covered cost sharing after a stated maximum has been reached, subject to plan rules.
Understanding these terms is essential when comparing health plans. A plan may have a lower premium but a higher deductible, greater coinsurance, or a larger out-of-pocket maximum. Producers must clearly explain the consumer's potential financial responsibility and must not imply that the insurer pays every medical expense once a policy is issued.
References/topics from the Study Guide: Major Medical Insurance; Deductibles; Coinsurance; Copayments; Out-of-Pocket Maximums.
NEW QUESTION # 29
Which of the following persons is NOT required to be licensed by the Nevada Insurance Commissioner?
Answer: B
Explanation:
A salaried insurance company employee performing only clerical and administrative work is not required to hold an insurance producer license. The exemption applies when the employee does not sell, solicit, or negotiate insurance and is not compensated by commission based on insurance transactions.
Licensing is required for persons whose activities bring them into the regulated functions of insurance production, brokering, adjusting, or other licensed insurance activity. A person who procures insurance for an insured is acting in a producer or broker capacity and requires appropriate authority. An individual involved in investigating and settling claims may require an adjuster license depending on the duties performed.
Likewise, an agency clerk who receives commissions related to processed applications is no longer functioning solely as a clerical employee; commission-based activity indicates involvement in the insurance transaction.
The distinction is based on the actual work performed, not merely the person's job title. A company may call someone an assistant, representative, clerk, or customer-service employee, but the individual must be licensed if the person sells, solicits, negotiates, or otherwise performs regulated insurance functions.
Study Guide references/topics: producer licensing; licensing exemptions; clerical employees; sales, solicitation, and negotiation; NRS 683A.117 .
NEW QUESTION # 30
An individual health insurance policy contains a Change of Occupation provision. If the insured experiences a loss in a more hazardous occupation than when the policy was issued, the insurance company may:
Answer: A
Explanation:
The Change of Occupation provision allows an insurer to adjust benefits when the insured changes to a more hazardous occupation after policy issue. Choice A is correct. If the same premium would have purchased a lower benefit amount for the new, more hazardous occupati on, the insurer may reduce the benefit to the amount that premium would have bought under the new occupational classification. The purpose is to preserve fairness between the risk assumed and the premium paid without automatically cancelling the policy.
The insurer does not simply increase the waiting period or deductible, because those are not the contractual adjustment method addressed by the provision. It also does not deny every claim for misrepresentation, because a later change in occupation is not necessarily a misrepresentation in the original application. If the insured changes to a less hazardous occupation, the provision may allow the insured to apply for an adjusted premium rate or greater benefit as appropriate under policy terms. The key examination rule is that occupational changes affect the amount of benefits or premium classification, not the basic validity of coverage. Study Guide References/Topics: Policy Provisions, Clauses, and Riders; Change of Occupation Provision; Individual Accident and Health Policies.
NEW QUESTION # 31
Under a life insurance policy with a revocable beneficiary designation, who normally has the authority to change the beneficiary?
Answer: A
Explanation:
The policyowner normally holds the contractual rights known as incidents of ownership. When the beneficiary designation is revocable, the policyowner may generally change the beneficiary without obtaining that beneficiary's consent, provided the policy is in force and no assignment or court order restricts the right.
The owner may also ordinarily exercise other ownership rights, such as selecting premium-payment modes, assigning the policy, taking a policy loan when available, surrendering the policy for cash value, and electing settlement options.
The insured and the owner can be the same person, but they do not have to be. The insured is the person whose life is covered and whose death triggers payment of the death benefit. A beneficiary is the person or entity designated to receive policy proceeds. Those roles must be kept separate on examination questions. A revocable beneficiary has only an expectancy until the insured dies; by contrast, an irrevocable beneficiary usually has a vested interest that limits the owner's ability to change the designation or exercise certain policy rights without consent.
Correctly identifying the owner is essential because ownership determines control of the policy during the insured's lifetime.
References/topics from the Study Guide: Policyowners' Rights; Beneficiary Designations; Revocable and Irrevocable Beneficiaries; Assignments.
NEW QUESTION # 32
In order to be covered under the Nevada Life and Health Insurance Guaranty Association, an insurance company MUST be:
Answer: A
Explanation:
An insurer must be admitted in Nevada-meaning authorized to transact the applicable insurance business in the state-to be a member of the Nevada Life and Health Insurance Guaranty Association. Membership is a condition of authority for insurers and health maintenance organizations writing the kinds of coverage protected by the Guaranty Association Act.
The Association provides limited protection when a member insurer becomes impaired or insolvent and cannot meet covered contractual obligations. It is not a general guarantee of every insurance company or every policy. Coverage is governed by statute, subject to eligibility requirements, benefit limits, exclusions, and residency provisions.
An AM Best rating is an independent financial-strength opinion. It may be useful to consumers and producers evaluating an insurer, but it does not determine membership in the Guaranty Association. A fraternal benefit society is specifically excluded from the definition of a member insurer for this purpose. "Alien" refers to an insurer organized under the laws of another country and does not, by itself, establish Association membership; the key consideration is whether the insurer is authorized to transact covered insurance in Nevada.
Study Guide references/topics: admitted versus nonadmitted insurers; guaranty associations; insurer insolvency; NRS Chapter 686C .
NEW QUESTION # 33
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