HEALTH PROVISIONS · 6 MIN READ

Mandatory Uniform Provisions and the Claims Timeline

Every individual accident and sickness policy must contain the mandatory uniform provisions of the NAIC Uniform Individual Accident and Sickness Policy Provision Law, and the exam tests them as a chain of deadlines. The claim process runs: the insured gives written notice of claim within 20 days of loss, the insurer supplies claim forms within 15 days, and the insured furnishes written proof of loss within 90 days of the loss (or 90 days after the end of each period of continuing disability). Missing the 90-day proof deadline does not kill the claim if proof was not reasonably possible in time — but proof must then come as soon as reasonably possible and, absent legal incapacity, no later than one year. The grace period for late premiums slides with the premium mode: 7 days for weekly-premium policies, 10 days for monthly, and 31 days for less frequent modes such as quarterly or annual. Coverage stays in force during grace, and a covered loss in that window is paid minus the unpaid premium. After lapse, reinstatement procedures apply, and the insurer may require evidence of insurability. The Legal Actions provision brackets litigation: the insured must wait at least 60 days after filing proof of loss before suing, and must sue within 3 years of the date proof of loss was required. The insurer also retains the right, at its own expense, to examine the insured physically and to require an autopsy where not forbidden by law. Finally, the Time Limit on Certain Defenses clause is the health-insurance cousin of the life incontestable clause — with one crucial difference. After the policy has been in force two years, the insurer cannot void coverage or deny a claim based on application misstatements, except for fraudulent misstatements in jurisdictions that allow that defense. The fraud carve-back keeps the health version weaker than the life incontestable clause, which generally bars even fraud defenses after two years.