Free Individual Accident and Health Provisions Study Guide
New Mexico Life, Accident & Health exam — Individual Accident and Health Provisions.
The uniform individual accident and health policy provisions come from the NAIC model law and are explained in the national Individual Accident and Health Provisions guide. New Mexico enacted them in NMSA 1978, 59A-22, with some changes, most notably a 30-day reinstatement rule and a different time limit on certain defenses for major medical coverage. This guide lists the New Mexico version of each provision.
Required provisions
| Provision | New Mexico rule |
|---|---|
| Time limit on certain defenses | Policies other than major medical: after two years, only a fraudulent misstatement can void the policy or deny a claim (NMSA 1978, 59A-22-5(B)). Comprehensive major medical: a non-willful, non-fraudulent misstatement can't void coverage from issue, but the insurer may charge the correct premium going forward (59A-22-5(A)). |
| Grace period | At least 7 days for weekly-premium policies, 10 days for monthly-premium policies and 31 days for all others, such as quarterly or annual (NMSA 1978, 59A-22-6). |
| Reinstatement | If the insurer requires an application and gives a conditional receipt, the policy is reinstated on the 30th day after the receipt unless disapproved in writing before then. The reinstated policy covers injuries after reinstatement and sickness beginning more than 10 days later. Premium accepted on reinstatement can't be applied to any period more than 60 days before the reinstatement date (NMSA 1978, 59A-22-7). |
| Notice of claim | Written notice within 20 days after the loss begins, or as soon as reasonably possible. Notice to the insurer's office or any authorized agent counts (NMSA 1978, 59A-22-8). |
| Claim forms | Furnished within 15 days after notice. If not, the claimant may send written proof in any form (NMSA 1978, 59A-22-9). |
| Proof of loss | Within 90 days after the loss (for periodic payments, after the end of each period of liability). Late proof is accepted if given as soon as reasonably possible and, absent legal incapacity, within one year (NMSA 1978, 59A-22-10). |
| Time of payment of claims | Non-periodic benefits immediately on proof. Periodic benefits at least monthly (NMSA 1978, 59A-22-11). |
| Physical examination and autopsy | At the insurer's expense while a claim is pending, with autopsy where the law allows. |
| Legal actions | No suit until 60 days after proof of loss is furnished, and none more than three years after proof was required (NMSA 1978, 59A-22-14). |
| Change of beneficiary | The insured may change the beneficiary. Consent is needed only for an irrevocable beneficiary (NMSA 1978, 59A-22-15). |
Optional provisions
- Change of occupation: a move to a more hazardous job reduces benefits to what the premium would have bought at the higher rate. A move to a less hazardous job reduces the premium (NMSA 1978, 59A-22-17).
- Misstatement of age: benefits are what the premium would have bought at the true age.
Dependents and newborns
- Age 26: coverage for a dependent child can't end because of age before the 26th birthday, whether or not the child is in school (NMSA 1978, 59A-22-30.1).
- Disabled children: coverage continues for a child who can't support themselves because of a disability and is chiefly dependent on the insured, with proof due within 31 days of the limiting age (NMSA 1978, 59A-22-33).
- Newborns: covered from birth, including congenital defects. If an added premium applies, notice and payment may be required within 31 days (NMSA 1978, 59A-22-34).
- Adopted children are covered from placement, including conditions that existed before placement (NMSA 1978, 59A-22-34.1).
Free look on Medicare supplement policies
A Medicare supplement policy must let the buyer return it within 30 days of delivery for a refund (NMSA 1978, 59A-24A-10).
Common exam traps
- Reinstatement: 30th day after the conditional receipt in New Mexico, not 45.
- Back premium on reinstatement covers no more than 60 days before the reinstatement date.
- Major medical: innocent misstatements can't void the coverage from issue. Only rating changes going forward are allowed.
- Grace periods by premium mode: 7 weekly, 10 monthly, 31 for all others.
- 20 / 15 / 90 days: notice of claim, claim forms, proof of loss. The outside limit for late proof is one year.
- Age 26 regardless of student status, and 31 days for newborn notice.
Practice Individual Accident and Health Provisions questions All Life, 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.
