Washington Life & Health Insurance Exam — All Questions

Under the Uniform Provisions Law, the 'time limit on certain defenses' (incontestability) provision in an individual health policy generally prevents the insurer, after the policy has been in force for a stated period, from:

• a.Ever raising premiums on the class of policyholders
• b.Requiring proof of loss for a claim
• c.Denying a claim based on misstatements in the application (except fraudulent ones, where permitted)✓
• d.Paying benefits on time

The time-limit-on-certain-defenses (incontestability) provision bars the insurer, after the policy has been in force for a set period (often two or three years), from voiding the policy or denying a claim because of misstatements made in the application, with an exception for fraudulent misstatements where state law allows. It does not restrict the insurer's right to adjust premiums for a whole class, nor does it eliminate the routine requirement that the insured submit proof of loss. Paying benefits on time is required by a separate provision (time of payment of claims), not this one.

A 'pre-existing condition' provision in a health policy generally allows the insurer to:

• a.Limit or exclude coverage for a condition the insured had before the policy took effect, for a stated period✓
• b.Refuse to ever pay for accidents
• c.Increase the death benefit for prior illnesses
• d.Cancel the policy whenever the insured files any claim

A pre-existing condition provision lets the insurer limit or exclude benefits for a medical condition that existed (was diagnosed or treated, or would have prompted a prudent person to seek care) before the policy's effective date, typically for a defined waiting period after which the condition is covered. It is not a general right to cancel the policy upon any claim, and it does not let the insurer refuse all accident coverage. Health policies pay medical or disability benefits, not a death benefit, so the last option is inapplicable.

The mandatory 'notice of claim' provision requires the insured to notify the insurer of a claim within:

• a.Six months after treatment ends
• b.Exactly five days, with no exceptions permitted for any reason, which is stricter than the actual provision
• c.A stated period, typically 20 days after a loss or as soon as reasonably possible✓
• d.One full year after the loss

The notice of claim provision requires the insured to tell the insurer that a loss has occurred within a stated time, commonly 20 days after the loss or as soon as reasonably possible. A rigid five-day rule, six months, or a full year does not match the standard uniform provision. Prompt notice lets the insurer begin processing and, if needed, investigate the claim. This is the first step in the claims sequence, followed by claim forms and proof of loss.

Under the 'claim forms' provision, if the insurer fails to furnish claim forms within the required time (usually 15 days) after receiving notice of claim, the insured may:

• a.Immediately file a lawsuit against the insurer without first submitting any proof of the loss
• b.Automatically receive double the benefit
• c.Submit written proof of the loss in their own words and still be considered compliant✓
• d.Cancel the policy and demand a refund

If the insurer does not supply claim forms within the stated period after notice, the insured is allowed to submit written proof of the loss in their own words (describing the nature and extent of the loss) and is treated as having complied with the proof requirement. The insured is not entitled to sue immediately, cancel for a refund, or collect double benefits. This provision keeps the insurer's delay from defeating an otherwise valid claim.

The mandatory 'proof of loss' provision generally requires the insured to submit proof of loss within:

• a.Five days after the loss occurs
• b.A stated period, commonly 90 days after the date of the loss✓
• c.Three years after treatment
• d.Ten years after the policy is issued, which is far too long a period

The proof of loss provision typically requires written proof within 90 days after the loss (or as soon as reasonably possible, and not later than one year except in cases of legal incapacity). Five days is too short, and three or ten years is far too long. Proof of loss documents the details the insurer needs to determine what it owes. Failing to provide timely proof can jeopardize a claim, which is why the 90-day standard is worth remembering.

The mandatory 'time of payment of claims' provision requires the insurer to pay claims:

• a.No sooner than two years after the loss has occurred, which would defeat the purpose of prompt payment
• b.Only once at the end of the year
• c.Whenever the insurer chooses to
• d.Promptly, immediately or within a stated number of days after it receives proof of loss✓

The time of payment of claims provision requires the insurer to pay benefits promptly, immediately or within a specified number of days after receiving acceptable proof of loss, so a valid claim is not left unpaid. Paying at the insurer's discretion, only at year-end, or after a two-year delay would defeat the purpose. This provision protects insureds from unreasonable delays once they have properly documented a covered loss.

The mandatory 'payment of claims' provision specifies:

• a.The length of the elimination period before benefits begin, which is a separate matter from who is paid a claim
• b.To whom benefits are paid, generally the insured, with death benefits going to a named beneficiary✓
• c.The premium the insured must pay
• d.The size of the policy's deductible

The payment of claims provision states who receives the benefit money: benefits are ordinarily paid to the insured, while any death benefit under the policy is paid to the designated beneficiary (or the estate if none is named). It does not set the premium, the deductible, or the elimination period, which are addressed elsewhere. This provision ensures there is a clear, contractually defined recipient for each type of benefit.

