Free Individual Accident and Health Provisions Study Guide
Maryland 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. Maryland's version is in Insurance Article §§ 15-207 to 15-226. Most numbers follow the familiar pattern. The Maryland differences to know are:
- the intoxicants and illegal occupation exclusions are allowed only on disability income and AD&D benefits, not medical expense benefits
- a 10-day free look
- a three-year suit limit
Required provisions
| Provision | Maryland rule |
|---|---|
| Entire contract; changes | The policy, endorsements and attached papers. Only an executive officer can approve a change, by endorsement. Producers can't change or waive provisions (§ 15-207). |
| Time limit on certain defenses | After 2 years from issue, no misstatement except a fraudulent one may void the policy or deny a claim (§ 15-208). |
| Grace period | 7 days weekly, 10 days monthly, 31 days for all others (§ 15-209) |
| Reinstatement | Reinstated on the 45th day after the conditional receipt unless disapproved. Sickness is covered if it begins more than 10 days after reinstatement. Premium can't be applied to a period more than 60 days before reinstatement (§ 15-210). |
| Notice of claim | Within 20 days of the loss, or as soon as reasonably possible. For long-term disability benefits, notice of continuing disability may be required every 6 months (§ 15-211). |
| Claim forms | Within 15 days, or written proof may be sent without them (§ 15-212) |
| Proofs of loss | Within 90 days. Late proof is allowed up to 1 year after it was due, absent legal incapacity (§ 15-213). |
| Time of payment of claims | Immediately on proof. Periodic benefits are paid at least monthly (§ 15-214). |
| Payment of claims | To the insured, or for loss of life to the beneficiary (or the estate). Facility of payment up to $1,000. Medical benefits may be paid directly to providers (§ 15-215). |
| Physical examination and autopsy | At the insurer's expense while a claim is pending, with autopsy where not forbidden by law (§ 15-216) |
| Legal actions | No suit until 60 days after proof, and none after 3 years from when proof is required (§ 15-217) |
| Change of beneficiary | A revocable beneficiary can be changed without consent (§ 15-218). |
Optional provisions include:
- change of occupation (§ 15-219)
- misstatement of age (§ 15-220)
- relation of earnings to insurance (§ 15-224)
- unpaid premium (§ 15-225)
- conformity with state statutes (§ 15-226)
Maryland-specific rules
Exclusions limited to disability and AD&D (COMAR 31.10.28.03). An individual health contract may not exclude medical expense benefits for losses caused by:
- committing a crime
- an illegal occupation
- being intoxicated or under a non-prescribed narcotic
These exclusions are allowed only on disability income and AD&D benefits.
Preexisting conditions. A condition the applicant disclosed on the application can be excluded only by a signed waiver rider.
Free look (§ 15-201(h)). An individual health policy may be returned within 10 days after delivery for a pro rata refund.
Renewability (§§ 15-203, 15-209(b)). A policy that reserves the right to refuse renewal:
- may not refuse renewal solely because the insured's health changed
- may refuse only on an anniversary
- needs at least 30 days' written notice before the premium due date
Form filing (§ 12-203). Health and life forms are filed at least 60 days before use. They are deemed approved if not acted on.
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.
- A suit may be filed after 60 days and no later than 3 years after proof is required.
- Intoxicant and illegal occupation exclusions apply only to disability income and AD&D benefits.
- The free look is 10 days. Nonrenewal notice is 30 days, and health changes can't be the reason.
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.
