Health provisions
The standard clauses and the all-important renewability classes. All STABLE; specific waiting periods/thresholds are VERIFY.
Uniform Individual Accident & Sickness Provisions
Section titled “Uniform Individual Accident & Sickness Provisions”State law (via the NAIC model) standardizes many health-policy clauses, split into mandatory and optional provisions. High-value examples:
Mandatory (must appear):
- Entire contract — the policy + application are the whole agreement.
- Time limit on certain defenses (health’s version of incontestability) — limits how long the insurer can contest based on application statements.
- Grace period — time to pay an overdue premium without losing coverage.
- Reinstatement — restore a lapsed policy.
- Notice of claim / claim forms / proof of loss / time of payment of claims — the claims-handling timeline.
- Physical examination and autopsy — insurer’s right to verify.
- Legal actions — limits on when/how the insured may sue.
Optional (may appear):
- Misstatement of age, other insurance, illegal occupation, etc.
Renewability classes — the most tested distinction
Section titled “Renewability classes — the most tested distinction”How much control the insurer has over keeping/repricing the policy, from most to least favorable to the insured:
| Class | Can the insurer cancel? | Can it raise your rate? |
|---|---|---|
| Noncancelable | No (must renew to a stated age) | No (premium guaranteed) |
| Guaranteed renewable | No (must renew) | Yes, but only by class, not you individually |
| Conditionally renewable | Only on stated conditions | Possibly |
| Optionally renewable | At the insurer’s option (at renewal) | Yes |
Memory hook: Noncancelable = nothing the insurer can change; guaranteed renewable = they must renew but can raise rates by class.
Pre-existing conditions & coordination
Section titled “Pre-existing conditions & coordination”- Pre-existing condition provisions limit coverage for conditions that existed before the policy — heavily regulated, and largely eliminated for major medical under the ACA. [STABLE concept; specifics VERIFY]
- Coordination of benefits (COB) — when two health plans cover the same person, rules decide which pays primary vs secondary (prevents over-payment).
- Subrogation — the insurer may recover from a liable third party (e.g., the at-fault driver who injured the insured).
Why claims provisions matter for the TPA stream
Section titled “Why claims provisions matter for the TPA stream”Health is where claims-handling discipline is most visible: notice, proof of loss, timely payment. Mishandling claims is an unfair claims settlement practice (see 12 Ethics & trade practices) — and the Cigna AI-denial litigation is precisely a health-claims dispute (see 02 AI claims litigation). This is the regulatory backdrop for the Glacis TPA / claims-attribution stream. GROUNDED · Law360
→ 09 Washington or jump to 12 Ethics & trade practices.
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