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| Section | Objectives |
|---|---|
| Accident and Health Insurance Fundamentals | - Medical Expense Insurance
|
| Government Health Insurance Programs | - Medicare
|
| Health Insurance Policy Provisions | - Claims and Benefits
|
| Producer Duties and Ethics | - Ethical Responsibilities
|
| General Insurance Regulation | - Nevada Insurance Department and Regulatory Authority
|
| Insurance Basics | - Risk Management and Insurance Concepts
|
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98. Frage
Under an individual Major Medical policy, a married policyowner has the right to take which of the following actions?
Antwort: B
Begründung:
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.
99. Frage
Which of the following organizations is the BEST example of a mutual insurance company?
Antwort: A
Begründung:
A mutual insurance company is an incorporated insurer without capital stock that is owned by its policyholders. Its governing body is elected by policyholders rather than by outside shareholders. Therefore, option B is the best description of a mutual insurer.
A stock insurer, described in option A, has capital divided into shares and is owned by stockholders.
Stockholders elect the board of directors and may receive dividends based on corporate profitability.
Policyholders of a stock insurer are customers, not owners, unless they separately own stock in the company.
Options C and D describe characteristics associated with a reciprocal insurer or interinsurance exchange. A reciprocal is an unincorporated aggregation of subscribers who insure one another through an attorney-in-fact.
Subscribers are both insureds and insurers of one another in that arrangement.
The mutual-company structure matters because policyholders may participate in governance and may receive policyholder dividends when declared. Those dividends are not guaranteed and are different from investment dividends paid to stockholders of a stock insurer.
Study Guide references/topics: insurer ownership; mutual insurers; stock insurers; reciprocal insurers; Nevada domestic insurer law .
100. Frage
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?
Antwort: C
Begründung:
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.
101. Frage
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:
Antwort: C
Begründung:
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.
102. Frage
Which of the following characteristics is typical of group insurance?
Antwort: B
Begründung:
Choice C is correct. Group insurance is designed to cover members of an eligible class, commonly all full- time employees of an employer, subject to the plan's participation, waiting-period, and eligibility rules. The employer or policyholder receives the master contract, while individual employees receive certificates of coverage describing their benefits. Therefore, choice B is incorrect because employees ordinarily do not receive separate individual policies. Medical examinations are generally not required for eligible employees during an initial enrollment period, especially when coverage is guaranteed issue. Choice A is therefore not a typical group-insurance feature. Enrollment is also not automatically available at any time. Employees normally enroll when first eligible or during an open enrollment period; late entrants may face evidence-of- insurability requirements or other conditions. Group insurance spreads risk across a defined group and is typically less individually underwritten than individual insurance. The key requirement is that the group be formed for a purpose other than obtaining insurance and that coverage be offered according to objective eligibility standards. Study Guide References/Topics: Group Health Insurance; Group Eligibility; Master Contract and Certificate of Coverage.
103. Frage
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