Free Individual Accident and Health Provisions Study Guide
Kentucky Accident & Health exam — Individual Accident and Health Provisions.
The uniform individual health provisions as they appear in NAIC Model 180 are covered in the national Individual Accident and Health Provisions guide. Kentucky enacted its own version in Subtitle 17 of KRS Chapter 304 (KRS 304.17-050 to 304.17-290). Several Kentucky numbers differ from the model, and the exam asks for the Kentucky ones:
- 60 days for notice of claim
- three years for the time limit on certain defenses
- three years to sue
- 30 days to pay claims
- $5,000 facility of payment
- a $300 relation-of-earnings floor
Required provisions
| Provision | Kentucky rule |
|---|---|
| Entire contract; changes | The policy plus the attached application. Changes are valid only if approved by an executive officer and endorsed on or attached to the policy. No agent may change or waive provisions (304.17-050). |
| Time limit on certain defenses | After three years from issue, non-fraudulent misstatements can't void the policy or deny a claim. A loss beginning after two years can't be denied for a preexisting condition not excluded by name (304.17-060). |
| Grace period | 7 days weekly, 10 days monthly, 31 days otherwise. If the insurer reserves the right to nonrenew, notice is due five days before the premium due date (304.17-070). |
| Reinstatement | Accepting a late premium without requiring an application reinstates the policy. If an application is required, reinstatement happens on approval or on the 45th day unless disapproved in writing. Sickness is covered only if it starts more than 10 days after reinstatement (304.17-080). |
| Notice of claim | Within 60 days after the loss begins, or as soon as reasonably possible. For long-term disability benefits, the insurer may require notice of continuing disability every six months (304.17-090). |
| Claim forms | Furnished within 15 days, or the claimant may send proof in their own words (304.17-100) |
| Proofs of loss | Within 90 days. Late proof is allowed up to one year after it was due, unless the claimant lacked legal capacity (304.17-110). |
| Time of payment of claims | Non-periodic benefits within 30 days of proof. Periodic benefits at least monthly (304.17-120). |
| Payment of claims | To the beneficiary, or to the estate if none. The optional facility-of-payment clause allows up to $5,000 to a relative (304.17-130). |
| Physical examination and autopsy | At the insurer's expense while a claim is pending (304.17-140) |
| Legal actions | No suit until 60 days after proof of loss, and none after three years from when proof is required (304.17-150) |
| Change of beneficiary | Reserved to the insured. The beneficiary's consent isn't needed unless the designation is irrevocable (304.17-160). |
Free look (304.17-170)
- Every individual health policy except a nonrenewable accident policy lets the buyer return it within 10 days of delivery for a premium refund.
- The returned policy is void from the beginning.
Optional provisions
- Change of occupation (304.17-190). Benefits drop to what the premium buys at a more hazardous classification. A move to a less hazardous job lowers the rate and refunds the excess unearned premium.
- Misstatement of age (304.17-200).
- Relation of earnings to insurance (304.17-240):
- Benefits can be adjusted only after the loss-of-time benefit has been payable for 90 days.
- Combined benefits can't be cut below the lesser of $300 or the total benefits.
- Unpaid premium (304.17-250). Any premium due may be deducted from a claim.
- Illegal occupation (304.17-280). Loss caused in part by committing or attempting a felony, or by an illegal occupation, is excluded.
- Intoxicants and narcotics (304.17-290). Loss while intoxicated or under a narcotic or hallucinogen is excluded unless the drug was administered on a physician's advice.
Other Kentucky rules
- Type size. Policy text must be at least 10-point type (304.17-030(4)).
- Family policies may cover unmarried children to 19, and from 19 to 25 if full-time students primarily dependent on the policyholder (304.17-030(3)).
- Policy contents (304.14-150). Every policy except group, surety and title must state:
- the parties
- the subject of the insurance
- the risks insured
- when coverage starts and how long it runs
- the premium
- the conditions
- the benefits
- Applications (806 KAR 17:020). An agent-solicited application discloses other health coverage in force. The agent certifies that each question was asked and the answers recorded accurately.
- Replacement (806 KAR 12:060). In an individual health replacement, the agent gives the applicant a replacement notice to sign at the time of application.
- Claims handling (806 KAR 12:092):
- claim forms within 15 calendar days of notice
- a status letter 45 days after notice and every 45 days after that while the investigation continues
Common exam traps
- Notice of claim in Kentucky is 60 days, not 20.
- The time limit on certain defenses is three years for misstatements.
- A suit is barred after three years.
- Non-periodic claims are paid within 30 days.
- Facility of payment allows up to $5,000. The relation-of-earnings floor is $300.
- The free look is 10 days, except for nonrenewable accident policies.
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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.
