Insurance Licensing NY-Life-Accident-and-Health Valid Exam Prep - NY-Life-Accident-and-Health Exam Paper Pdf
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Insurance Licensing New York Life, Accident and Health Insurance Agent/Broker Examination Series 17-55 Sample Questions (Q92-Q97):

NEW QUESTION # 92
Which of the following is a basic benefit of Medicare Supplemental insurance?

Answer: B

Explanation:
Medicare Supplement insurance (Medigap) is designed to fill gaps in Original Medicare (Parts A and B) by paying certain out-of-pocket expenses that Medicare does not pay in full. A commonly tested basic Medigap benefit is coverage for the first 3 pints of blood each year . Under Original Medicare, a beneficiary may be responsible for the cost of the first three pints of blood in a calendar year (unless replaced or covered under specific circumstances). Medigap policies include this "first three pints" coverage as part of the standardized core benefits, helping reduce the beneficiary's exposure to unexpected hospital or outpatient blood costs.
The other choices are not considered standard "basic" Medigap benefits. "At-home recovery" and certain
"preventive care" enhancements have been associated with limited or older plan designs rather than being universally basic. "Basic drugs limit of $1,250" reflects older outpatient prescription concepts that are largely associated with pre-Part D benefit structures and not a core Medigap basic benefit in the way the blood coverage is. Therefore, the correct basic benefit is the first 3 pints of blood each year .


NEW QUESTION # 93
When a provider does NOT have an agreement with the insurer for payment, they will be reimbursed

Answer: A

Explanation:
When a medical provider does not have a contract or payment agreement with an insurer (often called a nonparticipating or out-of-network provider), the insurer generally does not pay based on a negotiated contract rate. Instead, reimbursement is commonly determined using a UCR methodology- Usual, Customary, and Reasonable charges. "Usual" refers to the typical charge a provider makes for a service;
"customary" reflects what providers in the same geographic area commonly charge for that service; and
"reasonable" considers whether the charge is appropriate given the circumstances and local market norms.
Under many major medical plans, the insurer pays a percentage of the UCR amount (subject to deductibles and coinsurance), and the patient may be responsible for any difference between the provider's billed charge and the insurer's allowed UCR amount (often referred to as balance billing , where permitted).
The other choices do not match standard insurer payment terminology: "absolute" and "relative" fee are not the typical reimbursement basis described for noncontracted providers, and "non-scheduled plan customary fee" is not the recognized standard method used in these plan provisions.


NEW QUESTION # 94
An insured individual purchases a disability policy with a waiver of premium rider on January 1. The individual is disabled on June 1. On July 1, he receives proof of permanent and total disability, and submits a claim. He begins receiving benefits on July 15. When are his premiums waived?

Answer: D

Explanation:
A waiver of premium rider on a disability policy is designed to keep coverage in force by waiving required premium payments once the insured becomes totally disabled , subject to the policy's conditions (such as required proof and any waiting/elimination period stated in the rider). The key concept tested is that waiver is tied to the date the disability begins , not the date proof is submitted or the date benefit checks start. Proof of disability (submitted July 1) is the administrative step that allows the insurer to approve the waiver, but the waiver itself applies because the insured has been disabled since June 1 . In standard disability provisions, if premiums are paid while the claim is being evaluated (or during any waiting period), those premiums are typically refunded once the waiver is approved, because the rider treats premiums as waived back to the disability start date (or back to the end of any stated waiting period, depending on the contract). Since June 1 is the onset of total disability, that is when the premium waiver is considered effective for purposes of this question.


NEW QUESTION # 95
Which statement is NOT a characteristic of a Group Life Insurance Plan?

Answer: A

Explanation:
The correct answer is C. Individual underwriting. A Group Life Insurance Plan is designed to provide coverage to a number of people under a single policy, usually employees of an employer or members of an association. One of its key characteristics is that the insurer issues a master contract to the policyholder, such as the employer, while each covered member receives a certificate of insurance as evidence of coverage.
Group plans may also include probationary periods , especially for new employees, to require a certain length of service before coverage becomes effective.
What group life insurance generally does not involve is individual underwriting for each member. Unlike individual life insurance, where each applicant's health history, occupation, and personal risk factors are carefully evaluated, group life insurance is commonly written on a group basis . Eligibility is determined by membership in the group rather than detailed medical underwriting of each person, especially for amounts within the plan's basic coverage limits. Therefore, the statement that is not a characteristic of a Group Life Insurance Plan is individual underwriting .
Thought for 8s


NEW QUESTION # 96
Under the grace period, an insured submits a $300 claim for medical expenses. The insurer notes that the insured has a past due premium of $100, and as a result, the insurer only pays $200. Which of the following provisions covers this situation?

Answer: D

Explanation:
The correct answer is Unpaid premium . In accident and health insurance, the unpaid premium provision permits the insurer to deduct any premium that is due and unpaid from a claim payment when a loss occurs during the grace period. The grace period allows coverage to remain in force for a limited time after the premium due date, giving the insured an opportunity to make the overdue payment without immediate lapse of coverage. However, if a claim is submitted during that period, the insurer has the right to subtract the outstanding premium from the amount otherwise payable.
In this question, the insured submits a $300 claim , but because $100 in premium is overdue , the insurer pays only $200 . That is exactly how the unpaid premium provision operates.
The other choices do not fit. Payment of claims refers to how and to whom claims are paid, not deduction of overdue premium. Misstatement of age applies when an incorrect age affects premium or benefits. Payment actions is not the standard policy provision being tested here. Therefore, the correct answer is A. Unpaid premium .


NEW QUESTION # 97
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