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Accident and Health or Sickness Agent — Information & Free Practice

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Accident and Health or Sickness Agent

Provider
Pearson VUE
Format
Four-option multiple-choice examination
Exam questions
55 scored questions plus up to 5 unscored pretest questions
Time limit
1 hour, 15 minutes
Passing score
70 on a scaled 0–100 scale
Exam fee
$45 per examination attempt
Examination outline
  • I. ACCIDENT & HEALTH INSURANCE POLICIES
    • A. Disability income insurance
    • 1. Nature and purpose
    • 2. Insuring agreement / clause and perils covered
    • 3. Definition of total disability
    • a. Own occupation
    • b. Any occupation for which the insured is reasonably suited
    • c. Any occupation
    • d. Combination definitions (own occupation/any occupation)
    • e. Presumptive disability
    • 4. Partial disability
    • 5. Residual disability
    • 6. Recurrent disability
    • 7. Elimination (waiting) period
    • 8. Probationary period
    • 9. Length of coverage (benefit period)
    • a. Short term vs. long term
    • b. Accident vs. sickness
    • 10. Nonoccupational vs. full coverage
    • 11. Common exclusions
    • 12. Other benefit features or options
    • a. Cost of living adjustment
    • b. Guaranteed insurability option
    • c. Accidental death and dismemberment
    • d. Accidental bodily injury vs. accidental means
    • 13. Disability benefits in life insurance contracts
    • B. Basic Medical Expense insurance
    • 1. Nature and purpose
    • 2. Insuring agreement and perils covered
    • 3. Hospitalization expense
    • 4. Surgical expense
    • 5. Other physicians’ charges (regular medical expense)
    • 6. Common exclusions
    • C. Major Medical insurance
    • 1. Nature and purpose
    • 2. Covered charges (expenses)
    • 3. Inside (internal) limits
    • 4. Common exclusions
    • 5. Deductible
    • a. Per injury or sickness vs. cumulative (e.g., annual)
    • b. Common accident/common sickness
    • c. Family maximum
    • 6. Percentage participation (coinsurance)
    • a. Nature and purpose
    • b. Stop loss feature
    • 7. Benefit period
    • 8. Maximum limits
    • a. Per injury or illness vs. lifetime
    • b. Unlimited
    • 9. Pre-admission certification
    • 10. Carryover provisions
    • 11. Other benefit features, options, or expenses covered
    • a. Maternity
    • b. Dental
    • c. Prescription drug
    • d. Vision
    • e. Dread disease and limited coverage
    • f. Outpatient treatment
    • 12. Key features of the Affordable Care Act (ACA)
    • a. Preventive care
    • b. Unlimited lifetime benefit
    • c. Preexisting conditions
    • d. Dependents to age 26
    • D. Comprehensive coverage
    • 1. Basic plan plus major medical (Corridor deductible)
    • 2. Comprehensive major medical
    • E. Hospital indemnity
    • F. Managed Care
    • 1. Health Maintenance Organization (HMO)
    • a. Closed and Open Panel
    • (1) Staff
    • (2) Independent Practice Association (IPA)
    • b. Gatekeeper/Primary Care Physician
    • c. Concept of managing healthcare expenses
    • 2. Preferred Provider Organization (PPO)
    • a. In-network healthcare
    • b. Out-of-network healthcare
    • c. Concept of managing healthcare expenses
  • II. ACCIDENT & HEALTH INSURANCE PROVISIONS
    • A. Individual policy mandatory provisions
    • 1. Entire contract
    • 2. Time limit on certain defenses / Incontestable
    • 3. Grace period
    • 4. Reinstatement
    • 5. Notice of claim
    • 6. Claim forms
    • 7. Proof of loss
    • 8. Time of payment of claims
    • 9. Payment of claims
    • 10. Physical examination and autopsy
    • 11. Legal actions
    • 12. Change of beneficiary
