Free Individual Accident and Health Provisions Study Guide
North Dakota Accident & Health exam — Individual Accident and Health Provisions.
The uniform individual policy provisions and how they work are covered in the national Individual Accident and Health Provisions guide, based on NAIC Model 180. North Dakota enacts its own version in N.D.C.C. 26.1-36-04. North Dakota's version differs from the model in several places the exam targets:
- a 31-day grace period for every premium mode
- a $5,000 facility-of-payment amount
- a premium refund at death
- a relation of earnings provision with its own floor
- a cancellation provision among its optional provisions, which the current NAIC model no longer includes
Required provisions (26.1-36-04(1))
| Provision | North Dakota rule |
|---|---|
| Entire contract; changes | A change is valid only if an executive officer approves it by endorsement. No producer may change or waive a provision |
| Time limit on certain defenses | After two years, the policy's validity can't be contested except for nonpayment. Defenses based on ineligibility remain |
| Preexisting conditions | Limited to conditions treated or advised in the two years before the effective date. The limitation can't apply after two years of coverage |
| Grace period | 31 days for every premium after the first, regardless of premium mode |
| Reinstatement | With a conditional receipt, the policy is reinstated on the 45th day unless disapproved in writing. Sickness is covered if it begins more than 10 days after reinstatement. Reinstatement premium can't apply to periods more than 60 days back |
| Notice of claim | Within 20 days after the loss begins, or as soon as reasonably possible |
| Claim forms | Furnished within 15 days. If not, the claimant may send written proof in any form |
| Proof of loss | Within 90 days. Late proof is accepted if given as soon as reasonably possible, but no later than one year, unless the claimant lacked legal capacity |
| Time of payment | Loss-of-time benefits are paid at least monthly |
| Payment of claims | Death benefits go to the beneficiary, and all other benefits to the insured. A facility-of-payment clause may pay up to $5,000 to a relative |
| Physical exam and autopsy | As often as reasonably required during a claim. Autopsy where not prohibited by law |
| Legal actions | No suit until 60 days after proof of loss is filed, and none more than three years after proof was due |
| Premium refund at death | Unearned premium is refunded within 30 days after notice of the insured's death (26.1-36-04(1)(n)) |
Optional provisions (26.1-36-04(2))
- Change of occupation. A move to a riskier job reduces benefits to what the premium buys at the higher rate. A move to a safer job lowers the rate and refunds the excess premium.
- Misstatement of age. Benefits become what the premium would have bought at the correct age.
- Other insurance in this insurer. Coverage above the stated maximum is void, and that premium is returned.
- Unpaid premium. May be deducted from a claim payment.
- Cancellation. North Dakota's statute still lists it as an optional provision. The insurer may cancel on at least five days' notice with a pro rata refund. If the insured cancels, the refund uses the short-rate table.
- Conformity with state statutes. Conflicting provisions are amended to meet the statute.
- Illegal occupation. No liability for losses where committing or attempting a felony, or an illegal occupation, contributed.
- Relation of earnings to insurance (26.1-36-04(2)(h)):
- The adjustment applies only after loss-of-time benefits have been payable for 90 days.
- The percentage of earnings used can't be less than 60%.
- Benefits are never cut below the lesser of $300 or the unadjusted combined benefits.
Rules outside the uniform provisions
- Free look (26.1-36-02.1). 10 days from delivery, with the notice on the first page.
- Intoxicants. North Dakota requires hospital, medical, surgical and major medical policies to cover losses from intoxication or narcotics, subject only to the illegal-act limitations (26.1-36-09.13). They must also cover suicide attempts and self-inflicted injury (26.1-36-09.12).
- Prompt payment. A health insurer acts on a claim within 15 business days (26.1-36-37.1).
- Applications. A misrepresentation voids coverage only if made with intent to deceive or if it increased the risk (26.1-29-25).
Common exam traps
- The North Dakota grace period is 31 days for every mode, not 7, 10 or 31 by mode.
- Facility of payment is $5,000.
- The preexisting condition look-back is two years.
- Notice of claim: 20 days. Claim forms: 15 days. Proof of loss: 90 days. Legal actions: wait 60 days, sue within 3 years.
- North Dakota doesn't allow the usual intoxicants exclusion in medical expense 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.