The mandatory 'physical examination and autopsy' provision gives the insurer the right, at its own expense, to:

• a.Raise the insured's premium
• b.Have the insured examined during a pending claim and, where not prohibited by law, require an autopsy✓
• c.Cancel the policy during a claim it is investigating, which this examination-and-autopsy provision does not authorize
• d.Deny every claim automatically

This provision permits the insurer, at its own cost and as often as reasonably necessary while a claim is pending, to have the insured physically examined and, in the event of death, to require an autopsy unless state law forbids it. It does not allow the insurer to deny all claims, raise premiums, or cancel the policy. The right exists so the insurer can verify the nature and extent of a loss it is being asked to pay.

The mandatory 'legal actions' provision prevents an insured from bringing a lawsuit against the insurer until:

• a.A stated time (often 60 days) after proof of loss has been filed, and bars suits brought after an outer limit such as three years✓
• b.One day after filing any claim
• c.The moment the policy is issued
• d.The insured has switched insurers and obtained a replacement policy elsewhere, which has nothing to do with the timing rules this provision sets for filing suit

The legal actions provision sets a window for lawsuits: the insured cannot sue for at least a stated period (commonly 60 days) after submitting proof of loss, giving the insurer time to pay, and cannot sue after an outer limit (often three years) from when proof was due. It is not tied to policy issuance, a one-day wait, or changing insurers. This provision gives the insurer a fair chance to settle before litigation and sets a deadline for claims disputes.

The optional 'change of occupation' provision allows the insurer to adjust benefits or premiums if the insured:

• a.Moves to a different state
• b.Purchases a second unrelated policy from another insurer
• c.Gets married or divorced
• d.Changes to a more hazardous or less hazardous occupation✓

The change of occupation provision lets the insurer modify the benefit or premium when the insured switches to a job with a different risk level: a more hazardous occupation may reduce benefits to what the premium would buy at the higher risk, while a less hazardous one may lower the premium and refund the difference. It is not triggered by relocating, marrying, or buying another policy. The provision keeps the coverage aligned with the actual occupational risk being insured.

Under the misstatement of age provision in a health policy, if the insured's age was understated on the application, the benefits are:

• a.Adjusted to the amount the premium actually paid would have purchased at the insured's correct age✓
• b.Automatically doubled as a penalty on the insurer for accepting an application that stated an incorrect age
• c.Voided entirely, ending the policy
• d.Left completely unchanged

The misstatement of age provision does not void the policy; instead, if the age was misstated, the benefit is adjusted to what the premiums paid would have bought at the true age, so an understated age (which meant an underpaid premium) results in a proportionately reduced benefit. The policy is not canceled, benefits are not doubled, and they are not left unchanged. This keeps the insurer's payout consistent with the premium that was actually charged.

A 'probationary period' in a health insurance policy is:

• a.The time allowed to return a new policy for a refund, which is actually the free-look provision rather than an initial waiting period on coverage
• b.The days of leeway to pay a late premium
• c.A schedule for making premium payments
• d.An initial waiting period after the policy takes effect before benefits for certain conditions, such as sickness, are covered✓

A probationary period is an initial span of time (often the first few weeks) after the policy's effective date during which losses from certain causes, commonly sickness, are not yet covered, reducing the risk of insuring someone already becoming ill. It is not the free-look period, the grace period, or a payment schedule. The probationary period is a one-time waiting period at the start of coverage, distinct from the recurring grace period for premium payments.

The free-look provision in a health insurance policy allows the policyowner to:

• a.Change who is insured under the policy
• b.Permanently increase the policy's benefits beyond what was originally issued, which the free-look provision does not do
• c.Skip paying the first premium
• d.Examine the policy for a stated number of days and return it for a full premium refund if not satisfied✓

The free-look provision gives the policyowner a set number of days after receiving the policy to review it and, if dissatisfied for any reason, return it for a full refund of premium as though it were never issued. It does not let the owner skip a premium, change the insured, or increase benefits. The free look is a consumer protection ensuring buyers have time to make sure the coverage meets their needs before committing.