    • B. Individual policy optional provisions
    • 1. Change of occupation
    • 2. Misstatement of age
    • 3. Other Insurance in this insurer
    • 4. Insurance with other insurers
    • 5. Relation of earnings to insurance
    • 6. Unpaid premium
    • 7. Conformity with state statute
    • 8. Illegal occupation
    • C. Other provisions
    • 1. Preexisting conditions (Accident / Disability)
    • 2. Right to examine (free look)
    • 3. Consideration
    • 4. Policy continuation
    • a. Optional renewable
    • b. Conditionally renewable
    • c. Guaranteed renewable
    • d. Noncancelable
    • 5. Assignment
    • 6. Premium payment
    • a. Modes (frequency)
    • b. Effect of nonpayment
    • 7. Waiver of premium
    • 8. Insuring clause/agreement
    • 9. Intoxicants and narcotics
  • III. OTHER ACCIDENT & HEALTH TOPICS
    • A. Group insurance
    • 1. Types of benefits
    • 2. Group underwriting
    • 3. Master policy and certificates
    • 4. Nonduplication and coordination of benefits provisions
    • 5. Eighteen month extension of benefits
    • B. Approaches related to group insurance
    • 1. Blanket coverage
    • 2. MEWA coverage
    • C. Social Security disability
    • D. Accidental death and dismemberment coverage
    • 1. Insuring agreements and peril covered
    • 2. Principal sum
    • 3. Capital sum
    • 4. Beneficiary designations
    • E. Business uses
    • 1. Key person
    • 2. Business overhead expense
    • 3. Disability buy-out
    • F. Federal income taxation
    • 1. Accident and health insurance premiums
    • 2. Accident and health insurance benefits
    • G. Misrepresentation and concealment
    • H. Formation of the health insurance contract
    • 1. Application completion
    • 2. Types and uses of initial premium receipts
    • 3. Policy delivery
    • a. Modified/amended vs. issued as applied for
    • b. Nonprepaid vs. prepaid
    • 4. Elements of a valid contract
  • IV. North Carolina Statutes and Regulations Pertinent to Accident & Health
    • A. Contract of Insurance (Ref: Article 1 (G.S. 58-1-10))
    • B. Definitions (Ref: Article 1 (G.S. 58-1-5))
    • C. Commissioner of Insurance (Ref: Article 2 (G.S. 58-2-5, 40, 50, 60, 65, 69, 70, 155, 160, 161, 162, 163, 180, 185, 195, 200); 11 NCAC, Chapter 19, Section .0103)
    • D. General Regulations for Insurance (Ref: Article 3 (G.S. 58-3- 25, 30, 40, 115, 120, 130, 135, 140, 145))
    • E. Licensing of Agents, Brokers, Limited Representatives, and Adjusters (Ref: Article 33 (G.S. 58-33-1, 5, 10, 15, 17, 20, 26, 30, 31, 32, 40, 46, 50, 56, 60, 66, 70, 75, 76, 80, 82, 83, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 132, 135); 11 NCAC 4.0423,11 NCAC, Chapter 4, Section .0423)
    • F. Insurance Information & Privacy Protection Act (Ref: Article 39 (G.S. 58-39-5 through 58-39-120))
    • G. Unfair Trade Practices (Ref: Article 63 (G.S. 58-63-15, 20, 50))
    • H. False Pretenses and Cheats (Ref: Article 19 (G.S. 14-100))
    • I. Continuing Education (Ref: 11 NCAC, Chapter 6A, Section .0800)
    • J. General Regulations (Ref: Article 50 (G.S. 58-50-5, 20, 25, 26, 30, 35, 40, 45, 56, 57, 61, 62, 63, 65, 70); 11 NCAC, Chapter 4, Section .0423 (Ethical Standards))
    • K. Nature of Policies (Ref: Article 51 (G.S. 58-51-1, 5, 10, 15, 16, 20, 25, 30, 35, 37, 38, 40, 45, 55, 57, 58, 59, 60, 61, 62, 70, 75, 80, 81, 85, 90, 95, 100, 105, 110, 115, 116, 120, 125))
    • L. Group Health Insurance Continuation and Conversion Privileges (Ref: Article 53; CONTINUATION: (G.S. 58-53-1 through 58-53-40); CONVERSION: (G.S. 58-53-45 through 58-53-115))
    • M. Fraternal Benefit Societies (Ref: Article 24 (G.S. 58-24-1))
    • N. Life and Health Insurance Guaranty Association (Ref: Article 62 (G.S. 58-62-6, 21(d), 86))
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