continuing education insurance

In the absence of fraud, all statements made by applicants or Insureds will be deemed to be representations and not warranties.  No statement made for the purpose of affecting coverage will avoid coverage or reduce benefits unless contained in a written application signed by the Contract Holder and a copy of such documents has been furnished to the Contract Holder.

continuing education insurance

Eligibility for coverage under this Contract is determined by medical risk classifications applicable to the applicant and his or her dependents.  Among the factors we consider when making our underwriting decision are the medical information requested on the application, and the sex and age of the applicant and his or her dependents.

Material Misrepresentations, omissions, concealment of facts and incorrect statements made on an application or a medical statement by an applicant, Insured or a Contract Holder which is discovered within two years of the issue date of the Contract may prevent payment of benefits under this Contract and may void this Contract for the individual making the misrepresentation, omission, concealment of facts or incorrect statement.  Fraudulent misstatements in the application or medical statement discovered at any time, may result in voidance of this Contract or denial of any claims for the individual making or responsible for the fraudulent misstatement.

In the event of fraud or misrepresentation pertaining to, but not limited to, medical information, geographical area, or the sex and/or the age of applicant or his or her dependents made on an application or medical statement by an applicant, Contract Holder or Insured, the sole liability of YOUR INSURANCE COMPANY shall be the return of any unearned Premium, less benefit payments.  However, at our discretion, we may elect to cancel the Contract with forty-five (45) days prior written notice (Time may vary by state regulation &/or company practice) or continue this Contract provided that the Contract Holder makes payment to us for the full amount of the Premium which would have been in effect had the true facts been stated by the applicant, Contract Holder, or Insured.

C.A.

Bernadette was diagnosed with breast cancer in Oregon.  Her doctor in Oregon told her that she needed surgery as soon as possible.  However, since she was not employed and had no insurance, she decided to move back home to Indiana.

She found a job in Indianapolis, but it had no benefits.  Therefore she applied for an individual major medical policy.  She did not tell the agent about her cancer and the policy was issued on a standard basis with no riders.

60 days after the policy was issued she had a  "routine" mammogram" which "discovered"

(Continued from previous page) the cancer.  She told the radiologist at the clinic that she had had a mammogram about a year earlier, at a public health clinic.  She did not mention the finding, however.  She was immediately admitted to a hospital in Indianapolis and a mastectomy was performed.

During a routine claims review, the insurer sent an inquiry to the Public Health Service in Oregon, which duly reported the earlier findings.  Based upon these findings, the insurer canceled the policy based upon a material misrepresentation and refused to pay for any of the medical costs.
insurance continuing education
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The following text is typical of the language and provisions used on the first page of the Major Medical policy.  Much of this information is required by state regulations and may vary by state.

IMPORTANT NOTICE

(NOTE:  In most, if not all, jurisdictions, the copy of the Application becomes part of the insurance contract/policy, again stressing the necessity of complete and accurate information on the Application)
Please carefully read the copy of your application attached to this Contract and notify Your Insurance Company, Inc. within 10 days if any information on it is incorrect or incomplete, or if any past medical history has been left out of the application.  Your application is a part of your Contract, which has been issued on the basis that the answers to all questions and all information shown on the application are correct and complete.
This Contract Contains a Deductible Provision
(This statement required in most jurisdictions when applicable
(The following is the Identification section, and while the format may vary by company, it is the minimum required in most jurisdictions)

CONTRACT NUMBER:                                               GROUP #
CONTRACT TYPE:          
EFFECTIVE DATE:         
MONTHLY RATE:            
During the terms of this Contract, Your Insurance Company agrees to provide to covered individuals the health insurance benefits specifically provided in this Contract, subject to all the terms, conditions, limitations, and exclusions.
(The following refund statement or one very similar is used in used in most states, but this "10-day – no questions asked" provision is the most typical)

IF, AFTER EXAMINATION OF THIS CONTRACT AND COPY OF YOUR APPLICATION, YOU ARE NOT FULLY SATISFIED FOR ANY REASON, YOUR PREMIUM PAYMENT WILL BE REFUNDED PROVIDED YOU RETURN THE CONTRACT AND IDENTIFICATION CARDS TO YOUR INSURANCE COMPANY, INC. WITHIN 10 DAYS OF THE DELIVERY DATE. (THIS REFUND DOES NOT INCLUDE A REFUND OF THE APPLICATION FEE)
CANCELLATION PROVISION

This provision allows the company to cancel according to the provisions contained in the contract, but most states require that a statement of this type be on the first page.

This Contract will stay in effect as long as you remain eligible for coverage and you pay your Premiums on time, This Contract can be canceled if you have made a Fraudulent or Material Misrepresentation or omission on your application or we terminate the Contract for everyone covered by it.

We want you to understand and be satisfied with the terms of this Contract.  As you read through it, remember that the words "we", "us" and "our" refer to Your Insurance Company, Inc., the insurer (hereinafter referred to as YOUR INSURANCE COMPANY).  We use the words "you" and "your" to mean you, the Insured and your Covered Dependents.

We have issued this Contract in return for the completed application (which is made a part of this Contract) and initial Premium payment.

(NOTE:  The above typically completes the first page of the contract.  In some states, if a company is marketing their health insurance policies from an out-of-state trust (ERISA account), thereby removing or restricting the authority of the Department of Insurance to act in regards to that policy, some notification may be required.  One state requires a statement to appear in red ink on the first page, which states essentially that the provisions of that policy are under the jurisdiction of another state other than the one in which the policy is issued.  )

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