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17.1 NAIC Model Health Insurance Policy Provisions

The NAIC developed the Uniform Health Insurance Policy Provision Law in which 23 policy provisions are outlined.

Helpful Hint

The 11 optional provisions are considered to be at the discretion of the insurance company in order to better service their individual policy needs. However, it is prohibited to use any substitute language in any of the provisions unless, of course, the language used is for the benefit of the insured.

A clause is defined as a distinct article in a formal document. Policy clauses establish the rules in the contract that both the insured and the insurance company must adhere to. In this chapter, we will take a close look at some of them. It would be wise to understand and memorize these options.

MANDATORY PROVISIONS: Entire Contract, Time Limit on Certain Defenses, Grade Period, Reinstatement, Notice of Claims, Claims Forms, Proof of Loss, Time of Payment of Claims, Payment of Claims, Physical Exams and Autopsy, Legal Actions, Change of Beneficiary. OPTIONAL PROVISIONS: Change of Occupation, Misstatement of Age or Sex, Other Insurance with This Insurer, Insurance with Other Insurer, Insurance with Other Insurers, Relation of Earnings to Insurance, Unpaid Premiums, Cancellation, Conformity with State Statutes, Illegal Occupation, Intoxicants and Narcotics.