Free Individual Accident and Health Provisions Study Guide
Virginia Accident & Health exam — Individual Accident and Health Provisions.
Virginia sets out the individual accident and sickness provisions in Va. Code 38.2-3503 (required) and 38.2-3504 (other, optional). The free look is in 38.2-3502, and the minimum standards are in 14VAC5-141. Virginia's lists differ from current NAIC Model 180 in two ways. Its required list includes cancellation by the insured. Its optional list still includes cancellation by the company and intoxicants and narcotics. Learn the Virginia versions. The general concepts are in the national guide.
Free look (38.2-3502)
- An individual accident and sickness policy may be returned within 10 days of receipt for a prompt refund. It's then void from inception.
- The notice also tells the owner to report any misstatement or omitted medical history in the attached application.
Required provisions (38.2-3503)
| Provision | Virginia rule |
|---|---|
| Entire contract | The policy, endorsements and attached papers. Changes need an executive officer's approval and an endorsement. No agent may change or waive provisions. |
| Time limit on certain defenses | After 2 years, only fraudulent misstatements can void the policy or deny a claim. Under the alternative form, a claim starting after 1 year can't be denied because of a condition that existed before coverage and wasn't excluded by name. |
| Grace period | 7 days for weekly premiums, 10 days for monthly, 31 days for others. The policy stays in force. |
| Reinstatement | On the 45th day after a conditional receipt unless disapproved. Sickness is covered only if it begins more than 10 days later. Premium can't be applied more than 60 days back. |
| Notice of claim | Within 20 days of the loss. For disability benefits payable 2+ years, notice of continued disability every 6 months. |
| Claim forms | Within 15 days. If late, a written statement serves as proof. |
| Proof of loss | Within 90 days, or as soon as reasonably possible, but within 1 year unless the claimant lacked legal capacity. |
| Time of payment | On proof. Periodic benefits are paid at least monthly. Interest at the legal rate runs from 15 working days after proof (38.2-3407.1). |
| Payment of claims | Facility of payment of up to $2,000 to a relative. |
| Physical exam and autopsy | As often as reasonably necessary, at the insurer's expense. |
| Legal actions | Not within 60 days after proof. Not after 3 years. |
| Change of beneficiary | The insured may change it without the beneficiary's consent, unless the designation is irrevocable. |
| Cancellation by insured | At any time. Unearned premium is refunded pro rata. |
Other (optional) provisions (38.2-3504)
| Provision | Virginia rule |
|---|---|
| Change of occupation | A riskier job reduces benefits. A safer job lowers the rate and refunds the excess. |
| Relation of earnings | Can't reduce total monthly benefits below $200, or below the sum of the stated benefits if less. |
| Unpaid premium | Premium that's due may be deducted from a claim. |
| Cancellation by the company | Notice of at least 7 / 10 / 31 days, depending on the premium mode. |
| Intoxicants and narcotics | Excludes losses while drunk or under a narcotic, unless the narcotic was taken on a doctor's advice. |
Other Virginia rules
- A claim can't be denied for a condition the applicant didn't know and couldn't reasonably have known about (38.2-3514).
- Prior coverage is credited if it was continuous to within 30 days (38.2-3514.1).
- A form number appears in the lower left corner of each form's first page (38.2-3500).
- Disability income minimums (14VAC5-141-60):
- maximum elimination periods of 30 / 90 / 180 days, by benefit length
- individual benefit periods of at least 180 days
- at least 30 days after an accident for the loss to begin
- complications of pregnancy must be covered
- Dental plans may use waiting periods of up to 12 months, or 24 months for orthodontics (14VAC5-141-70).
- Guaranteed renewable policies may change rates only by class. Noncancelable policies can't change premium or provisions.
Common exam traps
- Free look: 10 days from receipt.
- Grace periods: 7 / 10 / 31 days.
- Notice of claim: 20 days. Claim forms: 15 days. Proof of loss: 90 days. Suits: 60 days to 3 years.
- Cancellation by the insured is a required provision in Virginia, with a pro rata refund.
- Facility of payment is up to $2,000.
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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.