The insuring clause of a health insurance policy:

• a.Names the producer who sold the policy
• b.Sets the schedule for paying premiums
• c.States the insurer's promise to pay benefits for covered losses and defines the basic scope of coverage✓
• d.Lists the conditions the policy will not cover, which is the function of the exclusions rather than the insuring clause

The insuring clause is the insurer's core promise: it states that the insurer will pay benefits for the losses the policy covers and broadly defines the coverage being provided. Listing what is not covered is the function of the exclusions. Setting the premium schedule is a separate provision, and naming the producer is not part of the insuring clause. The insuring clause establishes the fundamental agreement to provide coverage, from which the rest of the policy elaborates.

An impairment (exclusion) rider attached to a health insurance policy:

• a.Permanently excludes coverage for a specified pre-existing condition or body part✓
• b.Adds coverage for a brand-new condition that first arises after the policy is issued
• c.Reduces the policy's deductible
• d.Increases the overall benefit amount

An impairment rider (also called an exclusion rider) allows the insurer to issue a policy while excluding a particular existing condition or body part from coverage, so the applicant can be insured for everything else. It does not add coverage, lower the deductible, or increase benefits, its effect is to remove coverage for the named impairment. This rider lets an insurer cover an otherwise higher-risk applicant by carving out the specific problem.

The optional provision addressing 'other insurance in this insurer' is concerned with:

• a.The size of the medical deductible
• b.Situations where an insured holds multiple policies with the same insurer, limiting total benefits to prevent overinsurance✓
• c.The insured's separate life insurance policies held with other companies, which is unrelated to holding duplicate health policies with the same insurer
• d.The length of the elimination period

This optional provision applies when an insured has more than one policy of the same kind with the same insurer; it lets the insurer limit the total benefits payable (often refunding the premium for the excess coverage) so the insured cannot be overinsured and profit from a loss. It does not concern separate life insurance, the deductible, or the elimination period. The provision reflects the principle that health coverage should reimburse loss, not create a gain from duplicate policies.

The mandatory 'notice of claim' provision generally requires the insured to notify the insurer of a claim within:

• a.Within 24 hours of any covered loss, or else the insurer becomes entitled to deny the entire claim outright
• b.One full year after the loss
• c.A stated time such as 20 days after a loss, or as soon as reasonably possible✓
• d.Exactly 90 days in every case

Notice of claim typically must be given within about 20 days of a loss or as soon as reasonably possible. It is not a strict 24-hour, one-year, or fixed 90-day rule.

Under the 'claim forms' mandatory provision, if the insurer fails to furnish claim forms within a set time (often 15 days) after notice, the insured may:

• a.Submit written proof of loss in their own words describing the occurrence, character, and extent of loss✓
• b.Wait indefinitely with no consequence
• c.Sue the insurer immediately without further steps
• d.Lose the right to the claim entirely, since proof of loss cannot be submitted without the insurer's official forms

If the insurer does not send claim forms promptly, the insured satisfies the requirement by submitting proof of loss in their own words. The claim is not forfeited, nor does this provision authorize immediate suit.

The 'proof of loss' mandatory provision typically requires the insured to furnish written proof within:

• a.10 days of the loss
• b.24 hours of the loss
• c.3 years of the loss
• d.90 days after the loss, or as soon as reasonably possible✓

Proof of loss is generally due within 90 days of the loss, or as soon as reasonably possible where 90 days is not feasible. The other intervals do not reflect the uniform provision.

The 'time of payment of claims' provision requires the insurer to pay claims:

• a.Only at the end of the calendar year
• b.Immediately, or within a stated period, after receiving acceptable proof of loss✓
• c.Only after the contestable period ends
• d.Whenever the insurer chooses, since no provision sets a firm deadline for paying an approved claim to the insured

This provision requires prompt payment once proof of loss is received, within the period the provision states. The insurer cannot delay at will or hold claims for year-end or the contestable period.

The 'legal actions' mandatory provision states that an insured may not sue the insurer until a set time after proof of loss, and no later than a stated outer limit. Those periods are commonly:

• a.1 year and 2 years
• b.immediately and never
• c.60 days after proof of loss and no more than 3 years after proof was required✓
• d.10 days and 6 months

The legal actions provision typically bars suit for 60 days after proof of loss and requires any suit within about 3 years. This gives the insurer time to process while preserving the insured's right to sue.

The mandatory 'physical examination and autopsy' provision allows the insurer, at its own expense, to:

• a.Raise the policy's premium at any point while a claim is being investigated by the company's claims department
• b.Deny all pending claims automatically
• c.Cancel the coverage during a claim
• d.Examine the insured while a claim is pending and require an autopsy where not forbidden by law✓

This provision lets the insurer verify a claim by examining the insured or, in a death claim, ordering an autopsy where state law permits, all at the insurer's cost. It does not authorize automatic denial, premium hikes, or cancellation.

