Free Individual Accident and Health Provisions Study Guide
Delaware Accident & Health exam — Individual Accident and Health Provisions.
Delaware writes the uniform individual health policy provisions into 18 Del. C. 3305 to 3326. They follow the traditional uniform provisions that NAIC Model 180 is based on, and the national guide explains what each one does. Delaware's minimum standards for individual policies are in Regulation 1304. This page gives the Delaware numbers, including the optional provisions Delaware still allows.
Required provisions
| Provision | Delaware rule |
|---|---|
| Entire contract | The policy plus attached papers. Changes need an executive officer's approval, endorsed or attached. No agent may change or waive terms (3305) |
| Time limit on certain defenses | After two years from issue, misstatements other than fraudulent ones can't void the policy or deny a claim for a disability starting after that (3306) |
| Grace period | At least 7 days (weekly premium), 10 days (monthly), 31 days (others) (3307) |
| Reinstatement | Reinstated on approval, or on the 45th day after the conditional receipt unless disapproved in writing. Covers accidents after reinstatement and sickness beginning more than 10 days later (3308) |
| Notice of claim | Within 20 days, or as soon as reasonably possible (3309) |
| Claim forms | If not furnished within 15 days, the claimant may submit any written proof (3310) |
| Proof of loss | Within 90 days. Late proof is accepted up to one year unless the claimant lacked legal capacity (3311) |
| Time of payment | Promptly on proof (3312) |
| Payment of claims | Facility of payment up to $1,000 (3313) |
| Physical exam and autopsy | At the insurer's expense while a claim is pending (3314) |
| Legal actions | No suit until 60 days after proof of loss, and none after three years (3315) |
| Change of beneficiary | Reserved to the insured. The beneficiary's consent isn't needed unless the designation is irrevocable (3316) |
Optional provisions Delaware allows
- Change of occupation (3318): a riskier job reduces benefits to what the premium buys. A safer job lowers the premium and refunds the excess.
- Misstatement of age (3319).
- Relation of earnings to insurance (3321):
- allowed only in a selectively underwritten policy with a loss-of-time benefit payable for at least 52 weeks
- it can't cut combined benefits below the lesser of $300 or the benefits without the provision
- Unpaid premium may be deducted from a claim (3322).
- Conformity with state statutes: a conflicting term is automatically amended to meet the law of the state where the insured lives (3323).
- Illegal occupation: no liability for a loss caused by a felony or an illegal occupation (3324).
- Intoxicants and narcotics: no liability for a loss while intoxicated or under a narcotic not taken on a physician's advice (3325).
- Refusal to renew: if the insurer reserves the right not to renew, it can take effect only on a renewal date (3326).
Minimum standards (Regulation 1304)
- Outline of coverage: delivered with the policy, or at application with a signed receipt.
- Replacement: once replacement is found, a replacement notice goes out before issue. Accident-only and single-premium nonrenewable policies are exempt.
- "Noncancellable" may be used only if the insured can keep the policy to 65 (or Medicare eligibility) by paying premiums, with no changes the insurer can make on its own.
- Total disability can't be defined only as being unable to do "any occupation whatsoever." Definitions based on the insured's own occupation, or on jobs suited to education and experience, are allowed.
- Recurrent disability separation periods can't exceed six months.
- Accidental death and dismemberment must pay if the loss occurs within 90 days of the accident.
- Accidents are defined with "result" language. An accidental-means test, or wording like "external, violent, visible wounds," isn't allowed.
- Sickness may have a probationary period of up to 30 days.
- Accident-only policies say so on the first page.
Exam traps
- Delaware's time limit on defenses excludes fraudulent misstatements. Fraud can still be raised after two years.
- Reinstatement takes effect automatically on day 45. Sickness is covered after 10 days.
- Notice 20, forms 15, proof 90 days, with a 1-year outer limit. Lawsuits: no sooner than 60 days, no later than 3 years.
- Delaware keeps the intoxicants and narcotics provision as an option.
Practice Individual Accident and Health Provisions questions All Accident & Health topics
Practice questions are study aids generated for exam preparation and are not actual exam questions. Content is provided for educational purposes and is not legal advice. Verify current statutes, rules, and exam specifications with the Insurance Department and the exam administrator before relying on it.
