Free Individual Accident and Health Provisions Study Guide
Massachusetts Life, 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. Massachusetts enacted its version in M.G.L. c.175 s.108. Most provisions follow the familiar pattern, with three Massachusetts differences to know:
- the physical examination provision has no autopsy right
- suits may be brought for up to three years after proof is required
- Massachusetts law doesn't require a free-look provision in individual health policies
Required provisions (s.108(3)(a))
| Provision | Massachusetts rule |
|---|---|
| Time limit on certain defenses | After two years from issue, no misstatement except a fraudulent one may void the policy or deny a claim. |
| Grace period | 7 days weekly, 10 days monthly, 31 days for all others |
| Reinstatement | Without approval or a written disapproval, reinstated on the 45th day after the conditional receipt. Sickness is covered if it begins more than 10 days after reinstatement. |
| Notice of claim | Within 20 days after the loss, or as soon as reasonably possible. For loss-of-time benefits payable two years or more, the insurer may require notice of continued disability every six months. |
| Claim forms | Furnished within 15 days of notice, or the claimant may send written proof without them |
| Proofs of loss | Within 90 days. Late proof is allowed up to one year after it was due, absent legal incapacity. |
| Payment of claims | To the beneficiary, or the estate if none. A facility of payment clause allows up to $1,000 to a relative. |
| Physical examinations | At its own expense, the insurer may examine the insured as often as reasonably required while a claim is pending. The Massachusetts provision has no autopsy right. |
| Legal actions | No suit until 60 days after proof of loss, and none after three years from when proof is required |
Optional provisions (s.108(3)(b))
The overinsurance provision is allowed only in an individually underwritten policy whose loss-of-time benefit may be payable for at least 52 weeks.
Other Massachusetts rules for individual health policies
- Accident-only policies (s.108(9)). The first page must say, in bold or contrasting type, that the policy covers accident only and pays nothing for sickness.
- Cancellable at 65 (s.110H). If a policy may be cancelled when the insured reaches 65, the insurer gives 60 days' notice. Without it, coverage continues until notice is given or until 90 days after the 65th birthday, whichever comes first.
- Family policies must cover children under 26 (s.108(2)(a)(3)). A disabled child stays covered past the limiting age if proof arrives within 31 days.
- Newborns are covered from the moment of birth (s.47C).
- Prompt payment (s.108(4)(c)). An unpaid and unexplained claim accrues 1.5% per month interest after 45 days, up to 18% a year.
- Disability insurance discrimination. Disability insurers may not discriminate based solely on:
- race, color, creed, national origin, sex, pregnancy, gender identity, sexual orientation or marital status (s.108N)
- past or planned lawful travel (s.108J)
- Genetic tests (s.108I). Disability and LTC applications may ask about genetic tests, but the applicant need not answer and must be told so.
- Readability (s.2B). Covered policy forms need a Flesch score of at least 50, 10-point type, and a table of contents or index.
Common exam traps
- The time limit on certain defenses is two years.
- Grace periods are 7 / 10 / 31 days. Notice of claim is due in 20 days, claim forms in 15, and proof of loss in 90.
- The physical examination provision has no autopsy right in Massachusetts.
- A suit is barred three years after proof is required.
- The facility of payment limit is $1,000.
- The overinsurance provision needs at least a 52-week benefit.
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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.