In individual health insurance, the length of the grace period usually depends on the:

• a.Premium payment mode (for example, 7 days for weekly, 10 days for monthly, 31 days for other modes)✓
• b.The insured's current attained age, with older insureds automatically receiving a longer grace period than younger ones
• c.Insured's state of residence only
• d.Amount of the policy's benefits

The health grace period varies with how often premiums are paid, longer intervals get longer grace periods. It is not tied to age or benefit amount.

After an individual health policy has been in force for the period stated in the 'time limit on certain defenses,' a claim for a pre-existing condition that is NOT specifically excluded by name:

• a.Can always be denied by the insurer
• b.Doubles the policy's premium going forward whenever a pre-existing condition is discovered by the insurer after issue
• c.Automatically voids the entire policy
• d.Cannot be denied merely because the condition existed before the policy took effect✓

Once the time limit passes, the insurer cannot deny a claim solely because the condition predated the policy, unless it was specifically named and excluded. It does not void the policy or change the premium.

Under the optional 'change of occupation' provision, if an insured changes to a MORE hazardous occupation, benefits will generally be:

• a.Reduced to what the premium already paid would purchase at the more hazardous classification✓
• b.Terminated immediately
• c.Left completely unchanged
• d.Increased to reflect the added risk

Moving to a riskier job means the premium paid buys less coverage, so benefits are reduced to that level rather than the insurer collecting more. Benefits are not increased, unchanged, or terminated.

If an insured changes to a LESS hazardous occupation, the change of occupation provision allows:

• a.The policy to be canceled
• b.No change of any kind
• c.The premium to be reduced and any excess refunded✓
• d.Benefits to be reduced

A safer occupation entitles the insured to a lower rate, with the overpaid premium refunded, since the risk decreased. Benefits are not cut and the policy is not canceled.

In a health policy, the misstatement of age provision adjusts the ________ to what the premium paid would have purchased at the correct age:

• a.policy deductible
• b.benefits✓
• c.premium payment mode
• d.provider network

As in life insurance, a health misstatement of age is fixed by adjusting benefits to reflect what the premium actually paid would buy at the true age, rather than voiding the policy. Mode, deductible, and network are unaffected.

The optional 'illegal occupation' and 'intoxicants and narcotics' provisions let the insurer deny claims for losses that:

• a.Involve a minor illness
• b.Occur only on weekends or public holidays, when the insured is presumed to be away from the regular workplace
• c.Occur while the insured is at work
• d.Result from the insured committing a felony or being under the influence of non-prescribed narcotics✓

These optional provisions exclude losses stemming from the insured's illegal activity or intoxication by non-prescribed narcotics. Ordinary work, weekend, or minor-illness losses are not what they target.

The insuring clause of a health policy:

• a.Sets out the types of losses covered and the insurer's promise to pay benefits✓
• b.States the premium and payment mode
• c.Names the policy's beneficiary
• d.Lists the specific exclusions and limitations that remove certain losses from the policy's coverage

The insuring clause states what the policy covers and the insurer's promise to pay. Exclusions, premium terms, and beneficiary designations are handled in other parts of the contract.

A probationary period in a health policy is:

• a.The waiting time after each disability before benefits begin
• b.The time allowed to return the policy for a refund
• c.An initial period after the effective date during which sickness-related claims are not covered✓
• d.The window during which the insurer is required to pay an approved claim after receiving the proof of loss

The probationary period is a one-time wait at the start of coverage before certain (usually sickness) claims are payable. Returning for a refund is the free-look, and the post-disability wait is the elimination period.

How does an elimination period differ from a probationary period?

• a.The probationary period applies once at the start of the policy to new sickness claims, while the elimination period is the waiting time after each disability begins before benefits are paid✓
• b.Neither one affects when benefits are paid
• c.The elimination period applies only to death claims
• d.They are simply two different names for the exact same single waiting period, which is applied only one time at the very beginning of the policy and is never applied again for any later claim or subsequent disability

The probationary period is a single initial wait; the elimination period recurs, delaying benefits after each covered disability starts. Both affect benefits, and neither concerns death claims specifically.

In a disability policy, the benefit period is:

• a.The contestable period
• b.The waiting time before benefits start
• c.The maximum length of time benefits will be paid for a covered disability✓
• d.The policy's grace period

The benefit period caps how long benefits continue for a claim. The pre-benefit wait is the elimination period, and grace and contestable periods are unrelated concepts.

