Life & Health · Lesson directory

HEALTH POLICY PROVISIONS · T229–T232

Health Claim Procedures

Follow a claim from notice and forms through proof of loss and payment.

4 cards · Three practice questions for each card

CARD T229

Notice of Claim

Notice telling the insurer that a covered loss has occurred. The standard individual-health provision calls for written notice within 20 days after the loss begins, or as soon as reasonably possible. State requirements may differ.

How it works

Notice of claim alerts the insurer that a loss has occurred; proof of loss supplies supporting details. The standard individual-health provision calls for written notice within 20 days after occurrence or commencement of loss, or as soon as reasonably possible. Notice to the insurer or its authorized recipient should sufficiently identify the insured. It does not itself establish that benefits are payable. [23]

EXAMPLE

An insured reports a disabling illness promptly, then completes the forms and medical evidence needed for proof of loss.

Key distinction

20 days is notice; 15 days is the insurer’s forms response; 90 days generally concerns proof.

Practice Notice of Claim · 3 questions

CARD T230

Claim Forms

Forms used to submit proof of a health claim. Under the standard individual-health provision, if the insurer does not furnish forms within 15 days after notice, the claimant can submit written proof describing the loss within the proof-of-loss deadline. State rules may differ.

How it works

Under the standard individual-health provision, the insurer furnishes claim forms within 15 days after receiving notice. If forms are not supplied, the claimant can satisfy proof requirements by submitting timely written evidence describing the occurrence, character, and extent of the loss. Missing forms do not create permission to ignore proof deadlines, nor do they automatically guarantee the claim. [24]

EXAMPLE

After giving notice, a claimant receives no forms within 15 days and submits written loss details within the applicable proof period.

Key distinction

The 15-day clock concerns the insurer’s response to notice, not the insured’s initial notice deadline.

Practice Claim Forms · 3 questions

CARD T231

Proof of Loss

Written information supporting a claim. Under the standard individual-health provision, proof is due within 90 days after the loss; for continuing periodic benefits, after the period for which benefits are owed. Late proof may be allowed when timely submission was not reasonably possible. State rules may differ.

How it works

The standard individual-health rule generally requires written proof within 90 days after the loss. For periodic benefits based on continuing loss, the clock runs after the relevant period for which the insurer is liable. If timely proof was not reasonably possible, proof must be furnished as soon as reasonably possible, generally no later than one year after it was otherwise due, except in the absence of legal capacity. State law can vary. [25]

EXAMPLE

A continuing disability claim requires evidence for the benefit period being claimed; the claimant does not assume the initial notice alone proves every later month.

Key distinction

Proof timing differs for a single loss and continuing periodic benefits.

Practice Proof of Loss · 3 questions

CARD T232

Payment of Health Claims

Under the standard individual-health provision, nonperiodic benefits are due immediately upon receipt of proper proof; periodic benefits are paid at least monthly.

Payment of Claims: Identifies who receives benefits, generally the insured for health expenses and the named beneficiary for death benefits. Assignments and state rules can affect payment.

How it works

Time of payment addresses when benefits are paid: under the standard individual-health provision, nonperiodic benefits are due immediately upon receipt of proper written proof, and periodic benefits are paid at least monthly. Payment of claims addresses who receives them: generally the insured for health benefits and the designated beneficiary for death benefits, subject to assignments and permitted direct provider payments. Facility-of-payment provisions can allow limited payments to appropriate persons in stated circumstances; amounts and rules vary. [26] [27]

EXAMPLE

An insured assigns eligible medical benefits to a provider. The insurer can pay that provider as permitted instead of sending the same benefit twice.

Key distinction

“When” and “to whom” are two different provisions.

Practice Payment of Health Claims · 3 questions

APPLY THE TERMS

Practice questions

Select an answer, then check it to see why each option is right or wrong.

T229 · Notice of Claim

0 of 3 answered

QUESTION 1 OF 3What is the standard individual-health notice-of-claim period?
QUESTION 2 OF 3How does notice differ from proof of loss?
QUESTION 3 OF 3If notice within 20 days was not reasonably possible, does the standard provision automatically destroy the claim?

T230 · Claim Forms

0 of 3 answered

QUESTION 1 OF 3Who has the standard 15-day forms obligation after notice?
QUESTION 2 OF 3If forms are not supplied in time, what can the claimant submit?
QUESTION 3 OF 3Does failure to send forms automatically establish coverage for an excluded loss?

T231 · Proof of Loss

0 of 3 answered

QUESTION 1 OF 3What is the usual standard proof-of-loss deadline for a nonperiodic health loss?
QUESTION 2 OF 3For continuing periodic benefits, what does the standard proof clock reference?
QUESTION 3 OF 3If timely proof was not reasonably possible, what is required under the standard exception?

T232 · Payment of Health Claims

0 of 3 answered

QUESTION 1 OF 3Which provision answers who receives the benefit?
QUESTION 2 OF 3Under the standard provision, continuing periodic benefits are paid at least how often?
QUESTION 3 OF 3What can a valid benefit assignment permit?

Sources & further reading

Original explanations and practice scenarios informed by the following regulatory, legal, and product resources. State examples are not presented as nationwide deadlines or requirements.