Optional health insurance provisions (from Chapter 22)

Health insurance policies issued in Florida may contain the following optional health insurance provisions, but it is important to remember that these are not required provisions. You will definitely want to know the difference between mandatory provisions and optional provisions.

Change of occupation *****

If the insured makes a claim for injury or sickness after having changed his or her occupation to a more hazardous occupation than that stated in the policy, the insurer will pay benefits equal to what the premium would have purchased for the more hazardous occupation, which may be less than the benefits stated in the policy document (because the policy references a less dangerous occupation). It is important to note that the claim for the injury or sickness is not required to be related to the occupation (meaning it did not have to happen on the job).

If the insured changes his or her occupation to one classified by the insurer as less hazardous than that stated in the policy, the insurer will reduce the premium rate accordingly, and will return the excess unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent.

Misstatement of age or sex *****

We've discussed this in several chapters now. If the age or sex of the insured has been misstated, all amounts payable under the policy will be such as the premium paid would have purchased according to the correct age or sex.

Other insurance with insurer

If two or more health insurance policies are issued by the insurer covering the same insured, the insurer shall pay the total benefits payable under all policies issued so long as it does not exceed the full amount of the claim.

(Note...If you are covered by more than one health policy from the same company (don't know why you would be), you will not receive more than what you lost.)

Insurance with other insurers: expense-incurred basis

(Note: Expense-incurred means a health policy that pays on a reimbursement approach for actual medical expenses incurred.)

If the insured has other coverage with a different insurer, the two policies combined will not pay more than 100% of the loss incurred by the insured and any excess premium will be returned to the insured on a pro rata basis.

(Note: Same as above, but having two policies from two different companies.)

Insurance with other insurers: other than expense-incurred basis

(Note: Other than "expense-incurred" is a disability policy or a hospital indemnity policy which pays a daily amount for each day of confinement. (It does not reimburse)

If the insured has more than one disability policy or more than one indemnity type policy, the the policies combined will not pay more than 100% of the loss incurred by the insured and any excess premium will be returned to the insured on a pro rata basis.

(Note: Same as above but for disability type policies.)

Relation of earnings to insurance *****

This provision really only applies to disability income policies. If the insured has more than one disability income policy and the total benefits exceed the total lost monthly earnings of the insured due to the disability, then the total benefits paid by all combined policies will not pay more than the total monthly earnings lost by the insured. Any excess premiums will be returned to the insured on a pro rata basis.  This provision shall not reduce the total monthly amount of benefits payable under all coverages upon the insured below $500 or the sum of the monthly benefits specified in such coverages, whichever is the lesser, nor shall it operate to reduce benefits other than those payable for loss of time.

(Note: If your income goes down, the company will not pay a disability income benefit which would be more than what you were making. They will take the average of your income over the last two years and pay a percentage of that. For example:Years ago you bought a disability policy that would pay $3000 per month, which represented 60% of your salary. If your income goes down they will pay you 60% of the average of the last two years' income.)

Unpaid premium *****

If a claim arises during the grace period, the benefit will be paid and the premium owed will be subtracted from the benefit.

Prohibited cancellation for HIV or AIDS

No insurer may cancel or nonrenew a health insurance policy because of diagnosis or treatment of HIV/AIDS.

Conformity with state statutes

If state statutes (laws) change, then the policy is automatically amended to follow the minimum standards under the law.

Illegal occupation *****

The insurer will not be liable for any loss that results from the insured committing or attempting to commit a felony or from the insured being engaged in an illegal occupation.

Intoxicants and narcotics

The insurer will not be liable for any loss resulting from the insured being drunk or under the influence of any narcotic unless taken on the advice of a physician.