A pre-existing condition provision allows the insurer to:

• a.Limit or exclude benefits for a condition treated or manifesting before the effective date, for a stated time✓
• b.Deny all future claims of any kind for the entire life of the policy once a pre-existing condition has been identified
• c.Cover every condition immediately with no limits
• d.Increase the policy's death benefit

The provision lets the insurer restrict coverage for conditions that existed before the policy, but only for a defined period, after which they are covered. It does not bar all claims or add a death benefit.

The coordination of benefits (COB) provision in group health coverage is designed to:

• a.Prevent an insured with more than one plan from recovering more than 100% of the actual expenses✓
• b.Double the deductible the insured owes so that the two plans together collect a larger share of the actual costs
• c.Cancel the insured's secondary coverage
• d.Let an insured collect full benefits from two plans and profit

COB establishes which plan pays first and limits total recovery to the actual expense, preventing profit from double coverage. It does not cancel coverage or raise deductibles.

Under COB, when a child is covered by both parents' group plans, the 'birthday rule' usually makes the primary plan the one belonging to the parent whose:

• a.Coverage has been in force longer
• b.Income is higher
• c.Birthday falls earlier in the calendar year✓
• d.Plan has the lower deductible

The birthday rule assigns primary status to the plan of the parent whose birthday comes first in the year (month and day, not year of birth). Coverage length, income, and deductible are not the deciding factor.

Subrogation in a health or medical policy allows the insurer, after paying a claim caused by a third party, to:

• a.Retain all of the insured's future premiums
• b.Deny the claim it already paid and demand that the insured personally return all of the benefit money received
• c.Recover the amount paid from the responsible third party or from the insured's recovery against that party✓
• d.Increase the insured's benefits going forward

Subrogation lets the insurer step into the insured's shoes to recover its payment from the at-fault party. It does not undo the claim, seize premiums, or raise benefits.

The main purpose of subrogation is to:

• a.Reduce the insurer's underwriting duties
• b.Prevent the insured from being paid twice for the same loss and hold the at-fault party responsible✓
• c.Extend the policy's grace period so the insured has additional time to pursue the responsible third party
• d.Reward the insured for filing a claim

Subrogation stops double recovery and shifts the cost to the party that caused the loss. It is unrelated to rewarding the insured, underwriting, or grace periods.

A recurrent disability provision states that if an insured returns to work but becomes disabled again from the same cause within a stated time (such as 6 months), it is treated as:

• a.A brand-new disability requiring a new elimination period
• b.A pre-existing condition
• c.An excluded loss not payable
• d.A continuation of the original disability, with no new elimination period✓

A relapse from the same cause within the recurrent-disability window is treated as one continuous claim, so the insured need not satisfy a new elimination period. If the gap were longer, it would be a new disability.

An impairment (exclusion) rider on a health policy:

• a.Lowers the policy's deductible
• b.Adds coverage for a specified condition
• c.Guarantees the policy's renewal
• d.Permanently excludes coverage for a specified condition or body part✓

An impairment rider excludes a particular condition the applicant already has, allowing the insurer to issue coverage for everything else. It does not add coverage, cut deductibles, or guarantee renewal.

A 'noncancelable' health policy guarantees that the insurer:

• a.Can change the benefits whenever it wishes
• b.Cannot cancel and cannot raise the premium above the amount stated in the policy, as long as premiums are paid, until a stated age✓
• c.May raise the premium at any time
• d.May refuse to renew the policy each year and may also increase the premium at any renewal based on the individual insured's changing health

Noncancelable is the strongest renewal guarantee: the insurer can neither cancel nor increase the premium beyond the scheduled amount up to a stated age. It cannot non-renew or alter benefits at will.

A 'guaranteed renewable' health policy allows the insurer to:

• a.Cancel the policy at any time it chooses, provided only that it gives the insured advance written notice
• b.Refuse renewal for a single insured
• c.Guarantee renewal to a stated age but adjust premiums by class, not for one individual✓
• d.Change an individual insured's benefits

Guaranteed renewable means the insurer must renew to a stated age but may raise premiums for an entire class of insureds. It cannot cancel, single out one insured, or change benefits arbitrarily.

A conditionally renewable health policy permits the insurer to non-renew:

• a.Only for reasons stated in the policy, such as reaching an age or leaving employment, not the insured's declining health✓
• b.For any reason, including the insured's declining health
• c.Never decline renewal under any circumstance, so the coverage effectively continues for the insured's entire lifetime automatically
• d.Only during the first policy year

Conditionally renewable lets the insurer decline renewal only for specified events (age, employment status), but not because the insured's health worsened. It is more restrictive to the insured than guaranteed renewable but not a free hand for the insurer.