Free Individual Accident and Health Provisions Study Guide
Washington Accident & Health exam — Individual Accident and Health Provisions.
The national Individual Accident and Health Provisions guide covers the uniform provisions from NAIC Model 180 and what each one does. Washington's versions are in chapter 48.20 RCW, where the health line is called disability insurance. Washington differs from the model in three ways:
- misstatement of age or sex is a required provision
- the intoxicants and narcotics provision was repealed in 2004
- the time limit on certain defenses is two years
This guide covers those rules, the free look, and Washington's minimum standards for policy definitions (WAC 284-50-315 and -320).
Free look (RCW 48.20.013)
- Every individual disability policy may be returned within 10 days of delivery for a full refund. Single-premium nonrenewable policies are excepted.
- A refund not paid within 30 days carries a 10% penalty.
Required provisions
The Commissioner may approve substitute wording only if it is at least as favorable to the insured (RCW 48.20.032).
| Provision | Washington rule |
|---|---|
| Entire contract; changes (.042) | A change is valid only if an executive officer approves it and it is endorsed or attached. No producer may change or waive a provision. |
| Misstatement of age or sex (.050) | Required in Washington. Benefits are adjusted to what the premium would have bought at the correct age or sex. Underpaid benefits are paid with the current payment. Overpayments may be charged against later payments, with interest of no more than 6%. |
| Time limit on certain defenses (.052) | After two years from issue, only fraudulent misstatements may be used to void the policy or deny a claim. |
| Grace period (.062) | 7 days weekly, 10 days monthly, 31 days otherwise. |
| Reinstatement (.072) | Without approval or written disapproval, the policy is reinstated on the 45th day after the conditional receipt. It covers accidents after reinstatement and sickness beginning more than 10 days after. |
| Notice of claim (.082) | Written notice within 20 days after the loss begins, or as soon as reasonably possible. |
| Claim forms (.092) | If forms aren't sent within 15 days, written proof of the loss is enough. |
| Proof of loss (.102) | Within the policy period. Late proof is accepted if it wasn't reasonably possible sooner, but no later than one year, unless the claimant lacked legal capacity. |
| Time of payment (.112) | Paid immediately on proof. Periodic benefits are paid at least monthly. |
| Payment of claims (.122) | Death benefits go to the beneficiary, or the estate if none. A facility of payment amount of up to $1,000 may go to a relative. |
| Physical exam and autopsy (.132) | At the insurer's expense, as often as reasonably required during a claim. Autopsy only where the law allows. |
| Legal actions (.142) | No suit until 60 days after proof of loss and none after three years from when proof was required. |
| Change of beneficiary (.152) | The insured keeps the right to change the beneficiary. The beneficiary's consent isn't needed. |
Optional provisions include change of occupation, optional provision No. 14 (RCW 48.20.172). It reduces benefits to what the premium would buy at a more hazardous class.
Intoxicants and narcotics: Washington repealed this optional provision (RCW 48.20.272, repealed 2004 c 112). A Washington policy can't use it.
Minimum standards for definitions (WAC 284-50-315, -320)
- Accident: policies must use "accidental injury" (results) wording. They may not use "accidental means" or require external, violent or visible wounds.
- Probationary period: at most 30 days, or 90 days in a cancer-only policy. Accident policies may have none.
- Preexisting condition: the most restrictive definition allowed looks back five years.
- Sickness may exclude illness covered by workers compensation, occupational disease or employer's liability laws.
- Accidental death or injury benefits can't be limited to losses within less than one year of the accident (WAC 284-30-620).
Disability income definitions
- Total disability can't be defined only as being unable to do "any occupation whatsoever" (WAC 284-50-315(9)).
- Residual disability is tied to a loss of earnings and may require a period of total disability first.
- When both partial and total benefits are paid, only one elimination period may apply.
- Return-of-premium features are allowed on disability income policies only under listed conditions, including guaranteed renewability and a separately shown premium (WAC 284-50-320(4)).
- The disability income outline of coverage says the policy covers disability from accident or sickness, not hospital, medical-surgical or major medical expenses (WAC 284-50-410).
Common exam traps
- Misstatement of age or sex is a required provision in Washington. NAIC Model 180 lists it as optional.
- The intoxicants provision was repealed.
- The time limit on certain defenses is two years, not three.
- The free look is 10 days, with a 10% penalty after 30 days.
- The probationary period is capped at 30 days, and accident policies have none.
- An accidental death benefit must allow at least one year after the accident.
- Grace periods are 7/10/31 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.
