Braindump NY-Life-Accident-and-Health Pdf - Reliable NY-Life-Accident-and-Health Exam Guide

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Insurance Licensing NY-Life-Accident-and-Health Exam Syllabus Topics:

Section	Weight	Objectives
Underwriting, Marketing and Sales Practices	15%	- Sales and Customer Service 1. Suitability and Disclosure Requirements - Application and Underwriting Procedures 1. Risk Classification and Selection
Accident and Health Insurance	35%	- Government Health Programs 1. Medicare and Medicaid 2. New York State Specific Programs - Health Insurance Basics 1. Group vs Individual Coverage 2. Medical Expense and Disability Income - Policy Provisions and Claims 1. Eligibility and Enrollment 2. Coordination of Benefits
Life Insurance Products and Provisions	30%	- Types of Life Insurance Policies 1. Term, Whole Life, Universal Life 2. Annuities and Retirement Products - Policy Provisions, Riders and Options 1. Beneficiary Designations 2. Non-forfeiture Values and Dividends
Insurance Regulation and General Principles	20%	- New York Insurance Code and Laws 1. Licensing Requirements and Procedures 2. Unfair Trade Practices 3. Producer Responsibilities and Ethics - Insurance Concepts 1. Contract Law and Policy Structure 2. Risk Management and Insurable Interest

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NY-Life-Accident-and-Health Exam Simulation: New York Life, Accident and Health Insurance Agent/Broker Examination Series 17-55 & NY-Life-Accident-and-Health Study Guide Materials

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Insurance Licensing New York Life, Accident and Health Insurance Agent/Broker Examination Series 17-55 Sample Questions (Q68-Q73):

NEW QUESTION # 68
Under the grace period, an insured submits a $300 claim for medical expenses. The insurer notes that the insured has a past due premium of $100, and as a result, the insurer only pays $200. Which of the following provisions covers this situation?

A. Payment of claims.
B. Misstatement of age.
C. Payment actions.
D. Unpaid premium.

Answer: D

Explanation:
The correct answer is Unpaid premium . In accident and health insurance, the unpaid premium provision permits the insurer to deduct any premium that is due and unpaid from a claim payment when a loss occurs during the grace period. The grace period allows coverage to remain in force for a limited time after the premium due date, giving the insured an opportunity to make the overdue payment without immediate lapse of coverage. However, if a claim is submitted during that period, the insurer has the right to subtract the outstanding premium from the amount otherwise payable.
In this question, the insured submits a $300 claim , but because $100 in premium is overdue , the insurer pays only $200 . That is exactly how the unpaid premium provision operates.
The other choices do not fit. Payment of claims refers to how and to whom claims are paid, not deduction of overdue premium. Misstatement of age applies when an incorrect age affects premium or benefits. Payment actions is not the standard policy provision being tested here. Therefore, the correct answer is A. Unpaid premium .

NEW QUESTION # 69
When a provider does NOT have an agreement with the insurer for payment, they will be reimbursed

A. a non-scheduled plan customary fee.
B. a usual, customary, and reasonable fee.
C. an absolute fee.
D. a relative fee.

Answer: B

Explanation:
When a medical provider does not have a contract or payment agreement with an insurer (often called a nonparticipating or out-of-network provider), the insurer generally does not pay based on a negotiated contract rate. Instead, reimbursement is commonly determined using a UCR methodology- Usual, Customary, and Reasonable charges. "Usual" refers to the typical charge a provider makes for a service;
"customary" reflects what providers in the same geographic area commonly charge for that service; and
"reasonable" considers whether the charge is appropriate given the circumstances and local market norms.
Under many major medical plans, the insurer pays a percentage of the UCR amount (subject to deductibles and coinsurance), and the patient may be responsible for any difference between the provider's billed charge and the insurer's allowed UCR amount (often referred to as balance billing , where permitted).
The other choices do not match standard insurer payment terminology: "absolute" and "relative" fee are not the typical reimbursement basis described for noncontracted providers, and "non-scheduled plan customary fee" is not the recognized standard method used in these plan provisions.

NEW QUESTION # 70
Under the Affordable Care Act, insurer may refuse to accept an internal appeal on a denied claim if

A. the claim is under $500.
B. the insured is unable to pay an appeal fee.
C. the appeal is filed more than 180 days after the claim denial.
D. the insured has submitted three appeals within the calendar year.

Answer: C

Explanation:
The Affordable Care Act (ACA) requires health plans to maintain a formal internal claims and appeals process and to provide access to external review when appropriate. A key consumer protection under the ACA is that, after a claim is denied (an "adverse benefit determination"), the covered person must be given a reasonable opportunity to appeal. Standard ACA claims-and-appeals rules provide a specific filing window for an internal appeal: the insured generally has up to 180 days from receipt of the denial notice to submit the appeal. If an appeal request is made after that deadline, the insurer (or plan) may treat it as untimely and can refuse to accept it as a valid internal appeal.
The other options do not reflect ACA requirements. ACA appeals are not limited by a minimum dollar amount like $500, and plans cannot impose an appeal fee as a condition of filing. Also, ACA rules do not set a
"three appeals per year" cap; appeal rights are tied to adverse determinations, not an annual quota. Therefore, the insurer may refuse only if the appeal is filed more than 180 days after denial.

NEW QUESTION # 71
Which of the following statements BEST describes a disability elimination period?

A. A benefit or utilization period.
B. A dollar deductible rather than a time deductible.
C. A qualifying period.
D. A time deductible rather than a dollar deductible.

Answer: D

NEW QUESTION # 72
Stranger originated life insurance violates which of the following statutory requirements?

A. Right of rescission.
B. Insurable interest.
C. Commission sharing.
D. Trust ownership.

Answer: B

Explanation:
Stranger-originated life insurance (STOLI) arrangements violate the fundamental legal requirement of insurable interest . In life insurance, the policyowner must have a legitimate interest in the continued life of the insured at the time the policy is issued. This usually exists when there is a close family relationship or a lawful economic interest, such as a business relationship where the death of the insured would cause financial loss. STOLI attempts to evade this rule by having a third party with no true insurable interest initiate or finance a policy for the purpose of benefiting from the insured's death.
That is why C. Insurable interest is the correct answer. The problem with STOLI is not trust ownership itself, since trusts may be used legally in life insurance planning when properly established. It is also not primarily about rescission rights or commission sharing. The key statutory violation is that the policy is effectively procured by or for someone who lacks a lawful interest in the insured's continued life. New York licensing materials treat this as contrary to public policy and inconsistent with lawful life insurance underwriting standards.

NEW QUESTION # 73
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