Free Individual Accident and Health Provisions Study Guide
Texas General Lines — Life, Accident, Health & HMO exam — Individual Accident and Health Provisions.
Texas puts the uniform individual accident and health provisions in TIC Chapter 1201, Subchapter E (1201.207 and following). The free look and dependent rules are at 1201.058 and 1201.059. The national guide explains NAIC Model 180's provisions in general. This guide gives the Texas versions and time limits.
Free look and dependents
- Free look: an individual A&H policy may be returned within 10 days after delivery for a full premium refund. It's then void from issue (1201.058).
- Single-premium nonrenewable policies are excepted.
- Disabled dependent child: coverage continues past the limiting age if proof of incapacity and dependency is given within 31 days after the child reaches that age (1201.059). After two years, the insurer can ask for proof no more than once a year.
Uniform provisions
| Provision | Texas rule |
|---|---|
| Entire contract; changes (1201.207) | A change is valid only if an executive officer approves it and it's endorsed or attached. Agents can't change or waive provisions. |
| Time limit on certain defenses (1201.208) | After 2 years, non-fraudulent misstatements can't void the policy or deny a claim. A condition not excluded by name can't be denied as preexisting. |
| Grace period (1201.209) | At least 7 days for weekly premiums, 10 days for monthly, 31 days for others. If the insurer reserves the right not to renew, the grace period doesn't apply when it gives notice at least 5 days before the due date. |
| Reinstatement (1201.210) | If an application is required, the policy is reinstated on approval or on the 45th day after the conditional receipt. Accidents are covered right away. Sickness is covered only if it begins more than 10 days later. |
| Notice of claim (1201.211) | Within 20 days after the loss begins, or as soon as reasonably possible. |
| Claim forms (1201.212) | Due within 15 days of notice. If they're late, written proof of the loss is enough. |
| Proof of loss (1201.213) | Within 90 days. Late proof is accepted if given as soon as reasonably possible, but no later than 1 year after it was due unless the claimant lacked legal capacity. |
| Time of payment (1201.214) | On receipt of written proof. Periodic benefits are paid at least monthly. |
Underwriting rules (28 TAC 21.704, 21.705)
- An HIV test requires written authorization on TDI's separate consent form. Results are confidential.
- An adverse decision requires an initial and a second positive ELISA, confirmed by a Western Blot.
- Insurers can't ask questions designed to find out an applicant's sexual orientation.
- An adverse decision can't rest on the applicant having had counseling about AIDS-related concerns.
Common exam traps
- Free look: 10 days, and the policy is void from issue.
- Grace periods: 7 / 10 / 31 days.
- Notice of claim: 20 days. Claim forms: 15 days. Proof of loss: 90 days, with a 1-year outer limit.
- After reinstatement, sickness is covered only if it starts more than 10 days later.
- Agents can't waive or change policy provisions.
Practice Individual Accident and Health Provisions questions All General Lines — Life, Accident, Health & HMO 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.
