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California Department of Insurance CA Life, Accident and Health or Sickness Examination Sample Questions (Q135-Q140):

NEW QUESTION # 135
Which health insurance contract provision addresses the problem of over insurance?

A. Reinstatement.
B. Assignment of benefits.
C. Coordination of benefits.
D. Incontestability.

Answer: C

Explanation:
* Definition: Coordination of benefits (COB) is a provision used in health insurance policies to prevent over-insurance, which occurs when a policyholder has multiple insurance plans that could potentially pay benefits for the same claim.
* Purpose: The primary purpose of COB is to establish the order in which multiple insurance plans will pay benefits and to ensure that the combined payments do not exceed the total cost of the healthcare expenses.
* Mechanism: The COB provision designates one insurance plan as the primary payer and the other as secondary (or tertiary, if applicable). The primary payer pays first up to its coverage limits, and the secondary payer then pays for any remaining eligible expenses.
* Regulations: California regulations, guided by the California Department of Insurance, enforce COB rules to streamline the claim payment process and prevent policyholders from profiting from multiple policies.
* Example: If a person is covered by two health plans-one through their employer and another as a dependent under their spouse's plan-the COB provision will determine which plan pays first.
References:
* California Department of Insurance guidelines on Coordination of Benefits.
* Standard health insurance policy provisions.

NEW QUESTION # 136
Every individual annuity policy that is sold to a senior in the State of California MUST include which of the following free look information?

A. The policy has a 30-day return for cancellation feature.
B. The insurer has the right to cancel if less than 30 days.
C. The insured forfeits any premiums paid if cancelled.
D. The premiums will not be invested during the return period.
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Answer: A

Explanation:
Every individual annuity policy sold to a senior in the State of California must include a 30-day free look period. This allows the policyholder to review the annuity contract and cancel it within 30 days for a full refund of premiums paid. This regulation ensures consumer protection by providing seniors with the opportunity to fully understand their purchase and reconsider if necessary, as mandated by California insurance laws.

NEW QUESTION # 137
According to the Employee Retirement Income Security Act of 1974 (ERISA) fiduciary standards, benefit plans are operated for

A. plan participants and beneficiaries.
B. plan sponsors and beneficiaries.
C. plan employees.
D. plan sponsors and employees.

Answer: A

Explanation:
According to the Employee Retirement Income Security Act of 1974 (ERISA) fiduciary standards, benefit plans must be operated for the exclusive benefit of plan participants and their beneficiaries. Fiduciaries managing the plans are required to act prudently and in the best interest of these participants and beneficiaries, ensuring that the plans are administered properly and that the assets are protected and used solely for providing benefits and defraying reasonable administrative expenses.

NEW QUESTION # 138
Which policy allows the insured to choose where the assets backing the cash value are invested?

A. Endowment life.
B. Variable life.
C. Term life.
D. Universal life.

Answer: B

Explanation:
Variable life insurance allows the insured to choose where the assets backing the cash value are invested.
Policyholders can allocate their premiums among various investment options, such as stocks, bonds, or mutual funds, which can influence the cash value and death benefit of the policy based on the performance of these investments. This type of policy combines life insurance protection with investment flexibility, appealing to those who want more control over how their policy's cash value grows.

NEW QUESTION # 139
What happens if an insurer violates the Medical Loss Ratio rule and spends too much money on administrative costs?

A. Insurers that do not meet the Medical Loss Ratio standard will be required to provide rebates to their customers and reduce spending on their administrative costs.
B. Insurers that do not meet the Medical Loss Ratio standard will pay a tax penalty to the Federal government, n
C. Insurers that do not meet the Medical Loss Ratio standard will pay a tax penalty to the Health Benefits Exchange.
D. Insurers that do not meet the Medical Loss Ratio standard will only be required to reduce their spending on administrative costs.

Answer: A

Explanation:
The Medical Loss Ratio (MLR) rule requires insurers to spend a minimum percentage of premium dollars on medical care and healthcare quality improvement, rather than on administrative costs and profits. For individual and small group markets, this threshold is 80%, and for large group markets, it is 85%. If insurers fail to meet this requirement, they must provide rebates to their policyholders to ensure compliance. This ensures that a significant portion of premiums is spent on actual medical care.

NEW QUESTION # 140
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