Free Individual Accident and Health Provisions Study Guide
Florida Life, Health & Variable Annuity (2-15) exam — Individual Accident and Health Provisions.
Florida writes the uniform individual health provisions into Fla. Stat. 627.605 to 627.630. They follow the traditional uniform provisions that NAIC Model 180 is based on, and the national guide explains each one. This page gives the Florida numbers, which differ from the model in several places. Examples are the 45-day claim payment rule, the $3,000 facility-of-payment amount, and the legal-actions deadline tied to the statute of limitations.
Required provisions
| Provision | Florida rule |
|---|---|
| Time limit on certain defenses | After two years from issue, only fraudulent misstatements can be used to void the policy or deny a claim (627.607) |
| Grace period | At least 7 days (weekly premium), 10 days (monthly), 31 days (others) (627.608) |
| Reinstatement | Without a written disapproval, the policy is reinstated on the 45th day after the conditional receipt. Covers injuries after reinstatement and sickness beginning more than 10 days later (627.609) |
| Notice of claim | Within 20 days, or as soon as reasonably possible (627.610) |
| Claim forms | If not furnished within 15 days, a written statement of the loss satisfies the requirement (627.611) |
| Proof of loss | Within 90 days after the loss (627.612) |
| Time of payment | Pay, or give written notice of contest or denial, within 45 days. Every claim must be paid or denied within 120 days (627.613) |
| Payment of claims | Facility of payment up to $3,000 to a relative (627.614) |
| Physical exam and autopsy | At the insurer's expense, as often as reasonably necessary. Autopsy where the law allows (627.615) |
| Legal actions | No suit within 60 days after proof of loss, and none after the statute of limitations runs (627.616) |
| Change of beneficiary | The insured may change it at any time by written notice. Consent is needed only for an irrevocable designation (627.617) |
Optional provisions and other rules
- Change of occupation (627.619): a riskier job reduces benefits to what the premium buys. A safer job brings a refund of excess premium.
- Relation of earnings to insurance (627.624): if total disability income from all coverage exceeds the insured's earnings, benefits may be reduced proportionately.
- Intoxicants and narcotics (627.629): an optional exclusion for losses while intoxicated or using narcotics not prescribed by a physician.
- Death benefits: a health policy may include a death-from-any-cause benefit of up to $1,000. Accidental death benefits aren't limited (627.603).
- Preexisting conditions (627.6045): an exclusion may last no more than 24 months after coverage begins, and may look back only 24 months. Prior continuous coverage must be credited.
- Renewability: individual coverage renews at the insured's option, except for listed reasons such as nonpayment, fraud, or the insurer leaving the market (627.6425).
- Notice of changes: 45 days' notice of cancellation, nonrenewal or a rate change, and 10 days for nonpayment. If notice is late, the old premium stays in effect until 45 days after notice is given (627.6043).
- Outline of coverage: delivered with the policy, or at application with an acknowledgment sent to the insurer (627.642).
- Medical necessity appeals: may be made by phone to the insurer's physician, who must respond within 15 business days (627.6141).
Underwriting limits
- Genetic information can't be used to deny, limit or rate coverage without a diagnosis (627.4301).
- HIV: health policies can't exclude or limit HIV except under a general preexisting-condition clause. Accident-only and specified-disease policies are excepted (627.429(5)).
- Disability coverage can't be refused or surcharged solely because of the sickle-cell trait or a severe disability (626.9705, 626.9707).
Exam traps
- Claims are paid or contested within 45 days, and finally resolved within 120 days.
- Facility of payment goes up to $3,000, more than the usual $1,000.
- Lawsuits are barred after the statute of limitations, not a fixed three years.
- The preexisting-condition limit is 24 months for individual health. Medigap uses 6 months.
Practice Individual Accident and Health Provisions questions All Life, Health & Variable Annuity (2-15) 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.
