Free Individual Accident and Health Provisions Study Guide
Maine Accident & Health exam — Individual Accident and Health Provisions.
The national guide walks through the Uniform Individual Accident and Sickness Policy Provisions as written in NAIC Model 180. Maine enacted its own version in 24-A M.R.S. 2705–2729. Most provisions follow the model, but a few Maine numbers differ. The biggest differences are a 3-year time limit on certain defenses and a ban on the intoxicants exclusion in major medical coverage. This guide covers Maine's version.
Required provisions (Maine numbers)
| Provision | Maine rule |
|---|---|
| Entire contract; changes | The policy and attached papers are the whole contract. A change is valid only if an executive officer approves it and it's endorsed on or attached to the policy. No agent can change the policy or waive its terms (2705). |
| Time limit on certain defenses | After 3 years from the date of issue, the insurer can't void the policy or deny a claim for non-fraudulent misstatements in the application (2706). Many states use 2 years. Maine uses 3. |
| Grace period | At least 7 days for weekly-premium policies, 10 days for monthly, and 31 days for all others. Coverage continues during the grace period (2707). |
| Grace period and nonrenewal | If the insurer reserves the right to refuse renewal, the grace period applies unless it gave written notice of nonrenewal at least 30 days before the premium due date (2707). |
| Reinstatement | If the insurer accepts a late premium without requiring an application, the policy is reinstated. If it requires an application and issues a conditional receipt, the policy is reinstated on approval, or on the 45th day unless the insurer disapproves in writing first. Covers accidents after reinstatement and sickness that starts more than 10 days later (2708). |
| Notice of claim | Written notice within 20 days of the loss, or as soon as reasonably possible (2709). For loss-of-time benefits payable for at least 2 years, the insurer may require notice of continued disability every 6 months. |
| Claim forms | If the insurer doesn't send forms within 15 days of notice, the claimant can submit written proof in any form (2710). |
| Proof of loss | Within 90 days of the loss. Late proof is still accepted if given as soon as reasonably possible, and no later than 1 year after it was due unless the claimant lacked legal capacity (2711). |
| Time of payment | Benefits are paid immediately on proof. Periodic benefits are paid at least monthly (2712). |
| Payment of claims | Death benefits go to the beneficiary, or to the estate if no beneficiary designation is effective. Up to $1,000 may be paid to a relative when the payee is the estate, a minor or incompetent (2713). |
| Legal actions | No suit until 60 days after proof of loss. No suit later than 3 years after proof was required (2715). |
| Change of beneficiary | The insured controls a revocable designation. The beneficiary's consent isn't needed (2716). |
Optional provisions
- Change of occupation (2719): if the insured moves to a more hazardous job, benefits are cut to what the premium would buy at the riskier occupation's rates.
- Unpaid premium (2725): premium due and unpaid can be deducted from a claim payment.
- Conformity with state statutes (2726): a provision that conflicts with Maine law is automatically amended to meet the minimum.
- Intoxicants and narcotics (2728): Maine bars this exclusion in major medical coverage. It's still allowed in accident-only, specified disease, hospital indemnity, dental, vision, disability income, LTC, Medicare supplement and other limited benefit policies.
Other Maine individual health rules
- Free look: every individual health policy must allow return within 10 days of delivery for a full refund. This doesn't apply to nonrenewable accident-only or credit health policies (2717).
- Renewal refusal: refusing to renew can't affect a claim that started while the policy was in force (2729).
- Noncancellable disability: a contract the insurer can't cancel or terminate at or after one year from its effective or renewal date (2737).
- Premium notice: a policy can't lapse for nonpayment until 3 months after the due date, unless the insurer mailed a premium notice 10 to 45 days before the due date (2739).
- Assignment: the insured must be able to assign benefits to the health care provider (2755).
- Third-party notice: the insurer must send a cancellation notice to a designated third party at least 10 days before cancellation (Rule 580).
- Cognitive impairment: if a policy lapses because of cognitive impairment, it may be reinstated on request within 90 days, with no gap in coverage and no new evidence of insurability (2707-A; Rule 580).
Common exam traps
- Time limit on certain defenses: 3 years in Maine, not 2.
- Grace periods: 7 / 10 / 31 days (weekly / monthly / other).
- Notice of claim 20 days. Forms 15 days. Proof 90 days, with an outside limit of 1 year.
- No suit before 60 days or after 3 years from when proof was required.
- Major medical can't exclude losses caused by intoxicants. Disability income can.
- Individual health free look: 10 days.
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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.
