Free Individual Accident and Health Provisions Study Guide
Nebraska Life, Accident & Health exam — Individual Accident and Health Provisions.
The uniform individual policy provisions are covered in the national Individual Accident and Health Provisions guide, based on NAIC Model 180. Nebraska's versions are in Neb. Rev. Stat. 44-710.03 (required provisions) and 44-710.04 (optional provisions). Nebraska differs from the model in a few places. It makes conformity with state and federal law a required provision, allows a $5,000 facility of payment, and keeps a cancellation provision among its optional provisions.
Required provisions (44-710.03)
| Provision | Nebraska rule |
|---|---|
| Entire contract; changes | A change is valid only with an executive officer's approval, endorsed on or attached to the policy. No agent may change the policy or waive a provision |
| Time limit on certain defenses | After two years from issue, non-fraudulent misstatements can't void the policy or deny a claim. After two years, a claim can't be denied because a condition not excluded by name or specific description existed before coverage |
| Grace period | 7 days for weekly premiums, 10 days for monthly, 31 days for all others |
| Reinstatement | With a conditional receipt and no written disapproval, the policy is reinstated on the 45th day. Sickness is covered if it begins more than 10 days after reinstatement. Premium can't apply to periods more than 60 days back |
| Notice of claim | Within 20 days after a loss. The policy may require notice of continuing disability at least once every six months |
| Claim forms | Furnished within 15 days. If not, written proof of the loss in any form complies |
| Proof of loss | Within 90 days. Late proof is accepted if given as soon as reasonably possible, but no later than one year after it was due, unless the claimant lacked legal capacity |
| Time of payment | Non-periodic benefits are paid immediately on proof. Periodic benefits are paid at least monthly |
| Payment of claims | Payments go to the beneficiary or insured. Facility of payment up to $5,000 to a relative. Benefits for hospital, nursing, medical or surgical services may be paid directly to the provider unless the insured asks otherwise in writing |
| Physical exam and autopsy | At the insurer's expense while a claim is pending. Autopsy where not forbidden by law |
| Legal actions | No suit until 60 days after proof of loss, and none more than three years after proof was required |
| Change of beneficiary | Reserved to the insured. Beneficiary consent is needed only if the designation is irrevocable |
| Conformity with state and federal law | A required provision in Nebraska. Conflicting terms are amended to meet the law |
Optional provisions (44-710.04)
- Change of occupation. Moving to a riskier job limits benefits to what the premium buys at the higher rate. Moving to a safer job lowers the rate and refunds the excess pro rata.
- Misstatement of age. Benefits become what the premium would have bought at the correct age.
- Relation of earnings to insurance. Benefits are reduced proportionately when total coverage exceeds earnings. Earnings means the greater of earnings when disability began, or average earnings over the two years before.
- Unpaid premium. Premium due may be deducted from a claim payment.
- Cancellation. Nebraska's statute still lists it as an optional provision. The insurer must mail written notice by certified or registered mail at least 30 days before cancellation, except for nonpayment or fraud.
- Illegal occupation. No liability where committing or attempting a felony, or an illegal occupation, contributed to the loss.
- Intoxicants and narcotics. Losses while intoxicated or under a narcotic not taken on a physician's advice may be excluded.
Other individual policy rules
- Free look (44-710.18). The buyer may return an individual sickness and accident policy within 10 days of delivery for a refund. Single-premium nonrenewable policies are excepted.
- The application (44-710.12):
- The insured isn't bound by any statement in the application unless a copy is attached to the policy when issued.
- If the insurer doesn't provide a copy of a reinstatement application within 15 days of a written request, it can't use that application as evidence.
- Disabled dependents stay covered past the limiting age if proof is given within 31 days (44-710.01(3)).
- Claim handling (210 NAC 61) runs on 15-working-day deadlines to acknowledge, investigate, decide and pay.
Common exam traps
- Nebraska makes conformity with state and federal law a required provision.
- The facility-of-payment cap is $5,000.
- Insurer cancellation under the optional provision needs 30 days' notice by certified or registered mail.
- Grace periods: 7 days weekly, 10 monthly, 31 for all other modes.
- Notice of claim: 20 days. Claim forms: 15 days. Proof of loss: 90 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.
